Greetings, and congratulations on the milestones! Does substack allow a pay-what-you-want subscription? If so, I'm curious it it would be a net gain for most newsletters...
I enjoyed part one of the group q&a (albeit without listening to the whole thing), and am looking forward to part two, especia…
Greetings, and congratulations on the milestones! Does substack allow a pay-what-you-want subscription? If so, I'm curious it it would be a net gain for most newsletters...
I enjoyed part one of the group q&a (albeit without listening to the whole thing), and am looking forward to part two, especially with the addition of Thomas Reilly. Could you please revisit the topic of personality disorders? I ask, partly because Reilly might add new insight, and partly because I didn't think you really answered the question that was submitted: (something along the lines of) "What is the de facto delineation between personality disorders and other disorders?" The answer kind of came down to "the distinction is difficult to operationalize" and "patients having difficulty relating to self and others," which make sense, but aren't informative of how the subcategory is "delineated" or used for any given purpose.
Also, the submitter claimed that ADHD could be interpreted as meeting the DSM-5's general criteria for personality disorders, based on a layperson's reading of the criteria, and you disagreed, without explaining why. Looking up the DSM-5 criteria for both, only knowing the plain meaning of the words, I'm not confident enough to guess how the general criteria for personality disorders are interpreted by yourselves to exclude ADHD:
DSM-5-TR Criteria for General Personality Disorder
* An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in 2 (or more) of the following areas:
a. Cognition (ie, ways of perceiving and interpreting self, other people, and events)
b. Affectivity (ie, the range, intensity, lability, and appropriateness of emotional response)
c. Interpersonal functioning
d. Impulse control
Abnormally low impulse control is more or less a defining characteristic of ADHD, and inattentive symptoms affect interpersonal functioning and "ways of perceiving and interpreting self, other people, and events"
* The enduring pattern is inflexible and pervasive across various personal and social situations.
True
* The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
For severe ADHD, true (In that ADHD criteria can be interpreted overly broadly, not necessarily, but the principled response to that may be to equally lower the threshold for "clinical significance" in THIS criteria, winding up in the same place.)
* The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
True
* The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
Unless ADHD is axiomatically defined as not being a personality disorder, true (And, if so, why is that an axiom? Why not the next-greatest-outlier personality disorder?)
* The enduring pattern is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, head trauma).
True
(No relevant change for the "Alternative" general criteria, so far as I can tell.)
But, again, I only know the "plain meaning" of the criteria, not how they're being used by mental health researchers and clinicians.
Sidenote about ADHD which might be an interesting, if relatively shallow, last-minute addition to the questions for part two: Anecdotally, people with ADHD frequently have a powerful sweet-tooth - between the five of you, does anyone know if this been formally studied and, if so, is there a genuine deviation from the norm and is it known whether it's an abnormally strong craving or an abnormally weak ability to resist a normal-strength craving?
Thanks for great writing, and best wishes for the next two years!
> Unfortunately, Substack doesn’t allow a pay-what-you-want subscription. I know there is a demand for it and I also think that it’ll be a net gain for most newsletters, but Substack leadership has showed any indication that this is something they are interested in.
> What I was trying to say in the Q&A was that there really isn’t a principled, empirically-validated distinction between conditions we call “personality disorders” and other mental disorders. So any rigorous attempt to understand this distinction ultimately leads to some sort of deconstruction of the distinction itself. One challenge here is that basically *any* *chronic* mental illness can be described as a deviant “enduring pattern of inner experience and behavior.” It is not surprising perhaps that chronic mild depression and cyclothymia were once considered personality disorders in the early DSM (“dysthymic personality” and “cyclothymic personality”). The conditions we currently call personality disorders are conditions where disturbances in relationship to oneself and others were thought to be particularly marked and pervasive (whereas in other cases of mental disorders, the disturbances were less marked or more restricted to particular domains). In addition, the profession wanted to differentiate between conditions that arise because of altered brain development (hypothetically) and conditions where brain development is normal but personality development (ways of relating to self and others) is altered. This differentiation is partly made based on age of onset. If the onset of a condition is in early childhood, it is seen as “neurodevelopmental” (autism, ADHD) even if it is an enduring pattern, versus personality disorders are thought to clinically manifest in adolescence, a formative period of identity development. In the ADHD, the core alteration is in area of attention-concentration and hyperactivity, which is considered to be relatively more restricted in range compared to more pervasive alternations in ways of perceiving and interpreting self, other people, and events seen in personality disorders.
Thank you for the response and I'm sorry for taking almost two months to reply
Pay-What-You-Want: Hopefully Substack implements it - I'd like to compensate writers whose work I value a non-zero amount, but this kind of reading is an indulgence, so paid subscriptions would be (for ME) an extravagance. What method of purchasing your book is most remunerative for you?
ADHD and Personality Disorders: I appreciate the points you're making, but I interpreted the spirit of the question of comparing the plain meaning of the criteria for the two to be the same as that of comparing plucked chickens to men, hotdogs to sandwiches*, and Quebecois or Algerians to other possible subgroups of Latinos** - the point is either to challenge the definition as incorrect for not matching our intentions or challenge ourselves to articulate definitions that better match our intentions. (I.E., Setting aside whether the DSM criteria is the best starting point for a discussion about nosology, you can't meaningfully comment on the DSM criteria, without directly referencing the DSM criteria. Hence suggesting you revisit the topic in part two, if/when that happens.)
(And a new question for the possible part two: Is there a good case for considering depression and anxiety as a single condition that can either manifest as predominantly emotional (depression) or cognitive (anxiety), rather than two overlapping conditions with a mix of emotional and cognitive effects? This came to mind as a possible explanation for why CBT has seemingly continued to outperform the Dodo Bird Verdict for anxiety, but not depression.)
And a general question about your writing: To better interpret your references to your own clinical experience, how much time is spent in clinical psychiatry, how much of that time is "general" psychiatry, and to what degree do your insights from geriatric psychiatry apply to other patient populations?
Thanks!
* I don't take a side on whether or not hotdogs are sandwiches, but I think "Texas BBQ" is not real bbq: For bbq to make ontological sense as a distinct subset of smoked meats, there must be some feature distinguishing it from other smoked meats and I think sauce is the obvious feature to use. If I expect bbq and am served a smoked meat intended to be eaten without a sauce, I take it as a - puts on sunglasses - faux-que.
While you're at it I'm curious about your perspective on whether PDs should be subsumed under other diagnostic constructs, and if so, which ones you think go where ;)
So you'd change the name and conceptualization, but otherwise preserve the category? I have read that article, I was actually trying to ask what you think about proposals to do away with the grouping and reconceptualize individual PDs as manifestations of other DSM disorders or eliminate them. Came to mind because my intuition runs in the other direction from pmopenthread: I've known enough people whose cluster B traits improve when they do something about their raging untreated ADHD to make me suspicious. Winky face because I'm sure you're eager to dive into that kettle of worms on pleasant Sunday.
I think borderline personality disorder is an interesting case because it can be conceptualized as a mood disorder and trauma-related disorder as well as a personality disorder, and I suspect when a lot of people talk about "eliminating" PDs, they are thinking of borderline. But there are other personality prototypes that are harder to eliminate or subsume under other disorders. Eg, antisocial, narcissistic, avoidant, obsessive-compulsive. It's helpful to have a general category that focuses primarily on self-interpersonal dysfunction.
[Deleted and resubmitted, for formatting]
Greetings, and congratulations on the milestones! Does substack allow a pay-what-you-want subscription? If so, I'm curious it it would be a net gain for most newsletters...
I enjoyed part one of the group q&a (albeit without listening to the whole thing), and am looking forward to part two, especially with the addition of Thomas Reilly. Could you please revisit the topic of personality disorders? I ask, partly because Reilly might add new insight, and partly because I didn't think you really answered the question that was submitted: (something along the lines of) "What is the de facto delineation between personality disorders and other disorders?" The answer kind of came down to "the distinction is difficult to operationalize" and "patients having difficulty relating to self and others," which make sense, but aren't informative of how the subcategory is "delineated" or used for any given purpose.
Also, the submitter claimed that ADHD could be interpreted as meeting the DSM-5's general criteria for personality disorders, based on a layperson's reading of the criteria, and you disagreed, without explaining why. Looking up the DSM-5 criteria for both, only knowing the plain meaning of the words, I'm not confident enough to guess how the general criteria for personality disorders are interpreted by yourselves to exclude ADHD:
DSM-5-TR Criteria for General Personality Disorder
* An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in 2 (or more) of the following areas:
a. Cognition (ie, ways of perceiving and interpreting self, other people, and events)
b. Affectivity (ie, the range, intensity, lability, and appropriateness of emotional response)
c. Interpersonal functioning
d. Impulse control
Abnormally low impulse control is more or less a defining characteristic of ADHD, and inattentive symptoms affect interpersonal functioning and "ways of perceiving and interpreting self, other people, and events"
* The enduring pattern is inflexible and pervasive across various personal and social situations.
True
* The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
For severe ADHD, true (In that ADHD criteria can be interpreted overly broadly, not necessarily, but the principled response to that may be to equally lower the threshold for "clinical significance" in THIS criteria, winding up in the same place.)
* The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
True
* The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
Unless ADHD is axiomatically defined as not being a personality disorder, true (And, if so, why is that an axiom? Why not the next-greatest-outlier personality disorder?)
* The enduring pattern is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, head trauma).
True
(No relevant change for the "Alternative" general criteria, so far as I can tell.)
But, again, I only know the "plain meaning" of the criteria, not how they're being used by mental health researchers and clinicians.
Sidenote about ADHD which might be an interesting, if relatively shallow, last-minute addition to the questions for part two: Anecdotally, people with ADHD frequently have a powerful sweet-tooth - between the five of you, does anyone know if this been formally studied and, if so, is there a genuine deviation from the norm and is it known whether it's an abnormally strong craving or an abnormally weak ability to resist a normal-strength craving?
Thanks for great writing, and best wishes for the next two years!
> Unfortunately, Substack doesn’t allow a pay-what-you-want subscription. I know there is a demand for it and I also think that it’ll be a net gain for most newsletters, but Substack leadership has showed any indication that this is something they are interested in.
> If you haven’t already read this post on personality disorders, I’d strongly recommend: https://www.psychiatrymargins.com/p/either-all-psychopathology-is-personality
> What I was trying to say in the Q&A was that there really isn’t a principled, empirically-validated distinction between conditions we call “personality disorders” and other mental disorders. So any rigorous attempt to understand this distinction ultimately leads to some sort of deconstruction of the distinction itself. One challenge here is that basically *any* *chronic* mental illness can be described as a deviant “enduring pattern of inner experience and behavior.” It is not surprising perhaps that chronic mild depression and cyclothymia were once considered personality disorders in the early DSM (“dysthymic personality” and “cyclothymic personality”). The conditions we currently call personality disorders are conditions where disturbances in relationship to oneself and others were thought to be particularly marked and pervasive (whereas in other cases of mental disorders, the disturbances were less marked or more restricted to particular domains). In addition, the profession wanted to differentiate between conditions that arise because of altered brain development (hypothetically) and conditions where brain development is normal but personality development (ways of relating to self and others) is altered. This differentiation is partly made based on age of onset. If the onset of a condition is in early childhood, it is seen as “neurodevelopmental” (autism, ADHD) even if it is an enduring pattern, versus personality disorders are thought to clinically manifest in adolescence, a formative period of identity development. In the ADHD, the core alteration is in area of attention-concentration and hyperactivity, which is considered to be relatively more restricted in range compared to more pervasive alternations in ways of perceiving and interpreting self, other people, and events seen in personality disorders.
> An association between sugar intake and ADHD actually has been reported in many studies (but not consistently seen, it appears). Eg, https://link.springer.com/article/10.1186/s12887-022-03123-6
My own suspicion is that inattention and impulsivity leads to more snacking behaviors.
Thank you for the response and I'm sorry for taking almost two months to reply
Pay-What-You-Want: Hopefully Substack implements it - I'd like to compensate writers whose work I value a non-zero amount, but this kind of reading is an indulgence, so paid subscriptions would be (for ME) an extravagance. What method of purchasing your book is most remunerative for you?
ADHD and Personality Disorders: I appreciate the points you're making, but I interpreted the spirit of the question of comparing the plain meaning of the criteria for the two to be the same as that of comparing plucked chickens to men, hotdogs to sandwiches*, and Quebecois or Algerians to other possible subgroups of Latinos** - the point is either to challenge the definition as incorrect for not matching our intentions or challenge ourselves to articulate definitions that better match our intentions. (I.E., Setting aside whether the DSM criteria is the best starting point for a discussion about nosology, you can't meaningfully comment on the DSM criteria, without directly referencing the DSM criteria. Hence suggesting you revisit the topic in part two, if/when that happens.)
(And a new question for the possible part two: Is there a good case for considering depression and anxiety as a single condition that can either manifest as predominantly emotional (depression) or cognitive (anxiety), rather than two overlapping conditions with a mix of emotional and cognitive effects? This came to mind as a possible explanation for why CBT has seemingly continued to outperform the Dodo Bird Verdict for anxiety, but not depression.)
And a general question about your writing: To better interpret your references to your own clinical experience, how much time is spent in clinical psychiatry, how much of that time is "general" psychiatry, and to what degree do your insights from geriatric psychiatry apply to other patient populations?
Thanks!
* I don't take a side on whether or not hotdogs are sandwiches, but I think "Texas BBQ" is not real bbq: For bbq to make ontological sense as a distinct subset of smoked meats, there must be some feature distinguishing it from other smoked meats and I think sauce is the obvious feature to use. If I expect bbq and am served a smoked meat intended to be eaten without a sauce, I take it as a - puts on sunglasses - faux-que.
** Example: https://i.redd.it/kxrb1uokdild1.jpeg
Thank you 😊 This requires a detailed response so I’ll attempt that in the morning (on my side)
While you're at it I'm curious about your perspective on whether PDs should be subsumed under other diagnostic constructs, and if so, which ones you think go where ;)
I'm sympathetic to the recommendation that personality disorders should be renamed as interpersonal disorders, as discussed here: https://www.psychiatrymargins.com/p/either-all-psychopathology-is-personality
So you'd change the name and conceptualization, but otherwise preserve the category? I have read that article, I was actually trying to ask what you think about proposals to do away with the grouping and reconceptualize individual PDs as manifestations of other DSM disorders or eliminate them. Came to mind because my intuition runs in the other direction from pmopenthread: I've known enough people whose cluster B traits improve when they do something about their raging untreated ADHD to make me suspicious. Winky face because I'm sure you're eager to dive into that kettle of worms on pleasant Sunday.
I think borderline personality disorder is an interesting case because it can be conceptualized as a mood disorder and trauma-related disorder as well as a personality disorder, and I suspect when a lot of people talk about "eliminating" PDs, they are thinking of borderline. But there are other personality prototypes that are harder to eliminate or subsume under other disorders. Eg, antisocial, narcissistic, avoidant, obsessive-compulsive. It's helpful to have a general category that focuses primarily on self-interpersonal dysfunction.