Maybe I’ve missed something (I haven’t read all your posts) but it seems like you never write about (structural) dissociation. That is, dissociative amnesia, dissociative identity disorder, OSDD. Without a knowledge of dissociation, our understanding of psychology is impoverished, even deluded. Do you, like so many others, not believe in it? Or do you, like so many others, think it is rare? It isn’t rare. It is more common than schizophrenia or bipolar. Could you write a post on structural dissociation? If you don’t believe in it or believe it’s too rare to bother with, could you give your reasoning?
Zida, you are absolutely right that I have neglected this topic. Dissociation is common indeed and I frequently encounter dissociative symptoms in my clinical practice. There are many interesting debates around dissociation as well that somehow I haven't really researched in detail. Time to address this shortcoming!
Congratulations on the two year anniversary. Your reflections have helped me to think deeply about a range of issues.
I would love to read your thoughts on navigating the gap between ‘best practice’ and ‘good enough’ care in mental health. I find this is both a clinical and philosophical challenge, and one that my training (psychologist) has not equipped me well for.
I am eager for discussions on how to I improve my treatment decision making skills to assist the person in distress who is sitting in front of me right, as opposed to hypothetical client being treated in abundant and limitless settings. To know how to select from the tools I have at hand and avoid get sucked into circular discussions of ‘if only we had xyz!’.
Thanks Emily! This is a really important question, one I struggle with on a daily basis. The response depends on the nature of the shortcoming, but one general thing I try to do is to remain mindful of the ways in which actual care is falling short of the ideal, and convey them to the patient as appropriate. I find that a lot of clinicians simply cannot practice with this kind of awareness and they end up rationalizing the status quo. I’ll see if I can post a more detailed discussion on navigating the gap that you are pointing out.
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.
Hi, Awais. I'm just going to toss out some mental illness things/topics/wonderings I've had lately. Maybe you want to expand on some or include within upcoming posts?
- pressured speech in mania as both a source of incredibly beautiful descriptive stories but also as confusing and annoying with repetition for those around and a painful disruption in functioning for the person
- the processing in ED and assessments and holds for beds prior to entering a psych unit introducing "new" trauma to recover from before even addressing what's brought patient into hospital
- for women, menopause leading to calming of things like bipolar and BPD symptoms and how older women still have the neuroplasticity to better accept diagnoses and benefit from treatment, and have greater wisdom in seeking out competent clinicians
- how psychiatric teams inpatient work, who composes them, their effectiveness when they also include outpatient clinicians (for both psychological and physical issues) that patients already see
If you're guessing that these may all be recent in my own life, then you'd be right.
I’m generally drawn to surrealist paintings, so there’s that. I like the color scheme, the juxtaposition and contrast of a floating rock and cloud. The appeal is at a very intuitive level. I can say more but I’d probably just be making up reasons 😊
I'd love to hear about your personal process for staying up to date on the field: how you stay exposed to new research/ideas, and how you decide what to read or engage with.
Thanks Eric! I rely on a mix of controlled and chaotic strategies. The chaotic part is mostly seeing what is being shared and discussed by colleagues from different disciplines on places like X, substack, and LinkedIn. I also follow updates from American Psychiatric Association, Psychiatric Times, Medscape, etc, and I browse some journals every once in a while to see what they are publishing. Engagement depends on what piques my interest.
Thank you so much for providing a sane, measured perspective on the cloudy world of psychiatry. I much appreciate your essays and many of the guest posts as well.
I'm writing to plant a seed for maybe a year down the line. Over the past 30 years I've been independently developing an approach to more precise and rigorous phenomenological investigation that has yielded what I believe will turn out to be important discoveries about the nature, structure, and dynamics of actual subjective experience. Currently, I'm crafting a two-volume book about this work and posting draft chapters on my 'stack, Frontiers of Psychotopology. At the moment, it's in its early stages, just laying the foundations including the fieldwork practice that's the primary method of observation.
Anyway, consider this an invitation to check it out, possibly subscribe to stay on top of it as it rolls out, and hopefully connect at some point in the future when it makes sense.
Wishing you continued success and fulfillment with Psychiatry at the Margins as well as your other projects!
Well this is silly but my question is, did you know that Paul Simon wrote a song titled "Rene And Georgette Magritte With Their Dog After The War" which is named after another painting by the same Rene Magritte credited for the painting at the top of this thread?
Maybe I’ve missed something (I haven’t read all your posts) but it seems like you never write about (structural) dissociation. That is, dissociative amnesia, dissociative identity disorder, OSDD. Without a knowledge of dissociation, our understanding of psychology is impoverished, even deluded. Do you, like so many others, not believe in it? Or do you, like so many others, think it is rare? It isn’t rare. It is more common than schizophrenia or bipolar. Could you write a post on structural dissociation? If you don’t believe in it or believe it’s too rare to bother with, could you give your reasoning?
Zida, you are absolutely right that I have neglected this topic. Dissociation is common indeed and I frequently encounter dissociative symptoms in my clinical practice. There are many interesting debates around dissociation as well that somehow I haven't really researched in detail. Time to address this shortcoming!
That's wonderful! I look forward to reading your thoughts.
Congratulations on the two year anniversary. Your reflections have helped me to think deeply about a range of issues.
I would love to read your thoughts on navigating the gap between ‘best practice’ and ‘good enough’ care in mental health. I find this is both a clinical and philosophical challenge, and one that my training (psychologist) has not equipped me well for.
I am eager for discussions on how to I improve my treatment decision making skills to assist the person in distress who is sitting in front of me right, as opposed to hypothetical client being treated in abundant and limitless settings. To know how to select from the tools I have at hand and avoid get sucked into circular discussions of ‘if only we had xyz!’.
Many thanks,
Emily
Thanks Emily! This is a really important question, one I struggle with on a daily basis. The response depends on the nature of the shortcoming, but one general thing I try to do is to remain mindful of the ways in which actual care is falling short of the ideal, and convey them to the patient as appropriate. I find that a lot of clinicians simply cannot practice with this kind of awareness and they end up rationalizing the status quo. I’ll see if I can post a more detailed discussion on navigating the gap that you are pointing out.
[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.
Hi, Awais. I'm just going to toss out some mental illness things/topics/wonderings I've had lately. Maybe you want to expand on some or include within upcoming posts?
- pressured speech in mania as both a source of incredibly beautiful descriptive stories but also as confusing and annoying with repetition for those around and a painful disruption in functioning for the person
- the processing in ED and assessments and holds for beds prior to entering a psych unit introducing "new" trauma to recover from before even addressing what's brought patient into hospital
- for women, menopause leading to calming of things like bipolar and BPD symptoms and how older women still have the neuroplasticity to better accept diagnoses and benefit from treatment, and have greater wisdom in seeking out competent clinicians
- how psychiatric teams inpatient work, who composes them, their effectiveness when they also include outpatient clinicians (for both psychological and physical issues) that patients already see
If you're guessing that these may all be recent in my own life, then you'd be right.
What attracts you to the Magritte painting? What thoughts does it bring forth for you?
I’m generally drawn to surrealist paintings, so there’s that. I like the color scheme, the juxtaposition and contrast of a floating rock and cloud. The appeal is at a very intuitive level. I can say more but I’d probably just be making up reasons 😊
I'd love to hear about your personal process for staying up to date on the field: how you stay exposed to new research/ideas, and how you decide what to read or engage with.
thanks
Thanks Eric! I rely on a mix of controlled and chaotic strategies. The chaotic part is mostly seeing what is being shared and discussed by colleagues from different disciplines on places like X, substack, and LinkedIn. I also follow updates from American Psychiatric Association, Psychiatric Times, Medscape, etc, and I browse some journals every once in a while to see what they are publishing. Engagement depends on what piques my interest.
Thank you so much for providing a sane, measured perspective on the cloudy world of psychiatry. I much appreciate your essays and many of the guest posts as well.
I'm writing to plant a seed for maybe a year down the line. Over the past 30 years I've been independently developing an approach to more precise and rigorous phenomenological investigation that has yielded what I believe will turn out to be important discoveries about the nature, structure, and dynamics of actual subjective experience. Currently, I'm crafting a two-volume book about this work and posting draft chapters on my 'stack, Frontiers of Psychotopology. At the moment, it's in its early stages, just laying the foundations including the fieldwork practice that's the primary method of observation.
Anyway, consider this an invitation to check it out, possibly subscribe to stay on top of it as it rolls out, and hopefully connect at some point in the future when it makes sense.
Wishing you continued success and fulfillment with Psychiatry at the Margins as well as your other projects!
Thanks Joe. This sounds like a fascinating project. I just subscribed and hope to dig more into your work. Best.
Well this is silly but my question is, did you know that Paul Simon wrote a song titled "Rene And Georgette Magritte With Their Dog After The War" which is named after another painting by the same Rene Magritte credited for the painting at the top of this thread?
I had no idea! I just looked up the song. So fascinating. I'm a big fan of Magritte's paintings.
Actually, I guess it was a caption for a photograph: https://fb.watch/wb1JieHtOh/