After reading and re-reading the essay, I wanted to highlight three quotes that didn't really sit well with me. Please note this is in the spirit of clarification because I don't think we have strong disagreements here! Here's the three quotes and my comments below:
1. "I am sympathetic to 3, although I’d like to think we can still meaningfully speak of BPD being a disorder of personality".
I have spent a number of years obsessively and extensively studying the literature on “personality pathology”, and I have found no evidence (to date) suggesting that there is a coherent definition of a “disorder of personality”. I am always open to such evidence in case it arises, so I look forward to hearing your thoughts on how we could meaningfully speak of BPD (or any other psychopathology) as being a “disorder of personality”.
2. On your point about splitting: "Splitting is a defense, and in its simplest version, it is employed by almost all of us in some manner, but what makes it pathological is the degree."
I agree that this is the “medical-psychiatric” definition of splitting. But that does not mean that this definition is correct, scientifically speaking. Indeed, my collaborators at UCL are perhaps the only people on the planet who have thoughtfully theorised about splitting – to the point where they formalised the concept mathematically in order to understand it! And, when they tested the concept empirically (see here: https://psycnet.apa.org/fulltext/2024-00165-001.html), they found no evidence that it operates as a defense. And, of course, this is absence of evidence (not clear evidence of absence), and we are continuing to test this… But my overall point here is precisely this: there is no convincing evidence for the current definition of splitting: at best, our evidence suggests that some people are more likely to make extreme evaluations of self and others in particularly stressful relational contexts, but there is no evidence that they do so defensively or that their doing so has anything to do with their “personality” (however “personality” is defined).
That being said, then, I think that what Emmett and others who criticise ideas like “splitting” might have in mind here is precisely the lack of evidence around this concept: the less the evidence, the more “allowed” (and “obligated” in some sense) we feel to provide alternative definitions and theories on the matter. So, my view on this point is that we cannot use current definitions to shut down alternative theories (regardless of where those alternative theories come from, and regardless of how consistent they are with the status quo). Instead, in the absence of strong enough evidence, all theories are possibilities and all should thus be examined scientifically so that we can determine their explanatory merit.
3. "And when psychiatrists reading the memoir point out that the schizophrenia diagnosis didn’t really make much sense and autism seemed more applicable, and that also explains why they had this sort of negative experience with treatment, and the person replied, “How dare you decide for me that I am autistic? I don’t give a shit about your diagnostic labels,” it would be apparent to anyone paying attention that the point being made about the existence of relevant features doesn’t depend on whether we adopt a medical conceptualization of the issue."
Although well-argued, this inference does not really hold for Delano’s case as it “retroactively fits the data”. To give a statistical analogy: it’s like having a clinical prediction model that fails to predict a patient’s suicide and then adding variables post hoc that allow you to explain (after the fact!) why the suicide occurred. Such an explanation may generate a hypothesis, but it cannot itself constitute evidence that the added variables provided the (uniquely) correct explanation.
To establish such a unique explanation, you would either need a time machine (to make the proper counterfactual comparison); or (more realistically) you would have to find a similar enough story like Delano’s and use your alternative explanation to show that, for example, the BPD diagnosis does indeed account for the new historical trajectory better than another diagnosis. But since none of this has happened here (because all we are doing as of now is just talking about Delano’s case and overfitting her historical narrative), all of this theorising is necessarily speculative.
But, to clarify, I want to note that I am sympathetic to this form of theoretical speculation because it serves a political function: in the absence of decisive evidence, all we can really do is question dominant interpretations by generating alternative scenarios. But again: I want to emphasise that these are primarily speculations and they should be noted to be speculations, because otherwise we risk undermining the scientific status of psychiatry: If every failure of an existing explanation can be accounted for by retrospectively introducing a different diagnosis, then we are probably working too hard to make the data fit our explanations rather than genuinely testing and scrutinising our own explanations.
1. I may be wrong, I am still in the processing of making my thoughts coherent on this issue. More later. Basically I am trying to salvage personality disorder talk in the Kernberg-McWilliams tradition as meaningful in some modest way
2. Oh, I wasn't aware of this paper, have to dig into it! TBH, I hadn't given much thought to the status of splitting *as* a defense before.
3. The BPD diagnosis isn't entirely retroactive; she wasn't aware of it at the time but she was given that formal diagnosis as a young adult while she was a college student. And this diagnosis recurs repeatedly in her clinical history until she ends up in a BPD treatment program under Gunderson himself.
1. Looking forward to hearing your thoughts on this (though it is worth noting that Kernberg views them as "character disorders" which is different from "personality disorder" though in his later work he kind of conflates the two; McWilliams, I don't know much, but she also called them character disorders in her book "Psychoanalytic Diagnosis"). So, I may agree with the idea of character disorder but definitely not with the idea of personality disorder.
2. Do have a look — it's the predecessor of my generative model paper and it's awesome!
3. My bad here: for some reason, I thought we were retroactively imposing a diagnosis. If she was genuinely diagnosed, then you're right to extrapolate from that diagnosis. But it is still worth noting that it could have been a misdiagnosis, despite fitting her historical narrative better than other diagnoses!
I might contest some of the details here where they diverge from what I can see from my own vantage point. But this is a great adjunct to Emmett’s piece in The Lamp — which is indeed long, but is also very deliberately rendered and beautifully wrought, deserving of the time it takes to really read it through. Even if it depicts Yours Truly as even more of a buffoon than I have generally come to anticipate.
I cannot possibly be objective in my appraisals of these things. I would never suggest I’d even want to try. But FWIW, I think both here and in the Lamp piece there’s something being said more broadly about “personalities.” Public persons were once something that could be stage managed. The public generally assumed a high degree of artifice. Now we live in the age of the “influencer,” which is essentially just a personality with fewer places to hide.
Emmett and Awais have both treated Laura more or less fairly. Though I sense just as much befuddlement in them as they seem to detect in Laura. I think their befuddlement is just as authentic as the one they ascribe to her. But there’s a twinge of puzzling here that suggests she might have access to more certainty than she actually does — that she’s choosing to be coy, or willfully avoidant of the question of “what do you REALLY think?” I just don’t think we live anymore in a world where we can expect public figures, no matter what agendas or ideologies their personae end up serving, to actually know themselves as fully as the public might seek to assume.
Rensin's disbelief in BPD is unfortunately ironic as he confronts a classic behavioral pattern in Delano's sincere and most-strikingly "wounded" belief that she has done no wrong, nor led anyone to do anything, much less to go astray. People with (untreated) BPD do not do seriously wrong things, in their own minds, because avoiding shame is the essence of the disorder. In keeping with the same drive, they tend to also categorically disavow their ability to control events or influence other people for the worse. If Delano really does have BPD, it's not unlikely that she is evolving her interpretation of her own story on an as-needed basis without even realizing she's doing it. And it's unsurprising that medication would fail her where a very public validation of suffering and sacrifice has served her, at least for as long as it may last.
Satel's opening reason for the borderline reading is that medications do not help much while alcohol and cocaine do, at least briefly. That reasons backwards from treatment response to what the illness is, and response to treatment is not among the five phases Robins and Guze set out for diagnostic validity: clinical description, laboratory studies, delimitation from other disorders, follow-up study, family study. Her other two reasons are follow-up observations, and they stand.
Delano insists she was not misdiagnosed, that she was diagnosed and medicated by the standard of care. Psychiatry replies that she was misdiagnosed, for years, by clinicians working inside that standard. That is not a rebuttal of a deprescribing movement. It is a donation to one.
After reading and re-reading the essay, I wanted to highlight three quotes that didn't really sit well with me. Please note this is in the spirit of clarification because I don't think we have strong disagreements here! Here's the three quotes and my comments below:
1. "I am sympathetic to 3, although I’d like to think we can still meaningfully speak of BPD being a disorder of personality".
I have spent a number of years obsessively and extensively studying the literature on “personality pathology”, and I have found no evidence (to date) suggesting that there is a coherent definition of a “disorder of personality”. I am always open to such evidence in case it arises, so I look forward to hearing your thoughts on how we could meaningfully speak of BPD (or any other psychopathology) as being a “disorder of personality”.
2. On your point about splitting: "Splitting is a defense, and in its simplest version, it is employed by almost all of us in some manner, but what makes it pathological is the degree."
I agree that this is the “medical-psychiatric” definition of splitting. But that does not mean that this definition is correct, scientifically speaking. Indeed, my collaborators at UCL are perhaps the only people on the planet who have thoughtfully theorised about splitting – to the point where they formalised the concept mathematically in order to understand it! And, when they tested the concept empirically (see here: https://psycnet.apa.org/fulltext/2024-00165-001.html), they found no evidence that it operates as a defense. And, of course, this is absence of evidence (not clear evidence of absence), and we are continuing to test this… But my overall point here is precisely this: there is no convincing evidence for the current definition of splitting: at best, our evidence suggests that some people are more likely to make extreme evaluations of self and others in particularly stressful relational contexts, but there is no evidence that they do so defensively or that their doing so has anything to do with their “personality” (however “personality” is defined).
That being said, then, I think that what Emmett and others who criticise ideas like “splitting” might have in mind here is precisely the lack of evidence around this concept: the less the evidence, the more “allowed” (and “obligated” in some sense) we feel to provide alternative definitions and theories on the matter. So, my view on this point is that we cannot use current definitions to shut down alternative theories (regardless of where those alternative theories come from, and regardless of how consistent they are with the status quo). Instead, in the absence of strong enough evidence, all theories are possibilities and all should thus be examined scientifically so that we can determine their explanatory merit.
3. "And when psychiatrists reading the memoir point out that the schizophrenia diagnosis didn’t really make much sense and autism seemed more applicable, and that also explains why they had this sort of negative experience with treatment, and the person replied, “How dare you decide for me that I am autistic? I don’t give a shit about your diagnostic labels,” it would be apparent to anyone paying attention that the point being made about the existence of relevant features doesn’t depend on whether we adopt a medical conceptualization of the issue."
Although well-argued, this inference does not really hold for Delano’s case as it “retroactively fits the data”. To give a statistical analogy: it’s like having a clinical prediction model that fails to predict a patient’s suicide and then adding variables post hoc that allow you to explain (after the fact!) why the suicide occurred. Such an explanation may generate a hypothesis, but it cannot itself constitute evidence that the added variables provided the (uniquely) correct explanation.
To establish such a unique explanation, you would either need a time machine (to make the proper counterfactual comparison); or (more realistically) you would have to find a similar enough story like Delano’s and use your alternative explanation to show that, for example, the BPD diagnosis does indeed account for the new historical trajectory better than another diagnosis. But since none of this has happened here (because all we are doing as of now is just talking about Delano’s case and overfitting her historical narrative), all of this theorising is necessarily speculative.
But, to clarify, I want to note that I am sympathetic to this form of theoretical speculation because it serves a political function: in the absence of decisive evidence, all we can really do is question dominant interpretations by generating alternative scenarios. But again: I want to emphasise that these are primarily speculations and they should be noted to be speculations, because otherwise we risk undermining the scientific status of psychiatry: If every failure of an existing explanation can be accounted for by retrospectively introducing a different diagnosis, then we are probably working too hard to make the data fit our explanations rather than genuinely testing and scrutinising our own explanations.
1. I may be wrong, I am still in the processing of making my thoughts coherent on this issue. More later. Basically I am trying to salvage personality disorder talk in the Kernberg-McWilliams tradition as meaningful in some modest way
2. Oh, I wasn't aware of this paper, have to dig into it! TBH, I hadn't given much thought to the status of splitting *as* a defense before.
3. The BPD diagnosis isn't entirely retroactive; she wasn't aware of it at the time but she was given that formal diagnosis as a young adult while she was a college student. And this diagnosis recurs repeatedly in her clinical history until she ends up in a BPD treatment program under Gunderson himself.
Thanks for the thoughtful response, Awais!
1. Looking forward to hearing your thoughts on this (though it is worth noting that Kernberg views them as "character disorders" which is different from "personality disorder" though in his later work he kind of conflates the two; McWilliams, I don't know much, but she also called them character disorders in her book "Psychoanalytic Diagnosis"). So, I may agree with the idea of character disorder but definitely not with the idea of personality disorder.
2. Do have a look — it's the predecessor of my generative model paper and it's awesome!
3. My bad here: for some reason, I thought we were retroactively imposing a diagnosis. If she was genuinely diagnosed, then you're right to extrapolate from that diagnosis. But it is still worth noting that it could have been a misdiagnosis, despite fitting her historical narrative better than other diagnoses!
Thanks for the exchange!
Thank you for the link to this paper - looking forward to reading it!
Well done.
I might contest some of the details here where they diverge from what I can see from my own vantage point. But this is a great adjunct to Emmett’s piece in The Lamp — which is indeed long, but is also very deliberately rendered and beautifully wrought, deserving of the time it takes to really read it through. Even if it depicts Yours Truly as even more of a buffoon than I have generally come to anticipate.
I cannot possibly be objective in my appraisals of these things. I would never suggest I’d even want to try. But FWIW, I think both here and in the Lamp piece there’s something being said more broadly about “personalities.” Public persons were once something that could be stage managed. The public generally assumed a high degree of artifice. Now we live in the age of the “influencer,” which is essentially just a personality with fewer places to hide.
Emmett and Awais have both treated Laura more or less fairly. Though I sense just as much befuddlement in them as they seem to detect in Laura. I think their befuddlement is just as authentic as the one they ascribe to her. But there’s a twinge of puzzling here that suggests she might have access to more certainty than she actually does — that she’s choosing to be coy, or willfully avoidant of the question of “what do you REALLY think?” I just don’t think we live anymore in a world where we can expect public figures, no matter what agendas or ideologies their personae end up serving, to actually know themselves as fully as the public might seek to assume.
Rensin's disbelief in BPD is unfortunately ironic as he confronts a classic behavioral pattern in Delano's sincere and most-strikingly "wounded" belief that she has done no wrong, nor led anyone to do anything, much less to go astray. People with (untreated) BPD do not do seriously wrong things, in their own minds, because avoiding shame is the essence of the disorder. In keeping with the same drive, they tend to also categorically disavow their ability to control events or influence other people for the worse. If Delano really does have BPD, it's not unlikely that she is evolving her interpretation of her own story on an as-needed basis without even realizing she's doing it. And it's unsurprising that medication would fail her where a very public validation of suffering and sacrifice has served her, at least for as long as it may last.
Satel's opening reason for the borderline reading is that medications do not help much while alcohol and cocaine do, at least briefly. That reasons backwards from treatment response to what the illness is, and response to treatment is not among the five phases Robins and Guze set out for diagnostic validity: clinical description, laboratory studies, delimitation from other disorders, follow-up study, family study. Her other two reasons are follow-up observations, and they stand.
Delano insists she was not misdiagnosed, that she was diagnosed and medicated by the standard of care. Psychiatry replies that she was misdiagnosed, for years, by clinicians working inside that standard. That is not a rebuttal of a deprescribing movement. It is a donation to one.