In his majestic and memorable essay “Over the Borderline” (The Lamp, July 31, 2026) — a long and insightful profile of Laura Delano — Emmett Rensin (excellent writer, please devote some attention to his growing oeuvre, if you aren’t already following him) says at one point that borderline personality is a disorder that he doesn’t believe “properly exists.” He doesn’t quite elaborate on what that means, and the one example he discusses in some detail—his skepticism about splitting—isn’t particularly compelling.
But before I go into that discussion of splitting, I’ll outline a range of possible things someone who disputes the existence of BPD could mean.
The cluster of clinical features we call BPD doesn’t actually exist as a coherent, clinically recognizable cluster.
The cluster of clinical features we call BPD is clinically recognizable but it is psychometrically and/or etiologically heterogeneous. It is not a proper taxon, a category, a discrete entity, a natural kind, etc, etc.
The cluster of clinical features exists but it is a mistake to conceptualize it as a disorder of personality. These features are better conceptualized as some other sort of disorder, e.g. a trauma related disorder or a relational disorder.
The cluster of clinical features exists but these features are not disordered or pathological. They are “understandable,” even “adaptive” responses to life challenges.
The condition may exist but the diagnosis is too easily abused and misapplied, it is not reliable, it is too imperfect and harmful for clinical use, and cannot be trusted.
I believe: 1 is false; 2 is true, but true for most DSM disorders, nothing unusual; I am sympathetic to 3, although I’d like to think we can still meaningfully speak of BPD being a disorder of personality; 4 is true in a circumscribed sense (these features may once have been adaptive in a certain developmental context), but false generally and based on a misunderstanding of what “disorder” and “psychopathology” mean; and 5 is true in some situations.
Rensin says of “splitting”:
“Splitting is generally understood as a relational failure, its instability the anti-social characteristic that raises it to the level of pathology. But it may also be understood as a desperate, if unstable, search for a coherent story: of who you are, of what the world is, of how to make sense of those phenomena of human life that are inexplicable and painful. It is not so unusual to want that: to feel certain of what is going on, at least for a while, to find a story and stick to it, to feel its stabilizing influence and the control that comes with it. This does not strike me as pathological, or even unusual. It is the premise of sour grapes. It is work undertaken in the aftermath of every breakup, as the ego detaches from what was once irreplicable and precious. It is politics: “polarization” and “epistemic bubbles,”…”
“You have been told for your whole life that there are experts who know what this is and what to do, a story about disease and how to treat it. Imagine that she only gets worse. You are so terribly afraid. What is there to do but find another story, another theory of what is happening, another guide, another guru, and pray that this one proves correct, to think, This better work, because otherwise there is nothing left?”
Ok, but that is not what splitting is. The search for a coherent story is indeed not unusual, and there is indeed nothing pathological as such about switching to a different story or theory once a previous one has been disappointing, but these are not examples of splitting. It is like saying “Delusions can’t be pathological; don’t we all hold on to false or irrational ideas despite evidence against them? Silicon Valley founders seem delusionally optimistic. Isn’t it human to believe in prophets of God, anti-vaccine propaganda, trickle-down economics…?” But anyone saying so reveals their own lack of understanding of the difference between an ordinary, irrational, entrenched belief and a delusional belief, even though the difference between them may be a matter of degree. 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.
The Psychodynamic Diagnostic Manual (PDM-3) describes splitting this way:
““Splitting” refers to compartmentalization (dissociation) of positive and negative perceptions and feelings, with the result that the person views self and others in black and white, either–or, and idealized or devalued categories (e.g., heroes and rescuers, villains and abusers, coldly indifferent enablers of abuse)… Splitting is linked to identity diffusion, or the inability to integrate disparate aspects of identity (self-representations) into a coherent whole, or “stand in the spaces” between different self-states, especially under stress.” (p 658)
DSM doesn’t use the term “splitting” in criteria for BPD, but it describes a very similar phenomenon in a straightforward way:
“A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation”
And like the PDM bringing up identity diffusion, the very next criterion in the DSM is identity disturbance: markedly and persistently unstable self-image or sense of self.
Whatever we may think of break-ups, or political polarization, or people souring on psychiatry, these are not cases of splitting in the clinical sense of the word.
Now someone who already has an unstable sense of self and is prone to alternating between extremes of idealization and devaluation may very well display that in the context of their relationship with the psychiatric worldview, but a phenomenon like souring on psychiatry is over-determined as hell. On its own, it’s neither splitting nor evidence of borderline dynamics, but in someone with bona fide borderline dynamics, it also isn’t out of character.
The issue of borderline personality disorder is a sore point for Delano. Rensin writes in the profile:
“She knows that there are people out there—not in this room, but out there—who have read her book and “decided for me that actually I am borderline, no matter what I say.” They know who they are. “I still have plenty of darkness,” she admits. “I cry all the time. I have intense urges of anger. I’m a very angsty person. I would definitely qualify for various diagnoses”—that is, if she “gave a shit about that. And I don’t.””
It is Delano’s right to not give a shit about it and to understand herself using whatever story makes the most sense to her. But others aren’t obliged to abide by her self-assessment as they make sense of her story. And her story, a story that launched a thousand podcasts, has been thrust on us to make sense of, whether we want it or not.
I don’t know what diagnostic criteria, if any, Delano would meet now, and I don’t think it is appropriate to focus on that. It is not our business. From what we are told, she is not an active psychiatric patient, and in the absence of a clinical examination and given her own explicit preferences, no one should diagnose her in the current state. It would not only be epistemically futile, it would be actively disrespectful. But the Delano of the past, the Delano of the memoir years, the psychiatrized Delano, that version of Delano is now no longer the private story of an individual; it has become the backbone of a national movement seeking to reshape mental healthcare in its own image. And much can be said about this historical Delano.
A common response of psychiatrists to reading Delano’s memoir, including mine, has been that her childhood diagnosis of bipolar disorder doesn’t appear to be accurate. Delano is a likely victim of the pediatric bipolar disorder fad. The condition we call borderline personality disorder — you can use whatever name you prefer (emotionally turbulent self-interpersonal relational style?) — appears to be a far better fit.
Here is, for example, the psychiatrist Sally Satel in her review of Delano’s book Unshrunk:
“For many years, Laura Delano was vulnerable and suffering. She was drawn, as many are, to the exonerating power of a diagnosis. She could then blame her brain, in addition to her parents, her school, and, later, the psychiatric establishment. But perhaps the crowning irony is that psychiatry can explain a lot.
Recall Delano’s first year at Harvard, when she rejected borderline personality disorder? The fact is, seen from afar and based solely on her own account, the designation appears to have fit her. For one thing, borderline personality disorder is a condition for which meds are not especially helpful—but where alcohol, cocaine, and other street drugs tend to be, at least in the short term. Second, it is typical for borderlines to receive many diagnoses over the course of their lives. Third, the personality disorder tends to remit over time, in the sense that patients no longer meet the diagnosis but often retain scattered symptoms, or what psychiatry might call symptoms, such as the ones Delano says she still has.”
We have to distinguish between two senses in which a person could reject the diagnosis of borderline personality disorder:
They could say that they have been misdiagnosed, i.e., they don’t actually meet the official diagnostic criteria for BPD, and if a proper assessment were conducted adhering to actual criteria, the diagnosis would not be supported.
They could say that they do indeed meet criteria for the condition but they don’t find it meaningful or accurate or helpful to see their life and their problems through a medical diagnostic lens.
Delano herself leans towards the second interpretation. These are her own words from Unshrunk:
“I was once mentally ill, and now I’m not, and it wasn’t because I was misdiagnosed… In fact, I was properly diagnosed and medicated according to the American Psychiatric Association’s standard of care.” (p xiv)
[While Delano focuses on the diagnosis of bipolar disorder, as she discloses in the book, she was also formally diagnosed with borderline personality disorder and received formal treatment for it.]
That means we can’t ignore and discount the presence of the relevant features, however we frame them.
Let me give an example. Let’s say a person was diagnosed with schizophrenia and was treated as if they had schizophrenia and had a terrible experience with treatment. And then their clinical presentation and history were reassessed and it was determined that schizophrenia was never actually an accurate diagnosis for them and that they more accurately met criteria for autism and substance-induced psychosis. Now imagine that this person says, “Well, I don’t believe in autism. I don’t like to use medical labels to understand my life.” Fair enough, they can think of themselves however they prefer, but for everyone else, there is a huge difference between the features we refer to by schizophrenia and the features we refer to by autism. What is applicable to schizophrenia is not necessarily applicable to autism, and vice versa. Now imagine that this person wrote a memoir, “I was diagnosed with schizophrenia, and I only got worse with treatment, and I found liberation once I rejected the corrupt and unscientific psychiatric enterprise.” 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. A person may reject the medical gaze but that wouldn’t change the fact that they have impairments in social communications and restricted or rigid patterns of behavior. The problem is not about the right to self-conceptualization. The problem is about the accuracy of diagnostic interpretations and the generalizations being offered on the basis of that.
Here’s the basic problem for Delano. Delano has made her story the face of a movement around deprescribing, iatrogenic harm, and, more recently, MAHA. She has told her story to whoever would listen, whether that is the New York Times or Tucker Carlson or RFK Jr. or psychiatrists in positions of power and leadership. She has testified in front of the US House Committee on Oversight and Government Reform. Her story has been used as the poster for the MAHA agenda to tackle overmedicalization. So whether we like it or not, her story is one of great public interest and relevance and, therefore, invites public scrutiny. And yet, Delano also wants to believe, “I am literally just sharing my own story.” (quote from the Rensin interview)
Rensin describes his own bafflement quite well:
“In the months between the conference and the day that we finally meet, I had prepared myself for several possibilities with Laura. I had been prepared for the firm radical, a child of the movement more willing to adopt the opposition posture of anti-psychiatry with me than she had been on mainstream television. I had been prepared for a cynical Laura… I had not expected this utterly sincere belief—and I can only assure you that it was sincere, firm, plaintive, almost wounded—entirely contained within itself, that Laura believes, more than anything, in “pluralism,” in information, that she is, as she says, a “libertarian” about these things, someone who knows plenty of people on psychiatric medication and accepts that people indulge in “risky” actions all the time to cope with the pain of human life, who has ever only told her own story, and who is baffled—there was no other word that occurred to me over the four hours that we sat together but baffled—by the insistence of so many people, both fans and critics, followers and enemies, that her words, spoken in her book, or from her conference podium, or on television, or podcasts, or radio, over and over, containing phrases like “instruments of behavioral control” and “faith-based ideology” in reference to the D.S.M., or calling for a revolution in West Hartford—that all of this could not be understood to come with the disclaimer this is not intended as advice just because she said so. Who, maddeningly, is perfectly willing to express any number of views and advance any number of claims about science, medicine, and society from which the implied vision for others naturally follows.”
Either Delano’s story is the private story of an individual where she gets to decide what interpretation makes the most sense and its applicability to anyone else is uncertain and undetermined, or Delano’s story is one with generalizable lessons for people in psychiatric care, including people with serious mental illnesses, and it is the story on the backs of which an entire movement around psychiatric skepticism and countering medical overreach has been built, in which case it is not only open to but deserving of public and professional scrutiny, including how to best make sense of Delano’s diagnoses, whether she prefers to think of herself in those terms or not.
See also:
My review of Unshrunk: A Memoir For the Iatrogenic Age
Jesse Meadows’s review of Unshrunk: Unshrunk and MAHA: A Diagnosis-Critical Case Study
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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.
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.