The crazy thing about that guy that’s like “I think they’re just fragile“ is that… Even if that’s the case, then the person *is* that fragile and you still need to have some ideas how to help them navigate the world
I don’t know how you feel about the Maria Bamford routine about how we treat physical illness differently than mental illness (“I don’t wear glasses! I don’t believe in that western medicine shit! You’ve gotta *want* to see!”/“[sob] You’d think you could’ve stopped vomiting for me and the kids!”) but I think it’s often helpful, and it certainly would apply in a case like this. If a kid’s immune system just sucks really bad, we don’t say “lol yeah your immune system just sucks,“ we build them a plastic bubble or whatever.
There were a lot of years where I thought that the reason that I constantly felt as though I couldn’t breathe was because of some character problem that I needed to fix. There were definitely times when I tried out the theory that I was just too much of a wuss to live. But you still have to figure out how to live! And people whose job it is to help you with that still have to help you with that!
1) the immune system and the psyche are good analogies for one another bc they are both pretty amorphous concepts that are both objects of medicine AND folk medicine/holistic medicine/wackjobbery.
2) there is a relevant metaphor some clinicians use when talking about borderline. some say that borderline is a developmentally-based lack of emotional "skin". skin, of course, is a significant organ in the immune system.
3) if a kid's immune system sucks, there is a vast array of interventions available to immunologists. ditto psyche (or maybe emotional resiliency/regulation is actually the thing we are talking about specifically here).
4) the question of agency/personal responsibility with regard to psychic pain is actually a really salient question that I think about a lot. check this out tho. if you know anyone with really bad immune problems, especially autoimmune, then you may know that that patient group is also tasked with wrestling with questions of agency/personal responsibility. managing an immune condition is absolutely not as straightforward as living in a bubble almost ever. it has a lot to do with diet and lifestyle actually. ditto psychic pain.
5) i'm sure bamford's sketch is funny and i'm sure it has a message a lot of people need to hear. but i absolutely don't think medical patients should uncritically accept standard interventions just because they are standard. ditto psych interventions.
you have to figure out how to live indeed. knowing that you have bad shit in your past that has a bearing on your present is not on its own a “trauma excuse”. insanity to me personally, but Greenwald’s views are actually very mainstream hospital psych views. i wonder if those particular views help people figure out how to live. my guess is no. but a hospital psych’s job isn’t so much “helping you figure out how to live”, it’s more like “helping you calm down” and “helping you understand what’s wrong with you”, so that you can then go on to figure out how to live, ostensibly. which I’m sure is like a worthwhile goal or whatever, but DAMN I wish hospital psychs would get more self aware about their contempt for their patients
It’s meaningful, I think, that the borderline construct has served a dual role from the very beginning. a) used to tag the “difficult” “frustrating” patients, that seem to resist “treatment” that is available or being offered, b) used to characterize a particular symptom cluster encompassing mood instability, insecurity, self-destructive behaviors, etc, that may or may not present in a particularly antagonistic manner.
It's very interesting. I've been down this road and found nothing but frustration. There’s a real problem with the timing of onset, course of illness, and gendered differences—all of which throw a real spanner in the works of the C-PTSD hypothesis. C-PTSD sounds like a nice idea—morally, that is— and it looks really good statistically but it’s got problems. The theory is that long-term exposure to elevated levels of stress hormones during development leads to long-term changes in gene expression. It sounds great, but if that were true, it would have clear implications about the timing of trauma and the onset of illness. Unfortunately once you get beyond the headline stats, in individual cases there are often real temporal problems with when the trauma occurred and the onset of symptoms.
Borderline has a similar issue with onset, course, family history, and treatment response. The fact that cases with the same symptoms—symptomatically near-perfect phenotypes—can go into spontaneous remission and then relapse, or others vanish entirely with age, or still others stay constant throughout life, suggests these symptoms must be transdiagnostic. So Martin is quite right. That 80–90% of cases involve trauma sounds compelling, but it could just as easily be a red herring. The remaining group is by no means small—two out of ten people don't have the “right” case history.
Think of it this way: 80–90% of sore throats and runny noses are caused by the two most common respiratory infections—the common cold and influenza. That doesn’t mean sore throats and runny noses are pathognomonic of the cold or flu. Probability says it's likely one of those, but the symptoms themselves are just generic immune responses. The other big problem is the course. You can’t have a disease that vanishes in some people, recurs in others, and stays constant in yet others. There’s something wrong there. Again, it implies the symptoms are common and generic, not pathognomonic, and very much transdiagnostic.
The real place to look, historically, is back before psychoanalysis took off in the United States. Instead of searching for the first descriptions of "borderline" as a cohesive diagnosis, look at where these symptoms showed up earlier. Read Kraepelin and Wernicke and see what they made of this symptom profile. Kraepelin’s small section on “Amentia” is not to be overlooked. It’s also worth reading up on hysteria, neurasthenia, and "larval epilepsy." Of course, those ideas reflected the scientific thinking of their time, but you get the sense that people like Kraepelin and Fahlret were genuinely grappling with the same issue. Kraepelin seemed to recognize that the symptoms themselves were nothing more than symptoms common to any woman under enough stress. He surmised that some cases were hysterical and others decidedly organic. There were some borderline patients who recovered as outpatients under placebo. Others required hospitalization—and it’s quite clear the latter cases were the ones that interested Kraepelin. Again, you can see the brilliance in focusing on course of illness over symptoms. If you’ve had a sore throat for two and a half years—news flash—it ain’t the flu.
The most interesting thing of all though is the striking similarity in symptom profiles shared by severe BPD and some of the post partum cases recorded in the history books. Essentially what you have is post partum BPD, but its worse. These women self harm, they make suicide attempts in front of other, they're dissociative feelings are so strong its a psychosis. They're violent and irritable, and they weep and then they laugh. They vanish too from the history books around about the time drugs come into childbirth. Read their cases and tell me they don't sound familiar to a borderline lense. This extra data is likely the reason Kraepelin reached his conclusion about Amentia being part of MDI. When you have a post partum onset, you kind of have to admit that its organic.
And so still today, there’s something horribly wrong with BPD. The most confounding thing is that it looked like the problem was the diagnosis itself: that the symptoms were transdiagnostic—right up until the data on self-harm and sexual abuse came along. That was the moment real confusion set in. It just doesn’t make sense. Something doesn’t add up.
The situation is like this: suppose I made up a disease, more or less out of whole cloth—maybe based a bit on some people I disliked—and let’s say I called it “Flying Spaghetti Disorder.” People sort of knew it was a bit of nonsense, a bit of humbug, but maybe it was handy for a difficult case you didn’t want to slap with a label that would trigger a treatment order. So people went along with it. Then one day, someone announces that people with Flying Spaghetti Disorder have a self-harm rate of 87%, and 92% of them were never taught how to ride a bicycle. It sounds compelling—except, privately, you know Flying Spaghetti Disorder is essentially made up. So how can a made-up disease turn out to have such strong statistics associated with it?
It’s a hell of a problem. And what the hell is with all the POTS? Something is rotten in the state of Denmark.
My mother and wife have serious psychiatric conditions. I wasn't satisfied by the answers I was given so I became determined to get the bottom of it myself.
I've been replying to your essays because I find them relatable. Also I write to commit the information to memory and practice my writing for the GAMSAT.
Awesome! I mean not awesome to have so many serious psychiatric conditions around, but awesome that you are kicking the tires this way. You sure know a lot. Psychiatry as such isn’t really my bag, so I always learn something from your comments.
The crazy thing about that guy that’s like “I think they’re just fragile“ is that… Even if that’s the case, then the person *is* that fragile and you still need to have some ideas how to help them navigate the world
I don’t know how you feel about the Maria Bamford routine about how we treat physical illness differently than mental illness (“I don’t wear glasses! I don’t believe in that western medicine shit! You’ve gotta *want* to see!”/“[sob] You’d think you could’ve stopped vomiting for me and the kids!”) but I think it’s often helpful, and it certainly would apply in a case like this. If a kid’s immune system just sucks really bad, we don’t say “lol yeah your immune system just sucks,“ we build them a plastic bubble or whatever.
There were a lot of years where I thought that the reason that I constantly felt as though I couldn’t breathe was because of some character problem that I needed to fix. There were definitely times when I tried out the theory that I was just too much of a wuss to live. But you still have to figure out how to live! And people whose job it is to help you with that still have to help you with that!
ok last comment (probably):
1) the immune system and the psyche are good analogies for one another bc they are both pretty amorphous concepts that are both objects of medicine AND folk medicine/holistic medicine/wackjobbery.
2) there is a relevant metaphor some clinicians use when talking about borderline. some say that borderline is a developmentally-based lack of emotional "skin". skin, of course, is a significant organ in the immune system.
3) if a kid's immune system sucks, there is a vast array of interventions available to immunologists. ditto psyche (or maybe emotional resiliency/regulation is actually the thing we are talking about specifically here).
4) the question of agency/personal responsibility with regard to psychic pain is actually a really salient question that I think about a lot. check this out tho. if you know anyone with really bad immune problems, especially autoimmune, then you may know that that patient group is also tasked with wrestling with questions of agency/personal responsibility. managing an immune condition is absolutely not as straightforward as living in a bubble almost ever. it has a lot to do with diet and lifestyle actually. ditto psychic pain.
5) i'm sure bamford's sketch is funny and i'm sure it has a message a lot of people need to hear. but i absolutely don't think medical patients should uncritically accept standard interventions just because they are standard. ditto psych interventions.
like. fragility meaning what exactly? like, susceptible to psychopathology? the thing it’s your job to deal with, Martin?
you have to figure out how to live indeed. knowing that you have bad shit in your past that has a bearing on your present is not on its own a “trauma excuse”. insanity to me personally, but Greenwald’s views are actually very mainstream hospital psych views. i wonder if those particular views help people figure out how to live. my guess is no. but a hospital psych’s job isn’t so much “helping you figure out how to live”, it’s more like “helping you calm down” and “helping you understand what’s wrong with you”, so that you can then go on to figure out how to live, ostensibly. which I’m sure is like a worthwhile goal or whatever, but DAMN I wish hospital psychs would get more self aware about their contempt for their patients
Hah! Nicely done!
It’s meaningful, I think, that the borderline construct has served a dual role from the very beginning. a) used to tag the “difficult” “frustrating” patients, that seem to resist “treatment” that is available or being offered, b) used to characterize a particular symptom cluster encompassing mood instability, insecurity, self-destructive behaviors, etc, that may or may not present in a particularly antagonistic manner.
Btw, have you seen this post: https://www.psychiatrymargins.com/p/either-all-psychopathology-is-personality
Thank you! I certainly have seen that post and I delight in it. Still haven’t done my own fonagy deep dive but it’s coming.
It's very interesting. I've been down this road and found nothing but frustration. There’s a real problem with the timing of onset, course of illness, and gendered differences—all of which throw a real spanner in the works of the C-PTSD hypothesis. C-PTSD sounds like a nice idea—morally, that is— and it looks really good statistically but it’s got problems. The theory is that long-term exposure to elevated levels of stress hormones during development leads to long-term changes in gene expression. It sounds great, but if that were true, it would have clear implications about the timing of trauma and the onset of illness. Unfortunately once you get beyond the headline stats, in individual cases there are often real temporal problems with when the trauma occurred and the onset of symptoms.
Borderline has a similar issue with onset, course, family history, and treatment response. The fact that cases with the same symptoms—symptomatically near-perfect phenotypes—can go into spontaneous remission and then relapse, or others vanish entirely with age, or still others stay constant throughout life, suggests these symptoms must be transdiagnostic. So Martin is quite right. That 80–90% of cases involve trauma sounds compelling, but it could just as easily be a red herring. The remaining group is by no means small—two out of ten people don't have the “right” case history.
Think of it this way: 80–90% of sore throats and runny noses are caused by the two most common respiratory infections—the common cold and influenza. That doesn’t mean sore throats and runny noses are pathognomonic of the cold or flu. Probability says it's likely one of those, but the symptoms themselves are just generic immune responses. The other big problem is the course. You can’t have a disease that vanishes in some people, recurs in others, and stays constant in yet others. There’s something wrong there. Again, it implies the symptoms are common and generic, not pathognomonic, and very much transdiagnostic.
The real place to look, historically, is back before psychoanalysis took off in the United States. Instead of searching for the first descriptions of "borderline" as a cohesive diagnosis, look at where these symptoms showed up earlier. Read Kraepelin and Wernicke and see what they made of this symptom profile. Kraepelin’s small section on “Amentia” is not to be overlooked. It’s also worth reading up on hysteria, neurasthenia, and "larval epilepsy." Of course, those ideas reflected the scientific thinking of their time, but you get the sense that people like Kraepelin and Fahlret were genuinely grappling with the same issue. Kraepelin seemed to recognize that the symptoms themselves were nothing more than symptoms common to any woman under enough stress. He surmised that some cases were hysterical and others decidedly organic. There were some borderline patients who recovered as outpatients under placebo. Others required hospitalization—and it’s quite clear the latter cases were the ones that interested Kraepelin. Again, you can see the brilliance in focusing on course of illness over symptoms. If you’ve had a sore throat for two and a half years—news flash—it ain’t the flu.
The most interesting thing of all though is the striking similarity in symptom profiles shared by severe BPD and some of the post partum cases recorded in the history books. Essentially what you have is post partum BPD, but its worse. These women self harm, they make suicide attempts in front of other, they're dissociative feelings are so strong its a psychosis. They're violent and irritable, and they weep and then they laugh. They vanish too from the history books around about the time drugs come into childbirth. Read their cases and tell me they don't sound familiar to a borderline lense. This extra data is likely the reason Kraepelin reached his conclusion about Amentia being part of MDI. When you have a post partum onset, you kind of have to admit that its organic.
And so still today, there’s something horribly wrong with BPD. The most confounding thing is that it looked like the problem was the diagnosis itself: that the symptoms were transdiagnostic—right up until the data on self-harm and sexual abuse came along. That was the moment real confusion set in. It just doesn’t make sense. Something doesn’t add up.
The situation is like this: suppose I made up a disease, more or less out of whole cloth—maybe based a bit on some people I disliked—and let’s say I called it “Flying Spaghetti Disorder.” People sort of knew it was a bit of nonsense, a bit of humbug, but maybe it was handy for a difficult case you didn’t want to slap with a label that would trigger a treatment order. So people went along with it. Then one day, someone announces that people with Flying Spaghetti Disorder have a self-harm rate of 87%, and 92% of them were never taught how to ride a bicycle. It sounds compelling—except, privately, you know Flying Spaghetti Disorder is essentially made up. So how can a made-up disease turn out to have such strong statistics associated with it?
It’s a hell of a problem. And what the hell is with all the POTS? Something is rotten in the state of Denmark.
also yea the kraepelin section is coming
who are you lol
not like “stop replying” but like “what is your interest in this matter and why do you keep replying to my posts this way”
My mother and wife have serious psychiatric conditions. I wasn't satisfied by the answers I was given so I became determined to get the bottom of it myself.
I've been replying to your essays because I find them relatable. Also I write to commit the information to memory and practice my writing for the GAMSAT.
Awesome! I mean not awesome to have so many serious psychiatric conditions around, but awesome that you are kicking the tires this way. You sure know a lot. Psychiatry as such isn’t really my bag, so I always learn something from your comments.
I know nothing. The best information comes from talking to people. I have book knowledge but not clinical experience.