Leaving Psychiatry. J. R. Ó’Braonáin. M.D.

with type II bipolar disorder as the appropriate diagnosis, or a diagnosis that exists at all as opposed to borderline personality disorder being the authentic diagnosis that “exists”. But let’s take things further, for we haven’t escaped the DSM and psychiatry just yet, as opposed to simply flipping pages. Let us speculate on what the core of borderline psychopathology might be, or type II bipolar disorder if we choose to check its boxes (the patient may also check the boxes for ADHD and dysthymia, or cyclothymia and a dozen other diagnoses very easily). Without elaboration, nor me being fixed on this speculation to follow as anything more than speculation through and through (which is to say not a fixedness to what we might call attachment theory, and explicitly I say not to devalue the role of what we might call “trauma”, for many of these patients have had horrible upbringings), let us imagine the core problem in borderline personality or emotional instability is something we might simply call unfinished business of childhood. The infant is most certainly and justifiably insecure. And as any parent well knows, the child can behave in a dramatic way to attract and sustain love, connection, reassurance and nurturance. Now let us imagine this insecurity scaled up to one in whom it can be said has reached the legal age of majority, i.e. an alleged adult. When faced with threats to perceived security, loss of love, a painful memory or a million other speculative “triggers”, there may be a drive to drama within the psyche. In the sense of which certain hot headed shallow males might act out their insecurities with bullying others, lusting after things they must steal to “own”, and wanting to acquire security by dominance, they might add to the suicidal ideation some intimidation and beating upon others. And like an infant, their capacity for authentic empathy may be fragmentary or absent. Ergo with the same basic fault, the same insecurity and immaturity, this young man may be diagnosed as having an antisocial personality disorder when what he really has is a borderline character. On the other hand the young woman who usually introjects (that is inwardly directs and quasi identifies with) her insecurity is taken to acts of self cutting and self loathing, relational manipulations and marshalling around her others anxious to help and anxious to save, these others made all the more anxious by her distress (curiously often the two sit in inverse proportion to one another over the course of the psychotherapeutic transaction, as if to imply a transfer of neurosis from patient to the therapist or parent. The unsaid exchange is “when I have given you my problem, it is no longer my own”). We tacitly ignore the fact that she may have harassed and repeatedly texted the love interest, and stated to the clinician that if he/she does not save her from herself the suicidal blood would be on the psychiatrists hands. Can this be thought of as anything other than antisocial behaviour of a kind? The reader should see where I am heading, towards the question if what we usually diagnose as borderline in females and antisocial in males is but a product of sexism, with the core often, yet not always, the same. Yet the approach normally taken, the meaning in practice when drawings the boundaries between these “disorders”, is vastly different.

      Now we have diffused outwards, from a justified insecurity of a different kind, i.e. a diagnostic and conceptual blurring between bipolar disorder and between and within two discrete kinds of personality disorder. Let’s not stop there, for there are many other personality disorders besides. The lay reader may not be acquainted with the idea of “clusters” of personality disorders, as is still dominant in the DSM. Borderline and antisocial personalities fall within the so called “cluster B” personality disorders, along with narcissistic and histrionic personality (the other clusters are cluster A; paranoid, schizoid and schizotypal personality, and cluster C, dependent, avoidant and obsessional personality). Let’s imagine a different core problem, one that exists within the person just as strongly as undefined insecurity or a tendency to being a hybrid adult-infant emotional soup with unfinished business of childhood. Let’s imagine that all cluster B personality disorders are different manifestations of the same core, i.e. narcissism itself. In the case of the pure narcissistic personality disorder, the narcissism is directed to the ego or self as self, which is to say “I am superior and I’d like you to accept this fact”. In the case of the histrionic personality the narcissism is directed towards a specific kind of outward behaviour, one of shallow embellishment and being the centre of attention, which is to say “be I better or worse, it is all about me. Look at me”. In the case of the borderline personality the narcissism is directed towards one’s immediate emotional perceived needs and one’s own emotional pain at the expense of everyone else “it’s 2am in the morning but you all be damned I’ll kill myself if you don’t admit me to hospital, the blood is on your hands. No one’s pain is as important as mine. My pain is my world. My pain is the world”. Then there is the antisocial personality, whose narcissism is directed towards having and doing whatever they want, and damn the rules and social harmony “I do what I want, when I want, to whoever I want”. I have not even considered how other times and cultures may formulate peoples behaviours, all of which are as plausible as that offered by the best of psychiatrists. In any case, is a person’s character the business of medicine? This is very strange.

      One final example, moving from infantile adults to child and adolescent psychiatry per se. Into the consulting rooms comes the 10 year old boy Jaxxson, his concerned mother and his latest off several stepfathers. He has been irritable lately and stating in various ways and forms that he is unhappy. Perhaps by the side table upon which sits his enticing smartphone is the bed where he has a troubled sleep. Perhaps his appetite is reduced. Never excellent, his grades have slipped and his teachers are noticing some conflict with peers and the teachers themselves (always the royal road to mental illness is being a nuisance to others and embarrassed parents searching for an excuse). He might have even become anxious at the prospect of going to school, the last few weeks playing video games instead of attending to studies. Things may have come to a head when he started talking about death and drawing himself in the stick figure way a 10 year old draws himself as hanging from a tree. Various shades and permutations of cases such as this are typical and we need not dissect this hypothetical example, missing the forest for the trees. It does not matter really whether the child is 8, 10 or 12, boy or girl, white or black, rich or poor.

      Let us imagine a multiverse. Exactly the same child presents on exactly the same day and says exactly the same thing to exactly the same questions to 5 different child psychiatrists, only in each of 5 different universes. The psychiatrist observes the interactions with the family, speaks to the mother/stepfather alone also and consequently takes the history and examines the mental state.

      Child psychiatrist number 1 might formulate the case thus; the child is weighed down by a major depressive episode. At the hands of a sufficiently skilled sophist psychiatrist, major depression in everyone is quite a protean construct when attached to a person to whom we might say is “unhappy”. But it’s malleability is especially the case in that of children and the aged. As one can see in that enormously successful best seller of fiction that is the DSM, a child need not be depressed in mood to be depressed for reasons of diagnosis. They can merely be irritable, for somehow it is thought depression only then appears as depression. His lack of recent success in school is seen to be a product of the cognitive deficits that are part and parcel of the depressive illness. Similarly, his recent lack of hearty eating and the difficulty falling asleep are “neuro-vegetative dysfunctions” of the illness. These add to the diagnostic criteria in our checking of the boxes, and given the “neuro” prefix by extension taken automatically (though it is a non sequitur and semantic play) that the depression is a biological disease. Suicidal thoughts check another box. Psychiatrist number 1 may explain to parent and child alike that there is some brain mechanism for the depression and the remedy is, principally and in principle, an “antidepressant”. There are no shortages of first and second degree relatives also having been diagnosed with a mental illness. Up to a third or more of the females on both sides of the biological tree had been diagnosed with depression and/or bipolar disorder. This lubricates the mind of the psychiatrist into immediately assuming genetic vulnerability, and each generation the likelihood of diagnosis is made greater from the labels applied to those of the past. Like a pebble against the gravitational power of the sun, I have seen thousands of patients drawn into an almost inescapable orbit of attracting some diagnosis or another simply on the basis of what their parents, grandparents and Aunts and Uncles have been diagnosed (or diagnosed themselves) with. I guess in Salem witches had family too, and God help the family of the alleged witch if the diagnosis is made more probable by the idea of it being “genetic”.