Against Armchair Diagnoses

Or, Maybe Your Ex Doesn't Have a Personality Disorder

Hello dear ones,

I wanted to share some new — and very much in process — writing from my MFA thesis Wounding/Wanting: an archive. It’s messy! But I’m super curious/nervous to hear your thoughts.

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Over the past few years, I’ve watched as it’s become more and more common for folks to weaponize diagnoses against strangers, exes, and anyone they ever had a conflict with. And the most popular diagnosis, as TIME Magazine has noted, is Narcissistic Personality Disorder. The bible of diagnoses, the DSM-V, defines NPD as “a pervasive pattern of grandiosity, need for admiration, lack of empathy, with interpersonal entitlement, exploitativeness, arrogance, and envy.”

For TIME, labeling someone a narcissist “has become shorthand for anyone who appears self-centered or entitled,” while for Antonia Dolhaine, “most of the people you’re calling ‘narcissists’ are actually just emotionally immature and un-self-aware. These qualities, while unfortunate, are not pathological–they are extremely common. Pathological narcissism, on the other hand, is extremely rare.” The estimate is anywhere between 0.5-6% of the population.

The other most popular diagnosis to sling around is Borderline Personality Disorder (BPD). To receive a BPD diagnosis, you must meet five of the following:

• Interpersonal relationships: Unstable and intense relationships that alternate between idealization and devaluation

• Self-image: Unstable sense of self or identity

• Impulsivity: Self-damaging impulsivity in at least two areas, such as substance abuse, reckless driving, or overspending

• Mood instability: Intense mood reactivity that can last from hours to days, such as irritability, anxiety, or dysphoria

• Chronic feelings of emptiness: A persistent feeling of emptiness

• Anger: Inappropriate or intense anger, or difficulty controlling anger

• Dissociation: Transient paranoid ideation or severe dissociative symptom

In her book Sexy But Psycho, Dr. Jessica Taylor argues that the diagnostic criteria for BPD “are so broad that pretty much anyone who is traumatized or distressed could answer ‘yes’ to five or more of the items.” Let’s try:

• Interpersonal relationships: Unstable and intense relationships that alternate between idealization and devaluation – If you’re a human living with disorganized attachment, it’s very easy to swing from one end of the pendulum to the other. As a teenager, I idealized those who didn’t want me and devalued those who actually did. The second that someone started to come on “too strong” (e.g. didn’t hide how they felt about me), I would run. All of my relationships were unstable and intense. It was all that I knew from my family.

• Self-image: Unstable sense of self or identity – One of the hallmarks of attachment wounding is difficulty developing a strong sense of self. This is particularly the case for those who had overbearing caregivers. In my family, the only ways I received loved were by being a good student and a dutiful caregiver. As such, my whole sense of self and self-worth developed around caring for others. When my father died, not long after my 31st birthday, I would ask my therapist: “Who am I if I’m not caring for him?”

• Impulsivity: Self-damaging impulsivity in at least two areas, such as substance abuse, reckless driving, or overspending – While I never learned to drive, I struggled with substance abuse from ages 14-24, and was always overspending.

• Mood instability: Intense mood reactivity that can last from hours to days, such as irritability, anxiety, or dysphoria – Anxiety and I were intimate bedfellows. I didn’t know what it was like to not feel anxiety as a pervasive presence in my life until I started taking SSRIs in my late 20s. While I received a diagnosis of acute anxiety disorder, I know now that this was just a symptom of living in a chronically traumatizing environment.

• Chronic feelings of emptiness: A persistent feeling of emptiness – see: self-image. If I have no self-image to speak of, then I am empty.

• Anger: Inappropriate or intense anger, or difficulty controlling anger – When my first therapist asked me, at the age of eighteen, if I was angry, I responded “anger is a wasted emotion.” She gave me the book The Dance of Anger, and I never saw her again. I’ve never known how to express anger because I grew up in a home where anger equaled violence and was weaponized against me. Everyone else got to feel it except for me. Little did I know that I was burying it deep down within me. Like a sponge soaking up water, eventually I became so over-saturated with anger that my body responded with chronic pain flares and intense dissociation.

• Dissociation: Transient paranoid ideation or severe dissociative symptom – Hiiiiii, welcome to every person with complex trauma. Throughout my teen years, I believed that someone was going to break into my home and kill me and my family in our sleep. I used to stand on the subway platform, terrified that someone would come and push me in front of the train. Heard a noise in an empty house? Must be an intruder inside. Partner doesn’t call when they say they will? They must be dead. Dissociation and paranoia: I know them well.

While I know that diagnoses can be life-saving for so many, I’m deeply critical of the stories we tell about the symptoms that supposedly make up a diagnosis. In her book Pathological: The True Story of Six Misdiagnoses, Sarah Fay highlights the fictive nature of diagnostic criteria, citing numerous prominent psychiatrists on the subject:

“Allen Frances, one-time chair of the DSM-IV task force, is quoted as saying that DSM diagnoses confuse ‘mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition.’ Steve Hyman, another former NIMH director, called DSM diagnoses ‘fictive categories.’”

Diagnostic criteria is constantly shifting, and, as Fay recounts in great detail, the criteria becomes vaguer and more all-encompassing, which leads to more and more diagnoses. This spillage has, unsurprisingly, leaked out into popular culture, as more and more people declare that [insert person who hurt them or human that they simply don’t like] must have NPD or BPD. Crazy exes abound.