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bittersweetresilience · 2 years ago

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Adrien Agreste and Borderline Personality Disorder

DISCLAIMER: I've been a bit low on spoons this week, so I haven't gathered as much evidence as I probably could have. Also, I am but a humble student in clinical psychology. This is mainly a thought compilation for @moonieratty!

To introduce the topic, without going into it too much, personality is described by features and behavioral patterns, or traits, consistent across situations and across time. Personality disorders are therefore enduring patterns of highly maladaptive traits evaluated in personal and sociocultural context (Dozois, 2019, p. 290).

Like other disorders, personality disorders have diagnostic criteria. The DSM is used primarily for diagnosis in the US and Canada while the ICD is used more widely in Europe and other places. I'm more familiar with the DSM, but I've included a brief section on the ICD to be comprehensive. It ended up a bit longer than anticipated, so let's go below the cut. Warning for discussions of abuse, self harm, and suicide, and a brief mention of substance use.

Overview of Borderline Personality Disorder

BPD is prevalent in a small percentage of the population, about 1-2% by varying estimates, and is characterized by instability across domains of emotions, identity, interpersonal relationships, and behavior. Its onset is usually in late adolescence or early adulthood and symptoms may diminish with age, after one's thirties or forties, especially with therapeutic intervention. Along with ASPD, it has been the focus of a lot of clinical research; it is unfortunately associated with high rates of non-suicidal self-injury and suicide (APA, 2022, pp. 754–755; Dozois, 2019, pp. 308–309).

Etiological factors for BPD include both biological and environmental disturbances. Of note to our discussion is the heightened risk for BPD in cases of child abuse or neglect, as well as growing up with another family member with a serious mental health condition (NHS, 2022). It's been well established that Gabriel is emotionally neglectful if not outright abusive toward Adrien in multiple ways, so this is a clear risk factor. In addition, although I won't argue definitively for Gabriel having a psychological condition, he did keep Emilie's body in the basement, so there is clearly some kind of disturbance going on.

From a cognitive-behavioral perspective, Linehan argues that BPD stems from families who consistently invalidate childhood emotional experiences and "oversimplify the ease with which life's problems can be solved," which may cause children to learn to seek attention and communicate with others through emotional outbursts (Dozois, 2019, p. 297). This rings true for Adrien and Gabriel as well.

I have to apologize for my son, Ladybug, he's like his mother. Way too overly dramatic. (Jackady)

It doesn't seem like this is the first time Gabriel has thought this, and labeling an emotional reaction as being overly dramatic is very much invalidation of it. As for emotional outbursts, Adrien has had quite a few, mostly as Chat Noir. More on this later.

To round out this first section, attachment theory proposes a connection between poor parent-child attachments and BPD relationship difficulties. Specifically, maladaptive behavior in relationships may stem from childhood development of an anxious-ambivalent attachment style, where intense fears of abandonment interfere with a strong desire for intimacy (Dozois, 2019, p. 310). You can clearly see this in Chat Noir's relationship with Ladybug, and I'm sure other people have discussed Adrien's attachment style more in depth, but suffice to say I think this is an apt description.

Argument from DSM-5-TR

In the DSM, personality disorders are primarily diagnosed on a categorical model. There are a few general criteria which I won't be going into, but I will highlight that personality disorders are stable and pervasive, and would be diagnosed only if they were leading to significant distress or dysfunction. Adrien's mental state is not great, so the latter shouldn't be a problem, but this show does not always pay attention to consistency, so I'm going to be speculating some. Everything in this section is cited to the relevant DSM entry unless otherwise stated.

The DSM characterizes BPD with instability in relationships, self image, and affects, as well as marked impulsivity. It has no exclusion criteria, so BPD can be and frequently is comorbid with other disorders like mood disorders, PTSD, and ADHD. Of the below criteria, five need to be met in order for a diagnosis to be made.

Frantic efforts to avoid real or imagined abandonment

Hey, where're you going? . . . So you're allowed to know her true identity, but I'm not? (Syren)

You're not really replacing me with a turtle, are you? (Anansi)

A lot of people have delved into Adrien's abandonment issues, which feature most prominently in his relationship with Ladybug. His fears of being replaced result in him seeking reassurance from Ladybug, and he can lash out if he does not receive the response he hopes for. Ladybug is his world, and he wants to be hers, so anything infringing on that feels to him like a threat of being abandoned, and he does not like it very much.

Impulsive behaviors like giving up his ring can be interpreted under this lens: he can avoid abandonment by doing the abandoning first. Then it will be him leaving, and not the other way around.

I also interpret Adrien's nightmare (Le Marchand de Sable) as being a fear of being alone as much as it is a fear of being trapped.

Unstable and intense interpersonal relationships alternating between extremes of idealization and devaluation

We'll be united, more powerful and free. We'll defeat Hawk Moth, then we can both run away to an island! Far away from everything. We will live off nothing but fruits, and we will have a little pet hamster and we will name it— (Le Patineur)

I just can't do this anymore. I give up… on everything. Even you . . . If I become Chat Noir again, Ladybug will just end up rejecting me, over and over. (Kuro Neko)

Even though Adrien mostly keeps his head on straight regarding what he's owed and not owed by other people, his relationship with Ladybug is full of highs and lows. He thinks Ladybug is the most amazing girl, but this can recoil quickly into feeling as though Ladybug doesn't care about him enough or isn't meeting his needs.

Furthermore, he developed this idealization of Ladybug as a potential lover or caregiver at one of their first meetings (Cœur de Pierre), and continually sought to spend time together and share the intimate details of their secret identities early on. These are all common to individuals with BPD, as is the switch from idealization to feeling as if the other person "does not care enough, does not give enough, or is not 'there' enough." Ladybug is the only person Adrien consistently projects this instability and intensity on, which might be something interesting to explore.

Identity disturbance: unstable self image or sense of self

When I was a kid, I always wanted to be what my parents wanted me to be! (Exauceur)

But, does that mean Chat Noir is who I really am? Deep down inside? (Kuro Neko)

With all the secret identities, it isn't surprising that Adrien fits this criterion, but canon even explicitly draws a link between Adrien's unstable sense of self and his childhood experiences. He doesn't know who he is, and he distracts from this by being Chat Noir, only to struggle even more when he feels useless and underlooked as his hero self. His behavior shifts dramatically between trying to prove himself with grand gestures and refusing to participate or lashing out. There is definitely something to discuss on this front.

Impulsivity in at least two potentially self-damaging areas

Giving you some extra time . . . I trust you to bring me back, m'lady. (Gamer 2.0)

There are only two liars left in Paris and one of them knows the ultimate way to catch her attention . . . Crazy about you, m'lady. (Mensonge)

This is walking a thin line between impulsivity and suicidal behavior, which would be excluded from this criterion, but I'll list self sacrifice here because I can see an argument for Chat Noir's impulsive behaviors being out of love or the desire to be useful. There may still be some self injurious intent or euphoria, but Chat Noir does have faith in Ladybug to bring him back eventually. Nevertheless, this is impulsive and unhealthy. Chat Noir jumps too quickly to this option to have thought it through.

I can't think of another area, because Adrien isn't old enough for reckless driving, spending, substance use, or sex. This is also a kids' show. Just presenting these options for fanfiction writers out there.

Recurrent suicidal or self mutilating behavior, gestures, or threats

I... I don't know what to do! (Chat Blanc)

This is all our fault . . . Cataclysm. (Culpabysse)

By itself, what happened in Chat Blanc would not be solid evidence, as that was an unprecedentedly traumatic situation. Combined with Culpabysse, though, there is a strong case to be made for at least passive suicidality for this to be able to come up as an option.

You could also interpret the self sacrifice in this category. Suicidal behavior in individuals with BPD is often preempted by fears of rejection or abandonment, so an interesting analysis could be made on this front.

Affective instability due to marked reactivity of mood

He's still only thinking of himself! I just want this terrible day to be over and done with! I hate Christmas! (Pire Noël)

Sorry! Sorry! I didn't mean to make you so mad. I get it. You're sick of me . . . No one can help me, Kagami. (Glaciator 2)

Adrien's prolonged episodes of anger and despair reflect a high reactivity to emotional stressors, especially interpersonal ones. In general, he just doesn't feel very well unless something is actively bringing him joy. Most of his outbursts are brief, though, and I will discuss them as part of a later criterion.

Chronic feelings of emptiness

I'm not Adrien, so I wouldn't know if this is the case, but I can say he has experienced at least one depressive episode (Kuro Neko) and emptiness would not be unfamiliar. You can look at him and decide.

Inappropriate, intense anger or difficulty controlling anger

How was your amazing evening with your "friends"? . . . What do you think? (Glaciator)

Why not? No one'll know if I quit. No one'll care! (Syren)

A two-person plan?! There's only one two-person plan, and that's Ladybug and me! (Sentibulleur)

Give me a break, Miss "I can't even come up with a superhero name"! (Hack-San)

Anger in individuals with BPD can manifest as bitterness, sarcasm, or recurrent verbal outbursts, which Chat Noir absolutely exemplifies. These outbursts are often followed by feelings of shame or guilt and contribute to a feeling of being bad. Chat Noir apologizes after being harsh in Glaciator, and I wouldn't be surprised if he felt badly about the other times. Again, these outbursts are often precipitated by interpersonal fears and perceived threats of abandonment. Unlike other symptoms, this specific one tends to be unique to BPD.

Transient, stress-related paranoid ideation or severe dissociation

I cannot recall any evidence for this but headcanon away, my friends.

All in all, I think Adrien has a strong case for BPD presentation according to the DSM. Canon is not always consistent, but I think it presents an interesting and mostly coherent narrative for this lens. From this perspective, Adrien's behavior reflects a deep intolerance of being alone and a dependence on other people to define the self.

As a corollary, BPD behavioral patterns are frequently linked to self sabotage and self undermining right when a goal is about to be realized, which could manifest as dropping out of school right before graduating or ending a relationship when it seems to be going well. Food for thought. Individuals with BPD may also feel more secure with transitional objects like pets than with interpersonal relationships, which could reflect in Adrien's relationship with Plagg.

To add some subjective understanding to this clinical mumbo jumbo, I've added a source of genuine BPD experiences below (Mind, 2022).

Argument from ICD-11

With the release of the ICD-11, a dimensional model for diagnosis of personality disorders became the new standard. What this means is that individuals are no longer labeled as having 'histrionic' or 'dependent' or, indeed, 'borderline' personality disorders, but are rather assessed as having any form of personality disorder on a sliding scale of severity and with trait domain specifiers (Swales, 2022). To put it more simply, people are diagnosed only with a general personality disorder or personality difficulty which can be optionally specified as deviating on one of the personality traits in the Big Five model, which is well established in personality psychology.

This move has several benefits. Stigmatization related to particular personality disorders can be reduced, and differential diagnosis and comorbidity between personality disorders becomes irrelevant. However, people retain access to treatment and support. Evidence-based treatments like dialectical behavior therapy are particularly well established and crucial for BPD; for this pragmatic purpose, the ICD contains one additional specifier for borderline pattern personality disorder (Bach et al., 2022; Swales, 2022).

The DSM and ICD are designed to be compatible with each other in many ways, and in this case, the borderline specifier in the ICD is directly lifted from the criterion of the DSM (WHO, 2023, 6D11.5). Based on our previous discussion, Adrien would be equally qualified for a diagnosis in France. I would likely describe his personality disorder with moderate severity, where multiple areas of functioning are affected and self harming behaviors may be present, but not all areas or relationships may be equally impacted and traits are not as rigid and inflexible (WHO, 2023, 6D10.0–6D10.2).

Interestingly, the ICD includes three additional manifestations of borderline pattern which are optional and may vary across time (WHO, 2023, 6D11.5).

A view of the self as inadequate, bad, guilty, disgusting, and contemptible

An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness

Proneness to rejection hypersensitivity; problems in establishing and maintaining appropriate levels of trust in relationships; frequent misinterpretation of social signals

I'm fascinated by the number of adjectives in here. I simplified very slightly, as I did with the DSM criteria, but I had to keep all these adjectives. Anyway, I won't elaborate for too many more paragraphs, so let's say sentimonster moment and leave it at that. I will spare you my mirrored Félix essay. For now.

Qualifications and Limitations

First of all, Adrien is a teenager. The distinguishing factor between a personality disorder and regular adolescent difficulties would be longevity and identity concerns beyond his developmental phase (APA, 2022, p. 758). Second of all, Adrien has a uniquely terrible home life and magical problems. Some of his behaviors could be normal considering his experiences and sociocultural context, and this matters when it comes to psychological evaluation. Take everything with a grain of salt!

More generally, the categorical model of the DSM has several issues, not to mention diagnostic issues related to culture, gender, and stigma. Some but not all of these issues are addressed by the dimensional model it includes in a later section, which shares theoretical foundations with the model of personality disorders in the ICD. Even so, issues remain. Diagnosis, access to treatment, and political statements are intrinsically linked in complex ways. I won't get into all of the nuances, but be safe, remember this is a fictional character, and keep an open mind.

REFERENCES:

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Bach, B., Kramer, U., Doering, S., di Giacomo, E., Hutsebaut, J., Kaera, A., De Panfilis, C., Schmahl, C., Swales, M., Taubner, S., & Renneberg, B. (2022). The ICD-11 classification of personality disorders: A European perspective on challenges and opportunities. Borderline Personality Disorder and Emotion Dysregulation, 9(1). https://doi.org/10.1186/s40479-022-00182-0

Dozois, D. J. A. (2019). Abnormal psychology: Perspectives (6th ed.). Pearson.

Mind. (2022, September). What does BPD feel like? https://www.mind.org.uk/information-support/types-of-mental-health-problems/borderline-personality-disorder-bpd/experiences-of-bpd/

National Health Service. (2022, November 4). Causes - Borderline personality disorder. https://www.nhs.uk/mental-health/conditions/borderline-personality-disorder/causes/

Swales, M. A. (2022). Personality disorder diagnoses in ICD-11: Transforming conceptualisations and practice. Clinical Psychology in Europe, 4(Special Issue). https://doi.org/10.32872/cpe.9635

World Health Organization. (2023). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/

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religion-is-a-mental-illness · 1 year ago

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By: Christina Buttons

Published: Apr 11, 2024

[ Figure 3 from “Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1)” ]

A new systematic review of international clinical guidelines for children and adolescents with gender dysphoria has exposed deceptive practices by respected medical authorities who recommend medical transitions for minors. These guidelines are often cited as uncontroversial and scientifically robust. However, the review reveals that these organizations have misled the public by basing their recommendations on insufficient evidence and inaccurately labeling their approach as “evidence-based.” Furthermore, they have engaged in a corrupt practice known as “circular referencing.” Instead of conducting independent evaluations, they have relied on endorsements of sex-trait modification for minors from other medical bodies, artificially creating a consensus on the issue.

Commissioned by NHS England and chaired by Dr. Hilary Cass, the University of York’s research team evaluated 23 international guidelines using the Appraisal of Guidelines for Research and Evaluation tool to assess their quality. The study specifically examined how evidence informed recommendations, the development and agreement processes for these recommendations, the stakeholders involved, and how the guidelines referenced each other during their development.

Insufficient Evidence

The findings of the review were deeply concerning. It concluded that clinical guidelines globally used to treat gender-questioning children and adolescents were crafted in violation of international standards for guideline development. These guidelines recommended medical interventions for minors despite insufficient evidence, particularly regarding long-term treatment outcomes in adolescents. Additionally, they relied on other guidelines that recommended medical treatments as the basis for making similar recommendations.

Circular Referencing

The Endocrine Society (ES) and the World Professional Association for Transgender Health (WPATH) published initial guidelines recommending youth medical transition in 2009 and 2012, respectively. These guidelines became foundational for many subsequent guidelines, shaping their content and recommendations despite the lack of evidence and rigor. In the Cass Review, Dr. Hilary Cass highlighted the ways in which WPATH and ES were closely interlinked, noting their mutual co-sponsorship and input into each other’s drafts. This coordinated effort suggests that WPATH and ES were colluding to grant undue credibility to their guidelines.

The corruption persisted in the formulation of national and regional guidelines by prominent organizations such as the American Psychological Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Society for Adolescent Health and Medicine. It also extended to international guidelines from countries like Australia, Spain, Italy, and regions including Asia and the Pacific. Rather than grounding their recommendations in robust evidence, these guidelines deferred to the endorsements from the initial guidelines of WPATH and ES.

Years later, when WPATH and ES updated their guidelines, they referenced the same national and regional guidelines that had initially drawn from their recommendations. This perpetuated a cycle in which each iteration reinforced the others, each time without sufficient evidence to support the recommendations. Dr. Cass highlighted the problematic nature of this circular referencing, stating, “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”

Part 1 of the systematic review includes Figure 3, pictured above, which illustrates the various ways in which guidelines reference or influence each other. It shows how guidelines draw on the initial Endocrine Society (2009) and WPATH (2012) guidelines, which have influenced nearly all the national and regional guidelines identified. Additionally, it demonstrates how these subsequent guidelines cite and rely on each other, and how the latest Endocrine Society (2017) and WPATH (2022) guidelines have cited and drawn on the national and regional guidelines.

The systematic review highlights an example of this circular referencing: WPATH Version 8, published in 2022, identifies numerous national and regional guidelines published as early as 2012 as potentially valuable resources. It cites guidelines from the APA (2015), Australia (2018), New Zealand (2018), and University California, San Francisco (2016) multiple times to support their recommendations. Importantly, all of these guidelines were themselves significantly influenced by WPATH Version 7 (2012).

Broader Context

In the research world, such circular referencing is sometimes referred to as a citation cartel. This occurs when a group of academic authors collude to excessively cite each other's publications to artificially inflate their citation counts. However, what has occurred here differs slightly; their aim wasn’t to boost citation counts, but rather to enhance their own credibility through mutual referencing in the eyes of the public and other medical professionals. Nonetheless, this practice is highly unethical. By engaging in circular referencing, these medical bodies have actively deceived healthcare professionals and the public, leading them to believe in the validity and reliability of recommendations founded on weak evidence.

Unfortunately, much of the transgender rights movement has advanced through an approach that heavily relies on appeals to authority. Organizations that once focused on Gay and Civil Rights, now pivoting to champion transgender rights, are deferred to as authoritative bodies by news outlets, schools, teachers' unions, and even the Biden administration, which seeks their guidance on transgender issues. Within academia, idea laundering has bestowed Queer Theory and Gender Theory, foundational to modern gender ideology, with the illusion of legitimacy.

Moreover, significant changes in federal regulations under Title IX, granting biological males (who identify as women) access to female-only spaces and sport categories, have occurred through a process known as institutional leapfrogging. In this process, judges and administrators take incremental steps, each citing the authority of the other, ultimately leading to the expansion of federal mandates.

Not Evidence-Based

WPATH, whose stated mission is to “promote evidence-based care,” and ES, who refers to their approach as “evidence-based transgender medicine,” along with any organization advocating for medical transition for minors, are misleading the public by portraying themselves as being “evidence-based.”

In an investigative report for the British Medical Journal (BMJ), Dr. Gordon Guyatt, a highly respected figure in the field of medical research methods and evidence evaluation, and who pioneered the evidence-based medicine (EBM) movement, stated that the current guidelines in the United States for managing gender dysphoria in adolescents should not be considered evidence-based. He emphasized that these guidelines fail to offer cautious and conditional recommendations appropriate for such low-quality evidence. Guyatt further underscored his concerns in a social media post, labeling these guidelines as "untrustworthy."

Similarly, the systematic review team arrived at the same conclusion:

Most clinical guidance lacks an evidence-based approach and provides limited information about how recommendations were developed. The WPATH and Endocrine Society international guidelines, which like other guidance lack developmental rigour and transparency have, until recently, dominated the development of other guidelines. Healthcare professionals should consider the lack of quality and independence of available guidance when utilising this for practice.

In the end, the team was only able to recommend two guidelines for practice: the Finnish guideline published in 2020, and the Swedish guideline published in 2022. Both guidelines conducted their own systematic evidence reviews, concluding that the risks of medical transition outweigh any purported benefits. As a result, they do not recommend medical transition treatments for minors but instead prioritize mental health support.

WPATH, ES, and any medical authority that misrepresents guidelines recommending medical transition for minors as “evidence-based” betray public trust and fail those seeking reliable guidance. Healthcare professionals and regulatory bodies must hold guideline developers accountable for these deceptive practices and ensure transparency in the basis of future recommendations.

The National Health Service England issued a statement in response to the Cass Report and new systematic reviews, asserting that their findings "will not only shape the future of healthcare in this country for children and young people experiencing gender distress but will also be of major international importance and significance."

Nobody who has been following the "gender medicine" space or read the interim Cass review would be surprised with the outcome. Or the denial of the activists. Including the ones masquerading as medical professionals.

What might be the most surprising outcome of the Cass review is the level of fraud and collusion by ideologues involved in the way pseudoscience and outright fantasy ("puberty blockers are fully reversible") has been framed as some unquestionable truth ("the science is settled").

It was always fraud. This was always an ideology.

#Christina Buttons #circular referencing #circular logic #citation cartel #academic fraud #fraud #appeal to authority #medical corruption #medical malpractice #medical scandal #academic corruption #gender affirming care #gender affirming healthcare #gender affirmation #queer theory #gender identity ideology #gender ideology #intersectional feminism #religion is a mental illness

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