Analyze Scripts

Welcome back to Analyze Scripts, where a psychiatrist and a therapist analyze what Hollywood gets right and wrong about mental health. Today, we are taking a deep dive into the newest season of the longtime Emmy winning show, American Horror Story. This season, Delicate, depicts a women, Anna Victoria, played by Emma Roberts, who is undergoing fertility issues. Anna is a famous actor who receives in vitro fertization (IVF) with all the spooky and horror elements that are associated with the show. Listen to our take on Kim Kardashian's performance and the accuracy of their depiction of IVF. Dr. Furey takes this lead in this episode with her expertise in pregnancy, IVF and postpartum care. We hope you enjoy!

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Dr. Katrina Furey MD: Hi, I'm Dr. Katrina Fieri, a psychiatrist.

Portia Pendleton LCSW: And I'm Portia Pendleton, a licensed clinical social worker.

Dr. Katrina Furey MD: And this is analyze Scripts, a podcast where two shrinks analyze the depiction of mental health in movies and TV shows.

Portia Pendleton LCSW: Our hope is that you learn some legit info about mental health while feeling like you're chatting with your girlfriends.

Dr. Katrina Furey MD: There is so much misinformation out there, and it drives us nuts.

Portia Pendleton LCSW: And if someday we pay off our student loans or land a sponsorship, like.

Dr. Katrina Furey MD: With a lay flat airline or a major beauty brand, even better.

Portia Pendleton LCSW: So sit back, relax, grab some popcorn.

Dr. Katrina Furey MD: And your DSM five, and enjoy. Welcome back to another episode of Analyze Scripts, the podcast. We are so excited you're joining us for our second YouTube episode. That's right. If you are just listening, you could also watch us on YouTube. Please don't do it while driving, but otherwise, please head on over to Analyze Scripts podcast. Today we are talking about the latest installment of American Horror Story, Delicate. We're going to talk about Part one. Part two is set to come out in early 2024, but I am really excited to talk about this episode. What did you think? Portia, I know you're not super into spooky things. I was really impressed that you watched this just right off the bat. What are your thoughts?

Portia Pendleton LCSW: I thought it was intense in the way, I think, because as a woman who goes to the gyn and who potentially will or will not experience the birthing process or the pregnancy process, I felt like it was a little traumatizing. But in a way that I want to hopefully be clear. And I think you can do a.

Dr. Katrina Furey MD: Better job at this.

Portia Pendleton LCSW: But this is not a normal experience. This is in so many ways horrific. And there were so many moments that she was invalidated, and I thought that that was just, like, bad. I mean, in this whole experience, that's already really scary and sometimes daunting and can be painful just to add this obviously extra fictional layer to it. But it was hard to watch.

Dr. Katrina Furey MD: Totally. So if you've been living under a rock, American Horror Story is a series on FX that's been around for many years now. I think next Halloween, we're hoping to cover season one because that was a really good season. But it's a really cool show by Ryan Murphy where it's usually the same sort of crop of actors. And the story each season is know, there's been, like, the clown one, there's been like the murder house one. There's. Yeah, you know, so it's all really interesting. And so we see Emma Roberts as the star of this season, she's playing an actress, Anna Victoria Alcott. And the whole plot, to sum it up real quick, of this first part of the season, is she really wants to have a baby, and she's struggling to get pregnant. So we see her and her husband Dex, who previously had been married, and we believe his wife died that now at the end of part one, we're not really sure, but they're struggling to get pregnant, so they're going through the IVF process. At the same time, her career is taking off, she's campaigning for an Oscar, and we come to find out there's something afoot. There's some sort of evil plot at play in regards to her baby. We don't exactly know what it is yet, but we see some flashbacks to someone else agreeing to give their baby away to these people in weird black crow outfits to be able to have power or money or something that they want. And it seems like this is going that way. Like, how much do you want a baby? How much do you want an Oscar? Right, right.

Portia Pendleton LCSW: It's like this cabal that's been around for centuries, apparently. And I don't know. I think obviously, we're missing so much that I hope we get from season two. But I have so many questions. Right? Like, is the husband involved? Is he not? Is the know Kim Kardashian? Yep. Siobhan. Is she involved? It seems like she is with those little supplements that look like blood. Obviously the Doctor is involved. But I have so many questions that I'm excited to hopefully get answered, even though it will be. Yeah.

Dr. Katrina Furey MD: In part two, I think my biggest question is, why is Kim Kardashian playing? Like, why? It was so Portia. I'm sorry. Like, I thought Kim Kardashian did a pretty good job on SNL. I'm not going to lie. I was like, well, she was kind of funny, but in this, I was just, like, cringe.

Portia Pendleton LCSW: And I think it's because.

Dr. Katrina Furey MD: I also.

Portia Pendleton LCSW: Don'T know if it would matter if she was better at acting because she's still Kim Kardashian, which is like, I think her being and persona and aura is just so powerful. And she was playing somewhat of a similar person, so it wasn't this crazy stretch. But I think it's just so hard because we know her from 20 years of reality TV that I can't see past that. So regardless, even if she was, I don't know. I can't tell. Is it poor acting or is it just like, I can't see her in another way.

Dr. Katrina Furey MD: I think it's both acting, but also why her? I've got to imagine there's so many good actresses out there that could have done a great job in the role. And it's not like American Horror Story has been doing badly as far as I know. Maybe the ratings have been down. I don't think they've been down that much. Why? I just feel like it's to use her for her following and to get eyeballs on the screen. But it honestly annoyed me. I would say of all the stuff we've watched so far, I felt like this was the worst, just in terms of. I didn't like it that, like, in terms of the acting and stuff like that and the storyline, I liked all the mental health themes. I'm excited to talk about them, but I was just, like, even Emma Roberts acting I didn't think was great. I don't.

Portia Pendleton LCSW: I mean, I just didn't love it. And I don't know if that's because it's not my favorite genre, but I finished the episode last night, and I started it when it came out. It's been difficult to kind of get through the episodes. I love Emma in other shows, so I don't know, it just kind of fell flat and for a couple of reasons. But I did watch the last episode in which I think it's the last one where she eats the raccoon, and I was literally, like, going to throw up. I couldn't look at it.

Dr. Katrina Furey MD: That took me by surprise. Yeah, same with me. It was like. And the episodes weren't that long, so you could just think you'd, like, plow through them, right? Like, morning show succession. You. I am like, can't wait to watch the next one. But this one, I was, ugh. And I just think it's because Kim Kardashian was not very sorry.

Portia Pendleton LCSW: She wasn't.

Dr. Katrina Furey MD: She wasn't. I'm sorry. And I get a little angry that she gets all these opportunities when there's probably so many good actresses out there dying for an opportunity. Like, it just.

Portia Pendleton LCSW: I feel morally opposed to it. I wonder if it was for shock value. You know what mean? Like, there's been a lot of bad feedback about it, and I think they've had to have known that even, like, she auditioned or in the acting and, like, Kim, you're great at a lot of things, and maybe this just thing isn't for you. Good for you for trying. I don't know.

Dr. Katrina Furey MD: She had such so much dialogue. I really thought she'd be in it, but, like, peripherally. And she was really in it, trying to act, and I was like, I don't know if we need that much.

Portia Pendleton LCSW: Something that I'm wondering, too, is that this whole thing came out while the sagstrike was. Is going on. So I think that's also interesting because I didn't see any promotions for it from Kim or anyone else. And I just thought that there's been other bigger hits that have still done well despite not having the actors. And so I just. I don't.

Dr. Katrina Furey MD: Let's.

Portia Pendleton LCSW: Let's get into the mental health theme. We both didn't give it five stars.

Dr. Katrina Furey MD: It's on our face. Okay.

Portia Pendleton LCSW: Yeah.

Dr. Katrina Furey MD: But there's a ton of mental health themes, I think, as it relates to IVF and the journey to motherhood and just being a woman. I think. So before I dive in, I want to hear about your perspective, Korsia.

Portia Pendleton LCSW: I would say that I felt like they did a good job at portraying just, like, the emotions related to having a miscarriage or the difficulties with getting pregnant and the stress that accompanies that. And ultimately, the loss is different for everyone. I think it's unique to the woman carrying the pregnancy initially and then potentially losing it or carrying a full to term. So I thought that Emma was able to portray that well. I think she is a mom, so I think that she probably kind of pulled on some of her experiences through that process. What's scary, what's exciting, the ups and the downs. So I liked that aspect. I thought that was pretty realistic, maybe. And, like, going to a clinic.

Dr. Katrina Furey MD: Right?

Portia Pendleton LCSW: Like, going to a separate place to receive the IVF procedures. I didn't love the red. Right. Red gloves, red walls. It was like all, like, first of all, why would you ever have a Red Glove? Obviously, they did it in the movie for a reason. But is there blood on it or not?

Dr. Katrina Furey MD: Do you think the red is for visual effect with the movie? The vitamins were red. No, they're not. I think that's all just for visual effect and very in line with the AHS genre, I would say. But certainly that theme of red and even the progesterone that she was supposed to take, I believe that's what it was that she had to keep in the fridge, came in these glass vials, and it's like, that's not what it looks like. Right. But whatever. It's for visual effect, so I get it. But, like, the vitamins that Siobhan gave her, that look like blood, that's obviously not B. Twelve. And also, why are you relying on Siobhan to know if this is safe in pregnancy? Just call your OBGYN. I mean, it turns out this guy is involved, so you shouldn't trust him. But in general, I was like, okay, I think that it's really important to point out that, and this is like one of those things that goes without saying, and yet we need to keep saying it, that IVF is incredibly stressful under the best of circumstances and capital T trauma in many circumstances. I'm not even going to say in the worst circumstances because I think it just is traumatic. Quite literally, it's very invasive in your body. It's very stressful emotionally. I think upwards of 40% of women going through IVF experience a mental health condition, mostly depression and anxiety. But I also see PTSD and I see OCD happen a lot around IVF. And that makes sense, right? I mean, because it is, like, traumatic to lose a baby, to have a miscarriage, to have a stillbirth. It's very stressful to always be in that cycle of uncertainty and waiting. Waiting to get your period, waiting to not get your period, waiting to take the pregnancy test, waiting to ovulate, tracking everything. I mean, it's just so unbelievably stressful and can be really all consuming. And you can see how it can lead to things like PTSD, how it can lead to OCD after the fact. Right? Because it's normalized to check the pregnancy test, check the ovulation strips, check this, check that, and then when the baby's here, you don't want to lose it. So you're still checking. I see some women weigh their baby obsessively, or sort of, like, obsessively track the baby's eating, peeing, pooping, like those sort of things. It's hard to let go of that and feel secure. So it's incredibly stressful. And I did really appreciate, even though I didn't love it as a viewer, I really appreciated this being on our screens in such a big way. Right. Like, just a woman going through IVF and just showing how stressful. I really appreciated.

Portia Pendleton LCSW: Yeah, I think it's important to highlight because it's common. Having a miscarriage is wildly common. Having infertility issues is common. I think one of the biggest. What would I say, like, supports or positive reinforcers of this experience is having a support system, which I feel like she didn't have.

Dr. Katrina Furey MD: Her husband.

Portia Pendleton LCSW: Her husband got worse over the season with, just, like, me being really suspicious of what was actually going on. Especially within the last episode with the conversation with his mom and her kind of coming in. So I initially kind of liked him and then I was like, what is.

Dr. Katrina Furey MD: She's like, Anna Victoria has been targeted. I feel like there was this evil plot all along and they're choosing her because she's like this famous actress to somehow have this baby. They're going to make a black crow or something weird and evil. But I didn't find her husband to be that great.

Portia Pendleton LCSW: No. And I think it's hard because I guess you could look at it from two sides. All the stuff that's happening to her from just a black and white on paper perspective seems a little outlandish. Or all of a sudden all this stuff is happening. So it's like, as her paranoia is growing, but it's like you either believe her or you don't. And if you believe her, you're in on the plot that something nefarious is going on and all of this is happening and it's real and she needs to be protected at all costs. And if you don't believe her, she's going crazy. Right? She is, but you're dismissing her and invalidating her and making things worse. Can you maybe speak to, does this happen within pregnancy or IVF due to.

Dr. Katrina Furey MD: The hormones and stuff?

Portia Pendleton LCSW: Like, do people become paranoid? How does this play out in real life?

Dr. Katrina Furey MD: So, no, I was so annoyed. But yet I think it's actually a good depiction because I feel like people say this to women overall. Like, oh, it's your hormones. Even like PMS. Right. We just so invalidate women's experience by chalking it up to hormones. And yet at the same time, it's like, okay, you're not acknowledging, like, yeah, these hormones actually do have an effect. So help me out here. Which is so infuriating, but women are most likely to experience a mental health situation or a mental health challenge during their childbearing years. And why is that? We know that in men, they're most likely to have their first episode, whether it's depression, bipolar disorder, psychosis in their late teens to their 20s. For women, it's a little later. It's like twenty s to thirty s, which is right around the time of childbearing. So it's like, okay. We sort of, in part, think that it's because that just happens to be the time we see first episodes. But we also know, and we're starting to. The medical field in general, is starting to have better understanding that there is something to the hormonal fluctuations. So if you've experienced a mental health condition before getting pregnant. Anything from depression, anxiety, trauma, OCD, psychosis, substance use. Your risk of experiencing it around the time of having children is higher than if you haven't experienced any mental health conditions beforehand. But even if you haven't experienced any mental health conditions beforehand, you're at highest risk over the course of your life during this time period. And we know postpartum depression is incredibly common. One in seven women and one in ten dads experience postpartum depression. The dad's hormones aren't changing. Okay? So there's just a lot of stress that goes into having children. We know that most cases of postpartum depression, if you trace it back, actually start during pregnancy. I think it's like 60% of cases start during pregnancy. The remaining 40% really show up after having the baby, but it's usually not picked up till after having the baby. And unfortunately, 75% of women who screen positive for postpartum depression don't end up accessing treatment, which is awful and way lower than the rates of treatment access for depression outside of pregnancy.

Portia Pendleton LCSW: So why is that? I imagine that there's multiple reasons, but.

Dr. Katrina Furey MD: I think there's a lot of reasons, and I don't think we know exactly why. I think that a, there's not good mental health resources in general. We've talked about that a lot. It's really hard to access care, period. And then I think once you've had a baby, when do you have time to go on Psychologytoday.com and look for a therapist and make all the calls and wait for them to hear back and schedule the appointment? When you have a newborn, it's just so hard. And I think there's a lot of shame and stigma. Right. I think in general, there's a lot of shame and stigma about living with a mental health condition that keeps people from reaching out for help. And then I think, especially when you've had a baby, you're thinking like, this is supposed to be the best time of my whole life. I don't want to talk about this. Right. I think a lot of women, especially when you're having intrusive thoughts of harm coming to your baby, which is really common with anxiety and OCD, a lot of women will feel worried. LiKe, if they're doing the dishes and they see a knife, they'll think, like, oh, my God, what if somehow my baby gets stabbed? Or if they hear a noise, they think, oh, my God, it's an intruder. Or they might think, like, you might have an intrusive thought or flash of an image of, like, throwing your baby out the window. It's really scary to tell someone that if you don't know that this is a super common thing to happen after having a kid and that it's a sign of an underlying anxiety or OCD disorder, you might be afraid that they're going to take your baby, or you might be afraid that you have psychosis. You're losing your mind. So these are really hard things to talk about. And I think one thing I always tell my patients, and I hope that we can tell our listeners and just keep getting the message out there, is that these conditions are really common and they're treatable, and it's important that we improve access to treatment, because suicide is the number one cause of mortality the first year postpartum, and postpartum mental health conditions are the number one complication of pregnancy overall. So this is really important. And so in that way, I'm really happy that this is on our screen, even if Kim Kardashian is in it and the acting is so know I can tolerate it for that reason.

Portia Pendleton LCSW: True. Yeah. So I guess separating, like, write fiction or TV effect from reality, what did you see that was maybe does they did do a good job of this is a typical experience or something that did make sense, and what's something that's like, this is 100% wrong.

Dr. Katrina Furey MD: Yeah. I think what I really liked about her character was I'm also imagining someone of her stature and fame going through IVF would be really nerve wracking. And when Preacher takes her picture at the clinic, she probably would be really terrified of that getting out there. That's her personal, private medical information. She's not going to want it to get out there. I would imagine as a famous person, that would be really accurate. We remember how when we were talking about suCcession, and we said, is it narcissism, or is it just growing up in this environment? I think for her, the same question came to my mind. Was the paranoia aspect, like, is she paranoid in developing a psychotic disorder, or is this her reality? And it is her reality. We see that, right? People are following her. They are trying to get her. It seems like they got her somehow. This is her reality, and we see her being invalidated over and over. And I do think as a woman navigating the health care system, unfortunately, we know this happens, and now there's all these studies out there that women and something even just like pain is constantly invalidated. Right. Like, we're all expected to go to work when we have awful menstrual cramps, it's like, well, just suck it up. And, I mean, we know now that these things affect certain members of the population even more so.

Portia Pendleton LCSW: Right.

Dr. Katrina Furey MD: Like, I'm thinking about racial disparities, socioeconomic disparities. We tend to get invalidated more, I think, near the end, the scenes with the physical therapist played by Cara. Right. Maybe it was.

Portia Pendleton LCSW: No, I don't think it was her.

Dr. Katrina Furey MD: When they were doing the ultrasounds and stuff. Right. The transvaginal ultrasound, they did show a lot. Right? Like, they showed her in the stirrups. They showed. That is what the wand looks like for the ultrasound. It's not small, and it doesn't feel like it hurts. Under the best of circumstances, it's not pleasurable. And I thought they actually did a good job of showing that and showing how, unfortunately, with pregnancy and everything, it is very invasive, and they're not doing a good job of obtaining her consent beforehand and stopping when she says to stop. And I think, I hope that's not the average woman's experience, but I can't say I'd be surprised if I heard some of this stuff happened. Even thinking about things like, I don't know if you know what a membrane sweep is, but cervical exams toward the end of pregnancy to see how much you're dilated, you should always ask permission before you're doing an internal physical exam on anyone. And I think sometimes people just do it even if the woman doesn't want you to. So there's a lot, I think, especially in obstetrics, that needs to be improved and continues to be talked about. And it did highlight that I was really annoyed when they kept saying, like, oh, it's the hormones you're taking. That's what's causing all of this, because. Sure, I guess any medication like progesterone or anything else, theoretically, I'm sure there's someone out there who's experienced psychosis related to the medication. I would imagine it's incredibly rare. That's not a common side effect for most people. Progesterone is an anxiolytic, which means it calms you down. It shouldn't make you paranoid. I think if she weren't actually being followed and she was hallucinating or having paranoia, she probably is experiencing psychosis, which can be triggered by the hormonal shifts and usually is an underlying indication that the woman has bipolar disorder. So whenever we see psychosis development, pregnancy, or in the postpartum period, it's bipolar disorder until proven otherwise. You of course, would do the normal workup for psychosis. Check labs, check brain imaging. Just make sure there's nothing else going on. But usually, again, this is the first time a woman will experience it, and it is an indication they actually have a bipolar disorder. And it is worth mentioning that postpartum psychosis is a psychiatric emergency, and it's associated with a 5% risk of suicide, a 4% risk of infanticide. So it's pretty scary. And again, I think, important to note that when I am treating women who have these intrusive thoughts about harm coming to their baby, I always try to tell them, like, yes, it's distressing, but it's a good sign if you're feeling distressed by that, because that means you're more likely to have anxiety or OCD. It's when it's not distressing or it feels almost like an altruistic delusion, like, I have to kill my baby because Satan has inhabited their body kind of freedom. That is Psychosis. And what's, you know, you'll often see sleep, know they can't sleep. They're very restless. They're agitated. They'll have delusional beliefs, like what I just mentioned with the baby. Delusional beliefs and broad strokes are somewhat a fixed belief that other people in your culture don't share. But, like, you believe you're getting messages through the radio or through the TV or things like that, and then you can have hallucinations, which are seeing or hearing things that aren't really there. So, again, if Anna Victoria had been having the same symptoms she was having but not been being followed, she'd be psychotic. But this is actually right with the pictures.

Portia Pendleton LCSW: I mean, the pictures when she was looking at them. And then she saw Ivy in the background at one like that. Felt like it was a hallucination, but everything else was right. Like, she was seeing her. The doll, the mean, that was real. And then what's her name? Anna? Sonia. Or Adeline. Right? Like the artist or the deceased wife. That's who's bizarre. And then what we're following, right?

Dr. Katrina Furey MD: Like, a lipstick Ivy doing the ultrasound was real, but no one else knew she was. Like, all this is happening. And I think what helps us realize that it's reality is when Kumal, the driver. Sorry. Kumal sees. Right, like, when he was driving her, right. We see someone outside of her who can confirm, like, no, this is really happening.

Portia Pendleton LCSW: So do you think that preacher is that woman that they showed in the flashback, in the think so, too. So she had to deal with it. And now she's trying to warn multiple people. So Anna Victoria and then Dexter's mom.

Dr. Katrina Furey MD: I was like, was the mom preacher's baby? Are we going to find out who that baby was? Has that baby become part of it? We don't really know.

Portia Pendleton LCSW: And what are the babies? Because they are like spiders.

Dr. Katrina Furey MD: They're like something and stuff.

Portia Pendleton LCSW: Yeah. So do they turn into people or do they turn into things that can look like people?

Dr. Katrina Furey MD: And is the husband.

Portia Pendleton LCSW: Is Siobhan one? Or do they sacrifice them? And that's how they keep the wealth and fame. Right? Because at the last episode, we find out that Siobhan, when she's with that writer guy who she hates but is like, having sex with, he's like, why did you. Who are you? You made me do this movie. You made me cast Anna Victoria. And now it's like, up for Oscars. It was like a terrible script and she's a bad actress. And I was just like, I just want to know what, obviously, and hopefully we'll find out in part two. But what is happening?

Dr. Katrina Furey MD: What is going. Yeah, exactly. Like, how are they all in on it? I think they're all in on. Think they're all, I think even, like, Nicolette, the house manager who just had a baby, I'm like, is her baby one of these crow, like, what's going, like, why are they all sacrificing their. Oh, it's just weird. And then also, when the younger actress died, got decapitated. Remember, like, Siobhan. Yes. Babet had called to be like, how bad do you want it? Are you willing to do anything? And then that happens. I was like, oh, yikes.

Portia Pendleton LCSW: Right?

Dr. Katrina Furey MD: Spooky.

Portia Pendleton LCSW: The last episode was a lot there at first when the mom came in. So Dexter's mom, she seemed like, overbearing, rude, inappropriate boundaries. And I was ready to kind of go down that path. And then all of a sudden, to see the way that Dexter dismisses her feels very similar to him dismissing his wife. I'm curious about, is his ex wife alive or his deceased wife alive? What happened with their father?

Dr. Katrina Furey MD: Is he part of it, going to court against him? Why does she ask him to testify on her behalf? How icky. And I just found that fancy lunch between the two of them so awful and cringey. And the way that she just kept saying, I wish I never had kids, but I didn't have a choice. And you're like, saying that to the kid you had. It's just so awful. But also, I feel like I've seen an iteration of that conversation on the Real Housewives. So I think there are awful parents out there who just don't know boundaries and this awful stuff to their kids.

Portia Pendleton LCSW: Right. Because I think there's ways to express things that if you really feel like they need to be expressed without saying it the way that they're saying it.

Dr. Katrina Furey MD: Right.

Portia Pendleton LCSW: Like, oh, pregnancy was really hard. Not, oh, I wish I was never pregnant with you or toddler years were really challenging as a parent. Oh, you were. You know, you were colicky, you didn't sleep a lot. Like, that's not. That's, like, kind of a fact versus. And I wished that I had given you up for an option.

Dr. Katrina Furey MD: It's like, right. There's what I think. Right. I think to be able to navigate that difference and see it, you have to be able to empathize with depths in this case, and imagine what's it going to feel like for him if I say this, and maybe I shouldn't, because maybe. But, like, there are people with narcissistic traits, borderline traits, sort of that cluster B personality realm, which, again, just as a refresher, includes things like narcissism, borderline personality disorder, histrionic personality disorder, and antisocial personality disorder, where they're missing that empathy chip, so they're really not able to think about that. They just sort of see everything through their point of view, and that's it. And I feel like she's right in line with that.

Portia Pendleton LCSW: No, totally. So that'll be a know to be continued or TBC for part two. But.

Dr. Katrina Furey MD: I think the last thing that I thought was a really interesting line was something that Sonia said, actually. Again, Sonia is like, I guess, like the artist that Dex is apparently working with, but she looks a lot like his ex wife and even identical. Yes. Like, even Anna Victoria asks her, are you related to her? Do you know her? And stuff? Like, she's starting to pick things up. And Sonia was know my mother was borderline or bipolar or both, who knows? And I actually thought that was such a smart line because those conditions, borderline personality disorder and bipolar disorder, often get misdiagnosed as each other. Sometimes you can have both simultaneously. I'd say that's probably pretty rare. But we're constantly misusing those labels, not only in popular media like this, but I think even, unfortunately, within the field, there can be similarities. And I think I often see people diagnosed with bipolar disorder when really what they have is borderline personality disorder. So I thought it might be helpful to maybe talk about the differences between the two.

Portia Pendleton LCSW: Yeah. And I think I just want know our listeners, if you have seen the bear in season two of the Bear, which is episode we released last week, there is a moment where the mom.

Dr. Katrina Furey MD: Donna, or is it Donna?

Portia Pendleton LCSW: So she's having, like, television. She's having kind of, like a moment. But I think that's kind of a good example of when she's, like, cooking and there's chaos of where people do get confused because I think if you're using kind of pop psychology references, it's like, oh, she's having an episode. She's manic. It's like, she's not manic. She's dysregulated. And so we throw that around a lot. And I see mostly now bipolar two constantly paired with borderline. And that is pretty frustrating, I think. Yeah. And it just seems like a label because most people are not borderline one, which is like, you meet full criteria, right, for mania. Yeah, bipolar one. And yes, bipolar one. So it's not common. It's like a rarer disorder. And so we now have this bipolar two, which is, like, less severe symptoms. Right. Which is. But I feel like it's often over diagnosed in teens, young adults who are just having episodes where they're feeling dysregulated. They have a lot of environmental stressors. So it's really frustrating. So, yes, let's talk more about the differences.

Dr. Katrina Furey MD: I would love to. I totally agree. And especially the bipolar, too. I will say anytime as a clinician, I see someone coming to me with a diagnosis of bipolar Two. I'm skeptical just because of this very phenomenon we're talking about, and especially once I see they have a quote unquote, history of bipolar two, plus trauma, plus substance abuse, plus ADHD. To me, what you're actually talking about are different characteristics of borderline personality disorder. You're just calling it different things again, not saying it's not possible to have all of those things. And sometimes it's not even borderline personality disorder. It's just trauma and, like, the sequelae of maybe living through traumatic experiences or complicated chronic traumatic experiences like child abuse or things like that. But I would love to talk about this topic. So when we think about borderline personality disorder again, revisit our Bear episode, revisit our episodes on succession and White Lotus, where we talk more about this know Roman in succession, and then Tanya and White Lotus again. It's a type of personality traits that are really stemming from know. Fear of abandonment is, like, at its core, and it can definitely have mood labelity. Which means that your mood changes rapidly. It can have impulsivity, you can have self harming behaviors, a lot of things that go along with it. But how you distinguish something like borderline personality disorder from something like bipolar disorder is the episodes, right? So like people with borderline personality disorder or other personality traits or perhaps trauma who have emotional label will have mood swings on the order of like minutes to hours to days, right. So usually their mood swings last short amount of time. Minutes, hours, days. These are the people who will say to you like 1 minute I'm happy, the next minute the world's awful and it's very black or white, very much all or nothing way of thinking. With bipolar disorder, what you have are discrete episodes of Time where for X number of days or more, you're experiencing multiple symptoms simultaneously, right? So the easiest way to think about it is when you have a major depressive disorder, you have symptoms of depression lasting for 14 days or more in a row, right? It's not like you get bad news and you feel really depressed or you lose a beloved pet and you're grieving. This is different. This is 14 days or more in a row. And it's not just the low mood and the anhedonia or loss of interest in things, it's other things too, like disrupted sleep, change in appetite, change in energy, trouble focusing, maybe some suicidal thoughts. Like all of that is depressive episode, right? So same thing applies for the other pole of mood disorders, what we call mania. Right, for mania for at least a week or more. So seven days in a row or more, you have to have a certain number of symptoms persist. That's very different from your baseline. And the acronym that we use to sort of remember, well, what are these symptoms you're looking for is dig fast. So distractability, impulsivity, grandiosity, flight of ideas, activity, increase sleep deficit and talkativeness. So basically these are people who feel like Superman on top of the world, very grandiose, have all these big ideas. They're engaging in impulsive behaviors, whether it's substance abuse, reckless spending, gambling, sexual encounters, flying down the highway on this skateboard, jumping off a roof because you think you can fly, like all of this stuff together. It's really hard to follow their train of thought because they're all over the place and they're talking so fast. We call it pressured speech. You can't get a word in. Once you've talked to someone with this, you know what I mean? But it's like, if you notice having normal conversations, like Portia, if you were to start talking, I would stop to listen to you. These people can't stop themselves. It's like they have a motor running and they can't stop. So that's the most extreme form called mania. Once you have one manic episode, you have bipolar one disorder. Most people with bipolar one disorder will also have depressive episodes, and they might have hypomanic episodes, but you have to have a manic episode, and usually the disruption in your functioning is so severe that you end up hospitalized. What's interesting is that most people with bipolar disorder, their first episode actually is a depressive episode, and it occurs in your late teens to 20s for men, twenty s to thirty s for women. Sometimes when you have mania, you also have psychotic symptoms like delusional thinking, hallucinations, things like that. And again, in pregnancy, if you have postpartum psychosis, that is most of the time indicative of an underlying bipolar disorder. And that's usually the first manic type episode that you're having or psychotic type episode. Bipolar two is a condition in which you have hypomania, so kind of like halfway between normal mood and mania. So maybe you're talking a little quicker, maybe you're not sleeping as much, but you're noticing it. You're having a bit more grandiosity, but it doesn't reach the threshold of mania, and that has to last for four days or more in a row. So again, it's not like you got great news and you're feeling high and on top of the world because of that for a short period of time, or you're having mood labely, it has to last for four days or more in a row. And for bipolar two, you have to have discrete episodes of hypomania and depression. So that's kind of a quick overview. Is that helpful?

Portia Pendleton LCSW: Yeah. I think the biggest takeaways are that, I don't know if this is just a really simplified way of thinking about it, but I like to think about borderline or BPD as more of typically, or just environment's effects. So, like wounds from childhood, attachment issues, trauma, and bipolar one, it feels more organic, like it's your brain. It's not happening because you experienced a trauma. Obviously that can trigger things, pregnancy can trigger it, but it's really more organic.

Dr. Katrina Furey MD: Medical.

Portia Pendleton LCSW: Yeah, exactly. And that's why medication is more effective. Right. For bipolar one, it's like it helps your brain kind of regulate itself, and that's why with BPD, we often see, and you could speak to maybe the specific ones, but like, seven different kinds of medication. Who medicating all the different symptoms?

Dr. Katrina Furey MD: Yeah, 100%. I think that's a great way to put it, is that I always think about BPD as the symptoms come out, when there's interpersonal conflicts. So often when you have a fight, you feel rejected, you feel emotionally abandoned, that's when you see the symptoms come out. And again, like, the mainstay treatment for BPD these days is DBT, dialectical behavioral therapy, where it's all about identifying emotions, learning how tolerate distress, learning interpersonal effectiveness to be able to communicate your needs more appropriately and more assertively without acting out behaviors like harming yourself or making threats or things like that. And you're totally right that the treatment for bipolar disorders, you really need medication to keep it under wrap, specifically mood stabilizers, and sometimes antipsychotics or atypical antipsychotics. It's really hard to convince people to stay on these medications because unfortunately, they do have side effects. And a lot of times, part of mania is this grandiosity where you feel like, above everything, you feel like you can handle anything, you feel great, like you don't want to take it, you don't want to come down, because it's, like, intoxicating. So, as you can imagine, it's really hard to get people on board to take these medications. And the crash after a manic episode is usually a really bad depressive episode. And so, as you can imagine, the risk of suicide and things like that is really high, especially when you add substances on board, which can happen. A lot of people living with untreated bipolar disorder rely on drugs or alcohol to either bring them down or bring them up. It's really tricky. But then you're right. With BPD, the best treatment is really good therapy, and we use medications more so to treat the symptoms of BPD. Sometimes there is evidence for things like lamictal, which is a specific mood stabilizer to help with BPD, or SSRIs to help. But usually with BPD, again, you're treating the symptoms. And sometimes, unfortunately, I see in my practice, when you have a patient with BPD who doesn't know it because they haven't been accurately diagnosed or they're in inexperienced hands, they might be told they have bipolar disorder and ADHD and depression and anxiety and OCD, and basically all of the diagnoses possible, which is incredibly rare, to have every single mental health diagnosis possible. So you see someone, I think I've shared with you before, once I see someone's on medications from five different medication classes or more. My suspicion for BPD is pretty high. So usually I see, like, an SSRI plus a benzo for anxiety, plus a stimulant for ADHD, plus an antipsychotic like seroquil to help them sleep, or for their brief psychotic episodes, which, again, some patients with BPD do have these brief kind of, like, psychotic experiences of dissociative quality or things like that. And then the fifth one is, like, dealer's choice, like some random thing like propranolol or gabapentin or some random medication from a class. Again, once I start to see that, I think, okay, we need to step back and think, like, what are we treating here? It looks like we're treating each of the individual symptom clusters of BPD without actually treating the BPD. So that's just sort of what I've seen and kind of developed over time.

Portia Pendleton LCSW: Yeah, I mean, it seems to pop up in a lot of TV and movies. It's like bipolar, or in older movies, like Manic depressive and BPD. And narcissism. Of course, we can't forget our friendly narcissists, but. Which I would say is, like, probably Siobhan, right? Like, big, high PR for marketing. Definitely. I think she portrays it, and I think that's probably just, like, a typical presentation, being in that big of a.

Dr. Katrina Furey MD: Position with power, right, where it's so image focused. And I did not get any with a narcissism from Anna Victoria, which I think is notable, even though she is, like, a famous actress. Again, not saying famous actresses have narcissism, but sometimes they do. So it's just interesting. And I think, even though as a whole, I didn't love it, I do think there were so many rich mental health themes that we keep seeing come up. And I always find it fascinating that in the art and media, this crossover of narcissism, BPD, bipolar disorder, kind of mirrors clinical experience that these things can be tricky to tease out because we don't have, like, a blood test or brain scans. Despite what the Amon clinic and all of their charlatan shenanigans will want you to believe. You can't diagnose this stuff with your favorite. Oh, my God, I just drives me nuts.

Portia Pendleton LCSW: Yeah, well, and you just had an article come out with CNN about some of the new medication that is available for postpartum. We will link it in the show notes if you want to check it. You know, I think there's more research being done, more evidence kind of coming out all the time. That's hopefully supporting women and their birth journeys or their pregnancies, IVF journeys. And just like, I think it's been lacking for so long, so maybe even a show, right? That's like it's American Horror Story, so it's supposed to be wild and cringey.

Dr. Katrina Furey MD: So it's like, I think it's so great. Let's keep the conversations going.

Portia Pendleton LCSW: Yes. Love it. Well, thanks for listening. Today we will be releasing part two as it comes out, and I am excited to do at some point, Murder House, just the psychiatrist in it. So that'll be fun. But you can follow us on all sorts of social media, TikTok, and Instagram at Analyze Scripts, podcasts. We are on YouTube now, so if you're watching, thank you. If you're listening and you want to watch, check us out there and make sure to like, share us and subscribe and we'll see you next time.

Dr. Katrina Furey MD: See you next Sunday.

Portia Pendleton LCSW: Bye.

Dr. Katrina Furey MD: This podcast and its contents are a copyright of analyzed scripts. All rights reserved. Any redistribution or reproduction of part or all of the contents in any form is prohibited. Unless you want to share it with your friends and rate, review, and subscribe, that's fine. All stories and characters discussed are fictional in nature. No identification with actual persons, living or deceased places, buildings, or products is intended or should be inferred. This podcast is for entertainment purposes only. The podcast and its contents do not constitute professional mental health or medical advice. Listeners consider consulting a mental health provider if they need assistance with any mental health problems or concerns. As always, please call 911 or go directly to your nearest emergency room for any psychiatric emergencies. Thanks for listening and see you next time.