A clinical breakdown and why diagnosing online doesn't work

One of our friends just asked me if I could shared my perspective as a psychiatrist, and I'll try my best here to do so. I want to actually lay out the clinical picture in some depth, not just react to it.

One of the main things we've been seeing is the amount of diagnosis online. But why you can't diagnose a personality disorder (or honestly, most things) from journals and social media?

Personality disorders are diagnosed from enduring, pervasive patterns across relationships and functioning, going back to early adulthood, assessed through direct clinical interview, old posts read after a tragedy, with full knowledge of the outcome are not the best resource for a diagnosis for different reasons. In fact, there's a real phenomenon called hindsight bias in retrospective diagnosis: once you know what someone did, their past writing gets reinterpreted as if it was always leading there. The nanny and pediatrician's testimony doesn't prove there was no underlying pathology, personality related or otherwise, people can mask a lot in front of others, including clinicians. But it does mean the "cold, calculating narcissist" read isn't something the current testimony actually supports either. Both the confident personality disorder takes and any confident psychosis takes are running ahead of what's actually been established.

The psychosis is another very disturbing point. People confuse it a lot and still take it in a Freudian way, as if psychotic people are out there naked on street, running, with their hair undone, saying things no one understands. And I want to focus on postpartum psychosis, which is a distinct psychiatric emergency that involves mood instability, disorganized thinking, and psychotic symptoms that can fluctuate rapidly, and yes, hours of apparent lucidity followed by deterioration within the same day. That fluctuation matters because it means moments of apparent function don't automatically rule psychosis out.

But I want to be fair to prosecution, because I think it's the strongest point: the sequence that night of sending Patrick out on an errand, then calling him and 911 afterward is genuinely hard to fully explain with psychosis alone. Why? Simply because it's hard to prove. Prosecutors are right to lean on it. On the other side, though: planning and psychosis aren't NOT mutually exclusive (people in psychotic states can retain procedural memory and even short term goal directed behavior). I don't think anyone, including expert witnesses, can say with certainty from the outside which of these features weighs more. How do you prove either side if you can't access her brain on that day?

Finally, the medications. She had prescriptions... Lots.of.them. What's come out in testimony with multiple prescribers, several psychiatric medications including benzodiazepines is significant on its own. Rapid medication changes or combinations prescribed without coordination between providers can produce disinhibition, confusion, or worsened mood and impulse control, especially postpartum. This is the defense's actual argument: that she was overmedicated and experiencing extreme postpartum psychosis. It's worth taking seriously as a documented, objective timeline, rather than dismissing it as an easy excuse, despite her not taking them.

But documented medication problems don't automatically prove impaired responsibility at the moment of the killings either, that's a separate, harder question, and it's exactly what the jury is being asked to weigh.

What I'm not saying here

I'm not diagnosing her, and I'm not arguing she should be found not criminally responsible, that's a legal threshold I'm not qualified to weigh in on, and it's not what this post is for. What I am saying is narrower: the personality disorder theories circulating online are not clinically supportable from the material being used to support them, regardless of how this trial ends. The psychosis explanation is at least clinically coherent with parts of the evidence, but it has real tension that we may never be able to connect.

What evidence/timeline cuts harder for you and why?