The story itself is crazy. Like this guy and girl get kidnapped in these really odd circumstances and they, then the girl comes back and everyone accuses her of being a gone girl and that they think the cops and everyone think that they made up this kidnapping. The guy is a Harvard trained Marine who has PTSD and Harvard trained Marines.
They train Marines at Harvard.
independently Harvard Harvard lawyer was a Marine PTSD and then goes the full just he kidnaps people he molests them okay but the details are really bizarre he kidnapped he kidnapped these this couple the reason why they thought it was a con girl he he kidnapped them in a wetsuit he took their blood pressure and he played soothing music while he did it and then this sexual assault was really weird and that like he he made it seem like he had to do it because the people higher up were forcing him.
Then he, and when they go and do like find out his previous crimes, he'll stop his crime. If like the person says something convincing, one girl was like, please don't do this. I have a history of this. So he doesn't do it because he feels bad. And then he gives the girl advice on how to avoid the situation occurring in the future. Okay.
This is fictional, right? This is true. No, then it's not American horror story. Why? Well, American Horror Story is fiction.
I think... Well, it's a true story.
Okay, which show is this? You gotta tell me the name of the guy, or what's this?
American Nightmare, maybe it is. American Nightmare.
Oh, okay, not American Horror Story.
They don't make these details clear in the documentary, but if you read the wiki, he's psychotic, and... Yeah, he's doing these crimes because he thinks he has to. So it's like a really interesting interplay that like, yeah, his driver for the crime.
That is interesting. I mean, obviously, I didn't eval this guy or view the case before. But the first thing that stood out to me, which is relevant to our episode today, I don't know if you're going to put this in or not. But what stood out to me is that it was a high level of achievement and persistence in achievement that did not match the kind of apparently psychopathic assaultive behavior that is usually the product of a personality disorder or a personality problem.
So that was a mismatch there. So immediately I flagged that for that something is a little off in this case. It's not your typical unpsychotic serial killer or a serial rapist.
Yeah, there was a lot of odd things that just didn't make it seem matched up with a psychopathic, I don't know, violent rapist.
Yeah, there's an oddity and there's a change in the life force that shows you that it's something that maybe is a little more organic, even if it's building on something that is fundamentally a psychology. Everyone's got psychology, but then when it interacts with a psychotic disorder, things can get strange.
Now, today's sponsor is Wim Hof Breathings.
Okay, I disagree with that being a sponsor, but you mentioned it earlier. What's going on with that?
Well, our sponsors are just random things that we think of 10 minutes before.
Yeah, I looked at a Google image search of this. It seems to be some kind of a mountain man, and he does breathing stuff. What's going on?
You hyperventilate, you do 30 hyperventilation breaths, and then you're able to hold your breath for a long time. And you're supposed to do a few cycles of this. You're supposed to do a few cycles and then go into the cold. I don't go into the cold. I just do the breathing. I do it every single day because it makes me feel better.
Good Lord. I'm just going to come out right away and recommend against doing that. I think there's probably better ways that you can achieve a similar result, but let's not get into it then. I disagree with that as a sponsor, but it's an interesting idea, let's say, for mountain men.
So it's a sponsor, an unofficial sponsor that we don't support. Or that we have a split.
Some guy that you mentioned and something you do, Dr. Malzberg. That's interesting. And I think we'll leave it at that. So good morning, Dr. Malzberg.
How are we doing?
What are we talking about today? I think I'm well. I believe that we reviewed all the comments. And yes, I do review all the comments, including the Reddit comments. I find them very interesting. And I felt that there was kind of an even split what people wanted to hear about in terms of kind of the really basic underlying theory on development and how personality works versus kind of how can you reasonably assess for personality conditions when you're a run of the mill med management person who just can't get that much time.
with somebody and i think we're doing the latter and it's not that we're not going to do the former but today we're going to talk about practical assessment of personality
That's correct. So I think what we're going to be going for today is practical assessment of personality in a relatively short period of time rather than, you know, getting to know someone over months and having tons of collateral. I also suspect we'll be going into a little bit more detail about the alternative model for personality disorders, but I'm going to have you be the.
You're giving it away. Oh, correct. Correct. That's the one I'm going to select to recommend people use here. Why? Because it is considered, it's alternative because it's not hypothetical. It's considered a coexisting and as valid model as the traditional DSM-IV model for personality disorders. This is a DSM system, you know, APA approved. So we have at least an air of legitimacy.
Yeah, and I want this podcast to be practical. I'm probably going to make sure you don't get pedantic, and I'm going to, as normal, keep you grounded. So to get started, what is a personality?
Well, a personality, in as brief as I can say it, is a collection of habits and responses that in terms of how we react to other people, ourselves, and situations, that is both informed by the characteristics we're born with and by our development. Strongly development, but the reality is the nature of our development, the quality of our development, comes from who we are to begin with when we're born.
And most people grow up in a family system that is informed by their basic biological characteristics. You know, people are similar to their family members. That's normal. That's genetics. So there's going to be some kind of style. But that's base theory. So I don't want to get too much into that. I want to stick on assessment. Let me ask you a question, if we can start briefly with that.
How do you think you approach personality disorder diagnosis, practically speaking? Or what do you think most people do?
So those are two different questions, and I'm just going to say what most people do. Most people use vague heuristics to diagnose just a few of the major personality disorders, and then from there feel as though medications won't work.
I totally agree. I feel like there is quite a trend in the community of diagnosing off vibes only, off countertransference only. Probably what I mostly see is that they ignore personality. I think even when personality is slapping an experienced clinician over and over in the face, they refuse to make the diagnosis. I think that's pretty common. I also see when essentially if they see enough recurrent self-harm and aggression, they just go straight for borderline.
Or if they see enough convictions or arrests, and they also see some kind of a behavior interpersonally that they don't like, then they go for antisocial. That's kind of the state of the community as far as I can see. Maybe I'm being a little too critical here. But we'll go into sort of at least my personal model about what I would recommend in terms of practical assessment of personality.
That's great. And yeah, I don't want, I feel it's too easy to become just a mock and criticize podcast. So today we're going to, I really want to hammer in your understanding.
Yeah. So to begin with, let's just, oh, go on.
Oh, I just wanted to, I assume you're going to be getting to this just to recap with the alternative model is basic definition of what a personality is. Pattern of perceiving, relating to, and thinking about the environment and the self. There is the The DSM personality disorder model, which is just 10 specific personality disorders. And those are 10 unique. It's the categorical model. So there are 10 unique personality disorders.
The issue with those... Yeah, you either have them or you don't. And the issue is that... If you actually learn people, they rarely fit into one. It's not like there's these 10 personality styles that everyone fits into. Now, the alternative model is a little bit better because it's more dimensional. And maybe we can talk a little bit.
Yeah, I would say it's a lot better, but we'll get to that bit later. All right, all right, all right.
I'll hand it over back to you.
Okay, let's start with some preliminaries. First, listeners, dear listeners, this is a quick off-the-cuff look at this, okay? It's a podcast, not educational seminar. Please take it with a grain of salt. Also, especially if you're a layperson or a professional listening to this, please don't feel too called out by anything we talk about with personality. I think the weakness of the categorical model in the DSM is that it sort of lists the characteristics that are most rare and extreme so that in a way, as professionals, we don't have to feel that we are pathological in any way.
Whereas the reality is, Personality, everyone's got personality. Everyone's got personality functioning and we all have flaws. So if you take a more nuanced look at personality, you may begin to think, do I have a personality disorder? You know, we all remember being hypochondriacs in medical school and we were learning about every single condition. So don't feel called out. These are all broad human tendencies and it's normal.
So when it comes to diagnosis, There's sort of state diagnosis and diagnosis via course of illness or history, right? You got the situations where it's very, very easy to make a diagnosis because it's there in front of you. Like if someone comes in and they're manic or floridly psychotic, that's a very easy diagnosis. But then you will have diagnoses where, let's say, for intermittent explosive disorder, picking a particularly history-based diagnosis, you're not necessarily going to see them exploding in front of you.
Maybe a better example or a more valid diagnosis is obsessive compulsive disorder, right? It's rare to see the patient exhibiting obsessions and compulsions in front of you day one. You really have to go off their description of their experience and history, right? So that's sort of two methods of reaching diagnosis. For personality, since it's such an all-encompassing syndrome and ever-present syndrome, I think it's very important to make sure that you're utilizing data from both the state in front of you in visits and also the course based on the history, and particularly the course.
Because, again, a personality disorder is supposed to be something that is present across settings and with different people.
And I think that matches something that kind of comes up in this podcast a lot in that you can't do, you know, a one hour snapshot of seeing someone and know exactly what the problem is. Sometimes you can hear things in the history, and I think you're going to get to that, that, you know, highly suggest those things. But observing someone over time is really the crux of understanding someone.
Yeah, though, I will say there is a lot of fear about diagnosing personality. Well-founded because it's not necessarily super well-taught in many training programs, and there is really a lot of stigma among clinicians when thinking about and looking at people who have personality problems. Inappropriate stigma, if you ask me, but it is what it is. We can't do much about that. I think you can, in some rare cases, confirm a personality disorder diagnosis within an hour it is possible but any diagnosis that you reach with short time you have to know that you're doing that with a lower degree of certainty than one that you've reached over time and from testing and retesting so just keep that in mind your diagnosis is only as good as the database that you're working with So if we need to know both the state and the course, and this is a relatively murky thing that anyone with or without a access one condition has, everyone has a personality, everyone has personality traits, then I think we need to be extra careful and take a process about the diagnosis.
So we probably all remember how we test for syphilis, right? We start with a very sensitive test and then we apply a confirmatory test with a specific test. So I think in personality, we do the same thing. We want to first listen carefully in a way that's more sensitive but not specific for signs of personality pathology within the visit, within interaction, and also in the history. And then once enough of those signs have been marked as present, In our minds, we go to something more specific in terms of our assessment, and that's essentially confirmatory testing.
And keep in mind, when it comes to psychiatric interviewing, your clinical judgment really modifies exactly how sensitive or specific any particular instrument is in making diagnosis. So make sure your clinical judgment is relying on a strong foundation of clinical experience.
I would love to go into more details on what you're talking about.
Well, we certainly will. There's a concept called listening with the third ear. What I would say is at the outset, make sure you are not just asking questions and getting information. You should be doing a mental status exam, right? You observe the patient and how they act, what they say and what they don't say, in addition to the literal information that they're telling you. On top of that, you observe how they interact with you.
You want to see how is this person interacting with me? In what way do they interact with me? And how does that compare to most patients? that's going to give you extra information as well. I'll give some concrete examples. Are they complimenting me more than usual? Are they expressing more fear or wariness of me or the treatment than the typical patient? Or do they seem to focus their speech, their communications on ways that they're doing well or that they're strong or good?
more than the average patient. These are methods of communication that may be salient. And then finally, you really need to pay attention to your internal experiences. Your emotional reaction to the patient is important diagnostic data. Again, not specific. None of these are specific signs or findings, but maybe you feel particularly fearful or agitated. Maybe you feel particularly bored or tuned out. All kinds of internal experiences that you have might have a pattern in terms of certain personality types.
And that's not universal in my experience. Different people get different pattern responses to different types of patients. So you have to start observing this across all your patients in order to be able to use this in your diagnostic process.
Yeah, and I think one thing that might be worth mentioning is it takes a lot of time and experience to get comfortable with this. The first few years that you're doing interviews, everyone, for me to maintain the structure, I was super rigid, was asking checklist questions, was going through very specific steps. And my entire working memory was trying to get through those questions and get the answers.
It took a few years for those to kind of be built into my head where I... instinctively would get those answers filled out without having to be like, okay, what's next? What's next? What's next? And then once I got to that point, I could pay a lot more attention to what the person's doing, what their eye contacts, what I'm experiencing. And so this is something that built over time.
If you threw me in as a third year medical student and asked me to do this, it's impossible. There's too much information because you don't have the structure built into your brain. These things layer on top of each other. So if you hear this, don't think that now you just focus entirely on the patient and feelings. It's a process and it takes time to build.
Yeah.
Yeah.
Yeah, really important point, right? Once the interview becomes second nature for a clinician, that is when it's easier to pay attention, attend to all those things. Absolutely true. And that you kind of do have to drill it into your practice before it gets to that point. You need time, you need repetition. One little tip is I would recommend when you start out doing everything the same way every time because that helps build a habit first once you do that you'll be able to deviate more from the interview process because you've already figured out what works what doesn't work and it's a little bit more second nature you don't need to be deliberate about it kind of like learning to tie your shoes right when you're a kid and you first learn to tie the shoes it's this whole process but you know you're tying your shoes 20, 30-year-old, you don't even think about it.
You just get down there and it happens. Similar way with the clinical interview.
And to go on to another point that you made, one of your instruments is your personal feelings towards the patient. And as you said, different clinicians that are extremely good have different emotions that are characteristic of different disorders. If we were to interview a narcissistic patient, we could have very different responses. It's not the exact response that should be overlapping. It's our interpretation of the response. And as you said, That's something you can hone by reflection in that if I have a certain experience of a patient that if a patient's telling me a very sad story and I don't emotionally feel something, that's information.
But I have to compare it to my other experiences. It's possible that there are some situations that just don't elicit emotion from me and they do in other people. So it's helpful to know yourself, know your internal responses and yeah, reflect on those things.
Yeah, it's not for some kind of a truth quality other than to know this what it is and then to, you know, compare that to your previous patterns, right? It's not like I felt a certain way so then I can definitively conclude this. You just need to get used to reflecting on and then naming your internal state and your responses during interviews. And, you know, one of my mentors would always ask during staffing, okay, but what was it like to be with this patient, okay?
That's an important question to ask yourself simply as practice with every particular patient. Another question that you can ask is, what did the patient seem like, right? Less technical, still really asking you to notice and describe into words the clinical observations that are more regimented or quote-unquote objective, objectively subjective. but by asking yourself those questions on every patient you're going to hone your instrument your personal lab test of the person so that's what we're kind of doing we're starting with sensitive stuff and then we'll go specific so what's sensitive and how do you get sensitive type of signs i would say that beyond the mental status exam The next part that's really important is the life course.
So the diagnosis personality truly relies very strongly on getting a honest and relatively thorough accounting of the patient's psychosocial life and their course in development. And yeah, that's going to take some time, as you probably know. We try to get all the really basic information on an intake, but often we're not going to get the specific details until we get more time with patients. And that is why most of the time it's not really feasible to make a definitive diagnosis of personality on the first visit.
Now, what sort of things... So I think to... Because sometimes sensitive and specific, those things can be a little confusing. There are signs that point you in the direction that it could be those things. And then you ask questions to really hone in and make sure it is those things. Those are kind of the two. Sensitive is getting it so you think it's possible. And then specific is making sure it really does fit that thing.
Now, what are the... So I want to not be vague and say, you know, the... longitudinal or the psychosocial history. Can you go into a little more detail by what you mean by that?
Yeah, and I wonder if it's actually better at this point to now be specific about the elements of personality functioning in the alternative model for DSM personality disorders. Because if we go through each of those, then I can highlight the aspects of the social history that we get with almost everybody that is pertinent. So maybe we'll do that. Remember, with personality functioning, In the DSM, we have it split into two areas with two sub areas.
It's about self-functioning and interpersonal functioning. Now let's start with self-functioning. Self-functioning has two areas, identity and self-direction. So identity is one's experience of the self as unique, with clear boundaries between self and others, stability of self-esteem, accuracy of self-appraisal, Capacity for and ability to regulate a range of emotional experience. You might ask, why is emotional experience regulation part of identity? That's an answer for more basic theory.
But this part is not quite as much in the social history. But this is something that you're going to get more of, I think, from fleshing out the patient's chief complaint and their force of illness. Let's move to self-direction, where I think in the terms of the DSM, it shows you a little bit more about social history is important. In self-direction, this is about one's ability to pursue coherent and meaningful short-term and long-term life goals.
Using constructive and pro-social internal standards of behavior, and having the ability to self-reflect productively. So what in the social history is important for this? We want to know about school performance. We want to know about any early misbehaviors, conflicts with authority, conflicts anywhere. And we want to know what has this person been doing in their life throughout their course of life. Keeping in mind that wobbliness or interruptions is natural and also expected in younger people and also people who suffer from axis one illnesses.
I should have emphasized this a little bit more, but you need to interpret personality functioning only after you have a good idea of what the access one conditions are like. So I'm talking about, we assume that you're, you have a reasonable idea of the onset and course of their access one conditions.
Okay. So Just to recap where you brought us so far, we know that there's two core elements to personality, and those are self and interpersonal. Self and others, I usually say, but you can say self and interpersonal. And then there are two elements within each of those. So for self, you can look at identity, who am I? And then self-direction, what do I do? And then the interpersonal, I guess you haven't talked about yet, but I'm assuming you're going to.
Yeah.
So I want to know things like, what's the longest job you've had? Were there any gaps in your educational history and into your work history? Why did those gaps happen? Did you get injured? Did you develop some kind of medical condition? Were you unsure of what you wanted to do? Is it because you had an idea when you were 20 and then you had a different idea entirely when you were 23 and then that idea changed again when you were 25?
Is it because you've never really had any particular wishes, wants, desires, values in which to direct yourself with? Right. And then beyond that, you also want to know legal history. Very important, especially when you're dealing with a community population. You want to know. Did you get into trouble as a kid? Did you steal little things? Did you do X, Y, Z? Think of your conduct disorder criteria.
Why did you get in trouble? How often did you get in trouble? Would you have conflicts with people? What was your friend situation like? Who were you friends with? How long were you friends with people? Those kinds of things matter. And of course, easy stuff, incarcerations as an adult, charges, convictions, anything like that, right? This shows you two things. Your ability to relate to others is predicated on identity.
And yes, I know I'm leading a little bit into the interpersonal element here because it all does tie together. But for self-direction, to summarize, we want to know their ability to regulate their behaviors to some kind of a pro-social standard. That's where the criminal history comes in and their history of sort of misbehaviors. And we want to know, can they self-direct and self-regulate and put themselves on some kind of track that is consistent?
And that's where your school and your work history really comes in.
And I think this might be a good time for me to mention, you know, criteria C and D, which is pervasiveness and stability. So these these things, you know, you mentioned legal history. If a person has, you know, one really bad thing that they did, that's very different than what we're looking at, which is a pattern of these things. These looking at things that are pervasive across social contexts.
And the concept of a personality disorder isn't that someone commits a crime or that, you know, someone, maybe they do change their career massively at a certain age. That doesn't, that's not necessarily indicative of a personality disorder. What we're looking for is the stability that these things are pervasive and, A big part of the definition of a personality disorder is that most personalities have some degree of adaptability, and personality disorders is a lack of flexibility with how they respond to their environment.
I just bring this up because it's not like any one thing will point like, oh, you're looking for a pattern over the lifespan.
That's right. And remember, we're still in the stage here when we're talking about this diagnostic process. We're not confirming any diagnoses. Right. This is all being sensitive, detecting signs. It's not pathognomic. We want to look for things that have happened repeatedly, ideally, or we want to see a pattern over time. But we're going to be sensitive to little science, too. And then, of course, the substance use history is then pretty important, even to looking at identity and self-direction.
Generally speaking, it is unfortunately the case that, at least up until recently, Most people don't use a lot of drugs regularly from a younger age, and I would actually say that that behavior is often indicated of problems with regulation of emotional experience. It's not always the case, but often people do use drugs repeatedly because they struggle with their internal regulation. So that can be a strong sign, especially from an early age with substance use.
It's also a soft sign that they did not receive a lot of other direction, right, from important loved ones, from parents, from society. And so naturally, if they're not getting much other direction as a child, there's not much expectation that we should have that they have much self direction. Some people, if they are using a lot of substances, yet they seem to be maintaining steady relationships, employment, and keeping actual law.
You might even wonder, well, this is actually seems like someone who has a lot of self direction. They're able to regulate themselves. That element of their personality functioning seems to be fairly intact or even outsized compared to their identity functioning, which includes again, their ability to feel and regulate a range of emotional experiences.
Interesting. So you're, you know, the same observable behavior, you can, you can mesh into more axis one or axis two, depending on your whole formulation of the patient.
That's right. And just in my experience, we consider substance use disorders to be an axis one condition. But to be frank, I think it's very rare to have a persistent and problematic substance use disorder in the DSM frame, right? Something that causes clear interpersonal dysfunction, distress, personal dysfunction, distress, symptoms, problems. It's very hard to have that maintained in a person and have total absence of personality pathology because in a way it's just wrapped up.
People who have good self-direction and emotional regulation, they find other ways of coping that are a little bit more productive. It's rare to find a situation where persistent use of recreational substances, especially illegal ones, is part of a stable and pro-social life plan. Might be a hot take, but that's just my opinion.
Thank you.
Now I think that's sufficient, broad discussion of self-functioning. Let's talk about interpersonal functioning. This includes empathy and intimacy. So empathy is comprehension and appreciation of The experiences and motivations of other people. Right. Not just yourself, but of other people. Tolerance of differing perspectives. Right. Being able to tolerate that other people disagree with you, feel and think differently. And also this, I think, is really important. Understanding the effects of your own behavior on others.
OK, so that last part. A person who has a deeper understanding feeling of how their behaviors affect others, they're going to have a lot less engagement in assaultive behaviors, combative behaviors, and illegal behaviors. People with a very depressive type personality, people who have very developed guilt sense, even an overdeveloped guilt sense, their internal reactions are going to prevent them from engaging in those behaviors most of the time.
So you're not going to see a pattern of any kinds of criminality, illegal behaviors in people who have a very developed personality in that sense. Empathy, again, as we discussed, is not just in the course, but also in your present interaction with the patient. You want to see how much do they seem to attend to your feelings and needs as a patient. Sorry, not as a patient, as a clinician.
Some patients are even... overly attuned to the needs and feelings of the clinician, they'll try to flip it around, almost make themselves a clinician and you the patient. But there are also some patients who just kind of come in and interact with you in a way that it's as if I need a certain thing from you and you're going to do it for me, right? I'm not saying these patients are wrong for that.
It's just that with a significant difference from your average patient, you might wonder about empathy. It's also housed in, the information is housed in how they talk about events with other people. How do they talk about what happened between them and other clinicians or what happened between them and a friend or a family member or the law or anyone? Do they seem to be able to automatically access and describe the reactions and internal motivations of other people?
Or do they mostly conceptualize things outside themselves? Like all these other people are doing things to me. Things are happening to me. I don't really contribute. They're not saying that, but that's what the narrative shapes. So that shows you a lot about empathy function. Now for intimacy, this one definitely lives a lot in the history. Intimacy is the final of the four elements here. It's the depth and the duration of personal connections with other people.
It's one's desire and capacity for closeness. And kind of related to what I was talking about with empathy, mutuality of regard in interpersonal behavior, right? Does the interpersonal behavior reflect some kind of mutual balance? So where do you get this one? Very easy. You want a good relationship history. You want to know a number of relationships, duration of relationships, how they met, how they broke up. You don't necessarily have all the time for this, but you can get a sense of it sometimes automatically, even from a patient telling you their life story about the troubles that they've had, right?
You want to know about conflicts in those relationships too, how much, you know, problems that they had, what types of problems. And you don't just want to know about romantic relationships. You do want to know about friendships. Do they have friends? How many friends do they have? Is it 30 friends? Is it two to five friends that they've been friends with since childhood, right? Those are different ways of relating to people over time.
And you also want to know about their relationships with family. Not simply do they have them, but the quality. What was the relationship like as a child with your mom or dad or who was raising you? And who are you still close to today? Who are your support systems? Having some kind of a picture of that, even vague, can essentially give you more indicators about whether this person is having problems with their intimacy functions.
I think something you mentioned earlier is that it really needs to, your comparison, there's no one answer that's right or wrong. You really need to talk to people who are psychologically healthy and get an idea of what normal responses are. Just because there's a lot of, there's things that you kind of get attuned to hearing that suggest that maybe something's a little off. Common patterns of personality disorders, probably one of the more common ones is...
idealization and devaluation. So they'll talk about this amazing relationship that was absolutely perfect. And then as they talk about more, you'll hear real discrepancies talking about how the relationship was perfect, but the partner cheated a lot. And I don't know, just listening for that ear of things that are not quite compatible to hear how you evaluate the intimate relationships.
Yeah. And so up until this point, we're not making a diagnosis and we're not even specifically assessing. We're basically getting information. Realistically, you should at least get a superficial idea at the end of the first intake. OK, it may sound like a lot. Just know that once you own your diagnostic instrument as a clinician, you you will know which cases to focus on psychosocial more and which cases to focus more on immediate symptoms and presentation, right?
You just have to triage. But when you have time, it's very important to assess these things in ostensibly normal patients. What do I mean by ostensibly normal? I mean patients that seem to have relatively normal personality functioning just on the face of it. people who are barely functional are in stable relationships don't have a lot of conflicts and are coming in for a more circumscribed problem like a panic disorder right new onset panic disorder new onset ptsd these are the patients that you can use to develop a clinical database in your mind about kind of roughly normal development versus your patients who have been abused, traumatized since the age of four, you know, in and out of foster care.
Those are not the patients that are going to give you the normal baseline, right? They did not have a normal childhood. They did not have the normal supports and developments and they had lots of traumas. And so I guess that brings me to another point. It's going to be a whole podcast if we get into it. But my opinion is that what they call complex trauma is essentially the same thing as what has been described as personality disorders.
Personality disorders acquired, in my opinion, from problems in development that usually are imposed by parents. Children are not responsible for their development, largely speaking. They can be a more challenging child than average because of the amount of aggression they have or whatever characteristics they have but nonetheless almost universally speaking a personality disorder happens because of developmental challenges that are not the fault of the patient and so that's the final life course sign that i really want people to look at what has happened to the patient okay it is totally implausible for someone who has a multi-trauma terrible developmental life from early childhood onwards to have a normal functioning personality.
It's completely clinically implausible. So in those cases, it's almost that you better find evidence for very good personality functioning if we're going to exclude a personality diagnosis.
That topic is loaded. I think let's leave that there. Okay. So, so far you've talked about listening with a third ear. You've talked about identifying the elements of personality functioning, the two core ones being self and interpersonal. Within self, thinking about identity and self-direction. With interpersonal, thinking about empathy and intimacy. Now, I guess we should start talking about what sort of things...
Confirmatory testing, basically?
Yeah.
Okay, so once you have a global sense of the patient's personality functioning, you have a few different options. If you feel that it's a very clear case where they do fit neatly into a personality syndrome as described in the traditional model of the DSM, I do find that the fastest way is to first exclude other axis one conditions causing those symptoms and then simply use what the format that's available in the SCID.
If you've never looked at the SCID, to be honest with you, you simply go through the criteria. I think we talked about this a little bit in the GPM section, maybe, but I'll give you one example. You literally might just ask, do your relationships with people that you really care about have a lot of extreme ups and downs? And you have the patient talk. We are not looking here for a yes or no response.
Obviously, we'll note that they say yes or no, but we want to get a narrative response. And so we'll say, well, tell me about that if they say yes.
Before, just to skid is the structured clinical interview for the DSM.
Right, yeah. and so you want to get them talking about the criteria you offer them the specific criteria and then you get them talking about that subject of course this relies on you having established a trusting emotional bond and therapeutic alliance where you're you both agree that we're working together doctor and patient to investigate what's going on with you to figure out how we can help right if you come into this with a mind internally or that the patient perceives that this is a punitive evaluation or that we are accusing, then you're not going to get the data by doing direct questioning like this.
Another example from this kid, you might say, have there been times when you thought that someone in the relationship was everything you wanted and other times when you thought they were terrible? Okay, well, tell me more about that. Well, how many relationships have you had that have been like this? OK, so that's one approach you can literally ask about specific sub criteria or assess for it by listing history using the original model.
I think that works perfectly fine for the very, very clear cut cases. We just should understand that the most appropriate diagnosis in personality disorders for most people is probably an other specified personality disorder where they have traits of multiple personality disorders, which is the manifestation of the core problems with self and interpersonal functioning. But it's quick, you know, it's been researched a lot and you can use it clinically.
So that's one way to do it. Now, if you need something more nuanced because a case is very subtle or hard to assess, I think that is when you have to really drill down and specifically look for evidence about all four elements of functioning. By the way, have you read through this type of R? Yes. So I would say that it's a great instrument. Now, obviously, to administer it formally, you're supposed to get special training where people supervise you.
But all those questions in the STIPO are, especially if you read the manual to get a sense of the purpose of those questions, they're just excellent questions to elicit general clinical data. You can use these questions on any of your patients, and you should, to get a sense of how different people respond. But using questions from this type of R, in my opinion, gets you a lot of clinical data automatically for all the four elements of personality functioning that you see in the alternative model.
So if you have a subtle case, I would recommend that you begin to look at more specific questions that get you a really global sense across the lifespan of how people are functioning with their personality. So I'll give an example. You could say, how important is work to you? What are your goals in work? Are you able to enjoy your work? What do you enjoy about it?
Tell me about what you wanted out of your work in the past, and what's it like today? And how's that been going for you over the last few years? Do you feel like you've been able to figure out what you want and get to what you want, or why not? And again, we're not looking for yes or no answers here. We want to get a narrative description that we can rely upon to make some kind of global assessment.
Another area we'll go to very specifically is just kind of knowing the patient's clinical picture and thinking about things like aggression and defenses. I know it sounds psychoanalytic, but there are specific clinical outputs that we can examine and point to and say, hey, that's something. Obviously, this is, as I think we mentioned at the beginning of the podcast, one of the ones that most clinicians use. If there is recurrent self-harming behaviors, that is a sign of a tendency towards aggression and a tendency to direct aggression towards themselves and also other directed aggression will be meaningful right fights physical verbal though we do want to be careful and we want to make sure that it's not the product of a axis one condition like a psychotic disorder or a traumatic disorder
Yeah. And I mean, I think just to reflect on the STIPO-R, you know, you don't necessarily have to go through all of it. I think kind of as you're saying is if you pick up on things, you can take a look at some of the questions and then think of the ones that will be helpful to hear the patient's responses to better flesh out, you know, whether the responses give you a holistic, real understanding of what's going on in their life.
And as you mentioned, there's no right or wrong answers. It's not, oh, it works great. It's listening for realistic answers that see, you know, the positive and negative in things. And also what's nice about it is it gives a little grading for how to grade what's healthy and what's unhealthy. So it can be helpful, even if you don't necessarily do the Stiple R, just to look at what they consider to be normal, healthy answers and what is considered to be more pathological answers.
Yeah. Oh, and I suppose I should mention some specifics about defenses, right? You all probably learned defenses when you were studying for a MS3 clerkship in psychiatry. You know, I think it's still useful to know some of these patterns when it comes to diagnosis, even if it's not very useful for psychotherapy or treatment, but some lower level defenses that can be quite present. in people with lower level personality functioning are general paranoia.
It's just a generally paranoid person. Are they always kind of guarded, looking out for people, taking advantage of them or trying to harm them? Obviously, as you mentioned before, tendency towards idealization or devaluation. Are you seeing evidence for that kind of splitting in relationships, professional relationships, personal relationships, treatment relationships? You might find someone that everywhere they go, they have some kind of a tormentor or some big bad person who's kind of the problem in their life, right?
And that's related to black and white thinking. When they talk about situations, is it all good or all bad? And these are things that you can ask about. And the patient who is with you, trying to investigate themselves with you, and on board with getting some kind of a diagnosis and explanation for their problems and distress, you can directly ask these, just like in SIFO-R, to get a sense of if they have these patterned defenses and if it's a problem.
Also externalization, as I mentioned before, is a major one, right? Do other people point out that they tend to externalize blame, right? Do other people find that they're somebody who doesn't quite understand the needs or wants of others? These are things that can be elicited directly in the history. And so having gotten that then in your subtle cases, this is going to take definitely a few hours of assessment meeting multiple times, you can begin to map the overall level of personality functioning.
for the patient. And how can you do that if you haven't done this before? I would have a full read through of the alternative model chapter, and I would certainly read through and use the table where they detail sort of different levels of impairment in personality functioning. This is table two. I believe it's on page 896 of the TR edition. Well, basically they show you level of impairments, you know, is it zero level or no?
Before you jump to that, I do want to just comment on the defenses. I'm curious if you have the same experience as I do. Usually in the moment, I can't identify what the defense is. It's only kind of after the appointment's over and I have some time to reflect that I'm able to maybe put words to what i was experiencing or identify what the specific defense was but usually in the moment it's just an odd feeling that i i feel something's off i don't know if you have that same experience no that's that's a great point i
think that often it's in reflection that we get a better sense of what was happening Because when you're in the moment, you can be in the moment. And the patient and you can be pulled into the interpersonal interaction. And that's different than being able to draw back and to reflect on yourself and the pair, you and the patient, right? Now, advanced clinicians... are able to both be in the moment and also pull back and observe at the same time and so when you practice you can get better at that but remember that recognizing defenses as written in this typo are you don't just have to look at what's happening in the moment between you and the patient that is a large part of it that's very important but you can directly ask for history right you can if the patient is ready if there's a good working relationship and they're being honest They'll be able to reflect on it unless they have a very severe level of personality pathology.
And we're not just here to look for severe personality disorders, right? Because we want to find the right clinical treatments for people. And if it's not a medication, that's important to prevent harm and to prevent wasting time with trying to treat a personality problem with a medication.
Yeah, and you definitely get better over time with your reactions to certain defenses. I think you really need to know what is your expectations in an appointment, be comfortable with yourself, have a good read on what certain emotions mean to yourself to be able to respond in the best way. Because yeah, as you said, patients will pull you into different dynamics or try to pull you into a defense mechanism.
And yeah, I think it takes time to not get pulled in and to respond appropriately. It's like a learned skill.
Yeah, it definitely is. So definitely going to take practice. Going back to my recommendations on the specific more confirmatory testing, so to speak, for the subtler cases, I just, again, read Table 2 in the alternative model. It will map out for you examples of different levels of impairment for all four domains. from little or no impairment all the way to severe or extreme impairment. Okay, you get enough data for that, you can make the diagnosis.
You can say, I have detected sufficient impairment based on this model in personality functioning. It's present over time. I also assessed and considered for the possibility that these impairments were not due to the personality, but more so due to an axis one condition that does not seem to be the case. My working diagnosis right now is this, okay? Once you have established the personality dysfunction, that tells you that a personality disorder is there.
If you want to specify the traits, then you can review all the different personality traits that may be present in order to get more specific. But you usually don't need a trait specified for most clinical purposes right because what we're really identifying here is that this is a person who through a combination of their own biology and their development has either underdeveloped emotional and habitual ways of relating to themselves or others or developed in a rigid and now maladaptive way patterns relating to themselves or others.
And then that's something that is pretty much best addressed through psychotherapy and changes in their lifestyle. If you really don't feel like this is enough, there are obviously tests and assessments. So if you want to get extra certain, you feel like you need it, you could try an MMPI. You could administer a PAI. If you don't know how to administer these, you can send them out for testing.
But remember, psychological testing results is just a tool. that helps you do the same diagnostic process that I just talked about. The DSM-5 also has some measures of self-assessment that you can give patients. I believe it's the level of personality functioning scale and also some kind of personality inventory for the DSM-5. I think it's the PID-5.
I actually think, I feel like you're relatively disagreeable, so you're probably going to disagree with this. I think it would be helpful for us to read the table two level personality functioning scale. Just read with level impairment zero and four, just because I feel like it really does paint a picture as to, you know, what healthy is and what unhealthy is.
It's going to be pretty long, I think. Yeah, I mean, we can consider it as a sample. You know, I think if you are okay with it, maybe just like one from each column and for level one and level... three, because I think that that actually gives us a better description of stuff that we're more likely to see. I think it's hard to find little or no impairment in a clinical population, I think even in a normal population.
And then extreme impairment usually is the kind of frequent flyers from institutions level of patients. So let's do levels one and three.
Sweet. I think it'll be helpful to review. Okay. So it's split up into self and Interpersonal, the self or identity and self-direction. So for some impairment, I'll read identity. You can popcorn read. I'll pass it off to you. So for level one, which is some impairment in self with the identity subheader has relatively intact sense of self with some decrease in clarity of boundaries when strong emotions and mental distress are experienced.
I like that brought up. We talk about personality. It's not like you're the same personality over time. People decompensate and show worse traits under stress and under pressure and under breakups. Worth mentioning. Self-esteem diminished at times with overly critical or somewhat distorted self-appraisal. And then lastly, strong emotions may be distressing associated with restriction in a range of emotional experiences.
And under self-direction, we have that they're excessively goal-directed, somewhat goal-inhibited, or conflicted about their goals. They may have unrealistic or socially inappropriate personal standards that limit their ability to be fulfilled. And they are able to reflect on internal experiences, but might overemphasize a single type of self-knowledge, intellectual or emotional. Again, I find that this is a pretty normal level of personality impairment. This is not a level that we would consider a disorder.
Now moving on to the interpersonal, we're going to talk about empathy. Again, this is some impairment. Is somewhat compromised. An ability to appreciate and understand others' experiences may tend to see others as having unreasonable expectations or wish for control. Although capable and considering of understanding different perspectives, resist doing so. I do that all the time. Has inconsistent awareness of effect of own behavior on others.
And for intimacy at this level, one is supposed to be capable of having enduring relationships in personal and community life. Some limitations on degree of depth and satisfaction. We don't find every relationship enjoyable. You should be capable of forming and wanting to form intimate and reciprocal relationships, but you might be a little inhibited in expressing yourself meaningfully, especially if you have some intense emotions or conflicts going on.
And you might be able to cooperate, but it could be also limited by unrealistic standards, or you're a little limited in your ability to respect or respond to others' ideas, emotions, or behaviors. I think that's very common for people.
So again, that fits you perfect.
It's not pathological, really, except in certain circumstances. Now, let's go to level three. That's severe impairment. This would be clearly if you have at least two domains impaired personality disorder.
And remember, this is a scale from zero to four. So we're talking about severe impairment. I'm going to be talking about identity, which is under self. has a weak sense of autonomy and agency, experience of a lack of identity or emptiness, boundary definition is poor and rigid, may show over-identification with others, overemphasis on independence from others, or vacillation between these. Fragile self-esteem, which is easily influenced by events, and self-image lacks coherence.
Self-appraisal is un-nuanced, self-loathing, self-aggrandizing, or an illogical, unrealistic combination. Emotions may be rapidly shifting or chronic, unwavering feelings of despair.
And for self-direction, a person like this has difficulty establishing and or achieving personal goals. OK, there's a lot of difficulty in that sense. You can't establish the goals. You can't keep them. You can't get yourself to them. The internal standards for behavior can be unclear, fuzzy or even contradictory. And life can be experienced as meaningless or dangerous. And the ability to reflect on and understand your own mental processes, also known as mentalization, is significantly compromised.
Then we're moving to the interpersonal empathy. Ability to consider and understand the thoughts, feelings, and behavior of others is significantly limited, may discern very specific aspects of others' experiences, particularly vulnerabilities and suffering, is generally unable to consider alternative perspectives, highly threatened by differences of opinion or alternative viewpoints, hashtag America, is confused about or unaware of impact of own actions on others, often bewildered about people's thoughts and actions with destructive motivations frequently misattributed to others.
Yeah, paranoid thinking, right? And then in the relationships and intimacy, at the severe level of impairment, you can have desire to form relationships, but the capacity for positive and enduring connections is significantly impaired. This is when you see the on and off again kind of quality to the relationships, right? Dropping some people even for years and then intensely being involved with them. uh the relationships themselves can be based on a strong individual belief internal belief of absolute need for the other person and also at the same time having expectations of abandonment or abuse and that feeling The feelings that they experience about intimacy and intimate involvement of other people, they'll alternate.
Sometimes they'll feel fear, rejection, and sometimes they'll have desperate desire for connection. And the relationship themselves, in terms of the back and forth, have limited mutuality. OK, the other people are conceptualized, felt primarily on how they affect that subject, the patient. Are they doing good things to me? Are they doing bad things to me? And being able to cooperate, work together in a relationship, build something that's greater than each individual can be disrupted because of perceptions of slights.
Oh, they harm me. I'm not going to cooperate anymore. It's not that they're necessarily thinking that consciously, but that's basically the effect. When there is a fracture, a rupture in a relationship, they have not been taught to, they are not accustomed to repairing that together with the other person, which this is an example of why the psychotherapy is so important in treatment. We are trying to provide new opportunities to experience different ways of interacting with, relating to themselves and others.
I think we just developed, if we ever run out of content, we just do Dr. Fu and Psychoform popcorn read.
Read the DSM and react. We react to the DSM. So yeah, I do apologize to the listeners for simply reading the DSM, but that's a little bit of a sample. You know, you really can't do this unless you do know the instruments and the concepts. But let's summarize. Don't be afraid to diagnose personality. You're not doing it. You shouldn't be doing it to punish patients. You're doing it because you want to be a good clinician and you want to correctly identify which things should be treated with psychotherapy and which things should be treated with medications and which things should be treated with both.
Like most diagnoses, you have to rely on the state in front of you and the course, but in personality, definitionally, it's something that's patterned and pervasive. It's all across the life course and across multiple relationships. So you really need to get good data. That's why I recommend that you start out with a global sensitive approach where you get a rich history of this person and their problems and what has happened in their lives.
Red flags in terms of I don't see how you can not develop personality problems with that kind of experience is obviously early or multi traumas. Right. That just changes how you're able to relate to other people fundamentally. So again, to me, complex trauma, personality disorder, same thing. uh and then once you have a clinical suspicion that uh there is a personality pathology that's happening a problem with the self or the others or relationships with others and you have excluded or that you've already identified co-occurring axis one conditions that could be producing these dysfunctions then you go to confirmatory testing in a sense you do a skid type interview with the original model if you think this is someone that does fit neatly into one personality disorder or you get more nuanced you get more data even and you come to some kind of a evidence requirement and if that fails using the alternative model you don't feel afraid to use some kind of a testing measure or to get the help of a psychologist that knows how I want I've been trying to get
Dr. Fu to do a course on this. And he's been, he's been resistant. I think I want to see some comments of people telling Dr. Fu to make his course with me.
Why would anyone want to buy a course on this when there are so many courses out there? You know, the personality disorders conventions, you know, you can already listen to the podcast. It's not necessary. I just hope people were interested, stimulus to your thinking. I would want to know from people, what is it like for you to try to assess for personality? And what are the challenges that you might have had that haven't been addressed by what we talked about today?
Wonderful. I really appreciate you bringing your expertise to this, and I'll see you next time.
All right. I'll see you next time. Take it easy.
Thank you.