We've been talking a lot about personality pathology. I'm curious if you have answers for what you consider healthy aspects of personality or just healthy traits, features of someone with a healthy personality.
That's basically the realm of positive psychology. I'll tell you, not an area of strength for me. I have more interest in abnormal psychology. But you can call these whatever you want. You can call them virtues. You can call them life skills. People often get upset at one type of word or another, but I think we're all referring to the same thing there. Interestingly, I think the next APA, American Psychiatric Conference, is covering wellness and positive psychology, possibly.
I may be misremembering that. But what are the good aspects of personality? A lot of different ways to conceptualize it. But honestly, if you can picture in your mind what a mature person is and does, that's it. It's really just the traditional virtues or good qualities that we've thought about for anyone in life, right? Emotional stability. Being able to balance your viewpoints, control your behaviors in the way that will build things for other people and to, I don't know, I think maybe the most commonly written and talked about in psychiatry today framework for this is actually the Ericksonian stages.
Because Erickson sets up these challenges, but he also writes about what virtues or strengths you can come out with if you've been quote unquote successful, or at least relatively successful in each stage. And even though I lecture on this, I don't, I'm not super good with it. I bring all them off the top of my head, but identity versus role confusion, identity there, a solid identity is the virtue.
autonomy versus shame and guilt, right? The virtue there is autonomy, the ability to direct yourself and make decisions for yourself. There's all the stages you can read about.
Yeah. And I think maybe just for people who aren't as aware of it, the general gist is that certain basic conflicts come up at a certain period, typically at around the same age. So like from zero to one, there's a certain basic conflict that the individual experiences, and that there are successful ways of dealing with that conflict, and that they come, if it's dealt with successfully, will deal with a virtue.
And if it's not dealt with successfully, will lead to problems that continue on for that person's life. I have it pulled up in front of me. From zero to one, the basic conflict is trust versus mistrust. And if you're able to properly negotiate that conflict, you'll develop hope. Then it continues on. And if you think back, you can think about your own experiences to remember these things.
Age 7 to 11 is industry versus inferiority. And if you conquer that phase, not conquer, but if you negotiate it, competence. 12 to 18, identity versus confusion. When you're in your teenage years, you're trying to figure out who the hell you are. It's normal to be prejudiced. meet criteria the reason why we have borderline personality disorder you need to be at least 18 is because it's normal to be testing your identities trying on new
identity hold on hold fast all right all right sticking point for me you do not need to be over the age of 18 but you know i'm saying no everyone a lot of people practice that way a lot of people say it's the responsible way to practice i disagree with that I don't think that people who are inexperienced or less judicious should be diagnosing teenagers for personality disorders.
But I would like there to be a little bit more a shift of practice to recognize the signs of it. And to recognize that a personality disorder at any age is not a lifetime sentence. You can stop meeting criteria for a personality disorder, especially with treatment. And that they, if anything, this is what I would like clinicians to think that personality disorder problems, personality disorder traits are more of a problem in development.
And that's what you're treating and that many people will even go on to lose that without treatment over time. But no, there is no age requirement, even though practically most people are unwilling to diagnose personality disorders in people who are under the age of 18. 18 being a totally arbitrary and legally derived cutoff, too.
Correct. You understand where it stems from in that behaviors that we... Acting in ways that we typically associate with personality disorders in some sense are normal in our teenage years. It's normal to... trying a ton of different hats, come in one day, think you're in a punk band. The next day, say I'm a jock. Those kind of super quick flits and who you are and your identity at 13, 14 is...
Okay, so let me... The problem with not having that age cut off is that if you tried to stop that behavior, what that individual is doing is trying on identities to see which ones fit. And it's a developmentally appropriate thing that's occurring. Whereas if you're 35 and you're still trying to figure out those things, those are behaviors that are not developmentally appropriate.
Sure, but I'm also going to push back on that. That's the problem there. Behavior stopping is not the treatment approach. We're so used to that because we're trying to conceptualize only pathological aspects of personality. And we're very interested in people's safety and well-being. So we say, when we recognize this problem, we're trying to stop it. No, you're trying to heal it. You're trying to develop somebody that has a personality pathology.
And you don't stop these behaviors. You work with them and help people progress.
But I guess what I'm saying is if a 15-year-old is doing those things, it's not a behavior that needs to be healed. There's not a healing process. They're undergoing a developmental appropriate... They're figuring out who they are at the right time. And there's no... If you look at that thing, you shouldn't see it as something that needs to be healed. I think it depends. Of course.
Because it depends on the other things going on in the case.
I understand your point, but your point... rests on another point that a lot of people don't get.
Yeah.
Well,
I'm still going to maintain people are not thinking about, talking about, and treating personality appropriately before the age of 18. And so what happens, at least in my impression, is that by the time they come to me, the adult psychiatrist, those issues have been fundamentally ignored or miscategorized for quite a long period of time. And what's the harm in that, you might say? Certainly there's a harm in stigma of diagnosis, but there's also a harm in ignoring a problem that you need to treat.
It's as if we had some social stigma against OCD and we didn't want to recommend exposure and response therapy all the way, exposure and response prevention therapy, that is, all the way from the age 11 to age 18 because there's a stigma. No, there are specific and now empirically based treatments that seem to be helpful for people with personality problems. And when we recognize that there's a personality problem early on, to me at least, that's a recognition that the developmental situation for this person is very harmful.
And that's something that needs to be addressed.
Now, I want to, I think, to maybe come full circle on all this stuff. The importance of recognizing personality. I think I'm going to do an amalgamation of a ton of different patients that I've met over my life, not any one real one. If you don't understand and appreciate personality, How much of something is personality based and how much of something is biological, then the treatment that you recommend is going to differ majorly.
So it's very important that you're constantly thinking of, I think you said this earlier, like how much of this is biological and how much of this is something that we can attribute to personality pathology. For patients with borderline personality disorder, they might come in and say, I'm depressed, I have mood swings, and use all the words that we typically associate with mood disorders. But if you dive into those symptoms, you can hear...
that they differ significantly from how we understand the mood disorder symptoms. The depression occurs after a breakup. The shutting down occurs after fights with parents. And they last shorter. They're not these things that last for three weeks. So that if I keep trying to throw different medications, I'm not fixing the underlying problem. Now, I think another point that we made in the first podcast is... Because someone has borderline personality disorder doesn't mean we've ruled out the mood disorders.
Someone with borderline personality disorders is probably more likely to have mood disorders. So that you can't say, oh, this is personality, therefore this person is not depressed. And you have to be on the lookout for parsing out, listen, a lot of these person's symptoms are the result of their borderline personality pathology, but they're also depressed on top of that. So I've seen both things that... will help you to communicate to the patient what the best treatment is and what the prognosis is.
I have a patient who... I'm making up a patient who has borderline personality pathology and they don't want to go through therapy. They don't want to do DBT. And I have to communicate to them that the treatments that I'm using are... really a bandaid for the problem. And I don't think we're going to find the right medication that's going to make you feel that's going to fix the problems that you're experiencing.
We can only have some medications that might temper the intensity, maybe if we but until you address these core things, my toolkit as a medication prescriber is incredibly limited for your problem.
Yeah, it's all about finding the right treatment. And that's what I'd like to emphasize, right? That whether or not something is biological or psychological has no bearing on whether it's a clinical problem or not. And we want to medicalize, clinicalize these problems in order to help people. That's why we do that. And on the end of communicating to patients, though, I do think that's where we run into a lot of problems, especially with the original writing and conceptualization of the personality disorders in the DSM.
Personally, I think if you read the DSM criteria that exists for the name disorders, they're all almost hateful. OK, it's like it's the encapsulation of all the frustrations and negative feelings that psychiatrists have for these poor patients. Just read histrionic personality. OK, it's fully a cruel way to talk about somebody, in my opinion. I'll just give you a criterion. One is uncomfortable in situations where he or she is not the center of attention.
OK, that's just like an indictment. Right. You could easily say feels anxiety or distress when alone. Right. Something like that. I'm not saying that's the best way to reconceptualize that, but the point is there are easier and kinder ways to think about the exact same problems and outputs that will help us build alliances with patients.
Yes, and to your point, a lot of I don't know if I've moved the direction too far. A lot of people's heuristic for these personality disorders is, I don't like this person. And borderline personality disorder stemmed out of problematic patients on the inpatient, or at least the way that it started being used, was this person is a problem when they're in the hospital, essentially. rather than the underlying etiology of what was occurring.
And a lot of providers today use the heuristic of borderline personality or say borderline to describe the most annoying patients in the hospital rather than what it was intended for. And a lot of patients that they use borderline actually aren't classically borderline personality disorder. They might be a different personality disorder, sure. But the heuristic that developed is essentially problem person in the hospital.
That's right. It's a problem. This is a problem that we have as a field. I'd like for us to move past in a productive way for patients, but I think it is reflected. The stigma and the tendency for people to use knee-jerk, counter-transference-based ways of diagnosing personality, the response to that can be seen in phenomena such as the conceptualization of complex PTSD as an alternative, right? We are not going to get into that debate today, but the fact is that there's an argument that a lot of people are not borderline.
Instead, they have complex PTSD. I would say that we're all describing the same clinical problems and we're trying to use different language because of poor practice on part of clinicians in terms of who they give diagnoses to and how they give those diagnoses, how they explain those diagnoses.
I did want to get to talking about trauma, connected to what you were saying and some of the things we talked about. Trauma as an explainer, as the new paradigm through understanding all pathology.
I would say the reason why trauma has become so important to us is because trauma is... A category that automatically trauma automatically identifies a victim and an abuser as a concept. Not that's a bad thing. There are many situations where it's pretty, pretty dang clear who's the abuser and who's the victim. But then it also makes that people would rather. use a trauma diagnosis or use a trauma conceptualization of pathology in order to avoid uncomfortable feelings of blaming a victim or even having a patient self-blame.
We don't want blame, but we do want productive change, and some productive change will be limited in a mild or significant way if we don't look at how the subject, the individual, contributes to what's going on.
And I think you were bringing up the individual not wanting feeling as though trauma is a more tolerable understanding of their problem. But and to connect it to your previous point, which I'm and also providers drop the ball in personality disorders, like the way that we have conceptualized them. And as we were saying in the beginning, it's, oh, you're a problem. and you're manipulative. Those heuristics and our understanding and losing the true understanding of personality pathology made it so it was inevitable that people were going to say, hey, that doesn't work for me.
You're telling me that to understand myself, I need a diagnosis that 80% of practitioners are going to negatively judge me and interpret my thoughts, behaviors through this pretty hurtful lens. Yeah, I'm going to look for a different diagnosis. Exactly.
Yeah, it's, it's, I really put the problem squarely on the field for this area. I don't think there's any doubt. It's our responsibility. We cause this problem. We need to essentially change trends in how people think about personality and communicate it. And I would love if they rewrote a lot of the criteria in the DSM for at least a categorical approach to diagnosis.
Yeah, and the thing, as you're saying with the categorical approach, there's, we can't, I think we're past the point of rewriting the criteria for the personality disorders because the damage in a sense is done already. Especially not just psychiatrists, but the average just doctor in your training you learn to associate just has such negative affiliations with personality disorders that we, it's hard for us to use that terminology today.
I'm hopeful. Just as in treatment in the field, I think it's never too late for change, and we can definitely make a difference here. And I'm not saying we lose the categories either. I actually will say that in forensics, as much as I'm a fan of the alternative model, it's not very practical for use, especially for one-off evaluations, yet it's still so important. to detect and discuss certain personality disorders within the confines of a forensic report.
And the categorical way of diagnosis since the DSM-3 is therefore really important and useful. We just need to temper it with our deeper understanding of the mind.
I think we should do another episode on trauma where I prepped a little bit more so that I can talk about it more better. But I'm curious now, why do you feel that we can't use, because you talked about why trauma is more appealing to have that diagnosis. What is your understanding as to why we can't use trauma to understand all pathology?
simply because not all pathologies do the trauma. I can't remember, there was a recent social media post, I think it was a psychoanalysis subreddit or something, where somebody was asking about how to differentiate or conceptualize two different things. And I found it interesting that both ways that they conceptualized those conditions were trauma-focused. But there's more to life than trauma. There's who you are when you're born, your temperament.
There's non-traumatic but still upsetting things that happened to you growing up. There's the way your personality matched the personality of your parents. You just have different personalities sometimes, right? Or different needs or different styles. There's how your innate self interacted with the confines of your culture and your society, right? That's not trauma. And I think the desire to call it trauma, which some people really broaden the term trauma to encompass a lot of different things in life, I think is, in my opinion, motivated by the desire to pick out clear villains, heroes, and victims.
And life's just not that simple.
The good guys, bad guys. What kind of people do that?
Everybody.
That's it. That's another topic. I had a question I want to ask, but I... In terms of wanting good guys, bad guys, you see, I really like the Netflix documentaries that kind of show these psychopathic individuals ruining the lives of other people. I'm thinking of Bad Vegan, Tinder, Swindler. What's really interesting is how natural their brain thinks in terms of good guys and bad guys. One of the core structures of cults and of these individuals who are able to really influence other people's behaviors is is there are these bad guys that are after us, and we need to protect ourselves, the good guys, from these bad guys.
In Bad Vegan, it was like terrorists or something. In Tinder Swindler, it was like bad people. The ability to break the world into these Marvel-like characters of heroes and villains comes natural to people with severe personality pathology.
It comes natural to all of us. It's the original state of mind. And we only pretend that we're not doing it. OK, when we're doing it, we say that's perfectly reasonable. And we can write a four paragraph essay on why my political view or my social value is better than yours. And you're wrong. And I'm not splitting, but you're splitting. And then that's the funny thing about Netflix, too, right?
They've got all these documentaries where they showcase someone that they've decided this guy's a psychopath. This guy should be condemned. And then they also have these documentaries on well-known criminals. Oh, this person was maligned. This person's innocent. Don't be so sure. Don't be so sure. And I think we're all villains and heroes inside of ourselves.
That's very nice. And yeah, your point that it comes natural to all of us. One of the traits that I remember reading about that showed good ego functioning, essentially like a healthy personality, is that someone, when they regress, I think I can... Regressions are creative and ego-mediated. Projections or regressions are owned. And that really helped me in that, like what you're saying that... Watching the satisfaction that we get from watching a Marvel movie where the good guy and the bad guy are fighting and the good guy takes over the bad guy, which is the enjoyment in that is a form of splitting.
The world is good guys and bad guys. To appreciate that, you can creatively regress. And that like a lot of your behaviors that I regress in relationships and it's done in a way that I understand that I'm doing it. And it's not necessarily not all good. Regressions, not all splitting is, this is ironic, it's not all good and bad. You can regress in healthy ways. You can watch and get satisfied from a Marvel movie because you're regressing to a point where there's good guys and bad guys, and that's satisfying.
But the important thing is that you- There's theory, right,
that it's normal and even healthy to be able to regress with your partner, right? And yeah, what you're saying, defenses are called defenses because we're calling them that way in a specific pathological context. But what they really are is they're just what the mind does. And ego, what's the ego? Ego is just a self. So what do people do? What do you do with yourself? You have habits.
You have different ways of thinking about things. And it's about using the right mechanism in the right context, the right way.
Yeah. And a fundamental part of personality disorders is the inflexibility of those defenses. I remember in residency, I had like classmates who were saying that someone was Are they personality pathology because they believe in astrology? And I forget exactly what it was. But what they didn't appreciate was that, no, what matters is the flexibility. Can that person who loves astrology in the Bay of California, if they were on the East Coast, would they be able to adjust and have a business that was more, I don't know, less floofy?
Yeah. Of course, that, again, that's a good antidote. It demonstrates a nice concept about how context and adaptability is important, but also shows you how people think of personality only as traits and not as self and other functioning, self and relationship functioning, right? And we got to move that needle.
We said we were going to talk about trauma, but we jump around like crazy. So talk to me a little bit about self and other functioning. Again, self,
okay, there's a lot of ways to talk about this, but I think the simplest way to think about it is that your self-functioning is how you feel and relate to yourself and how you can make yourself do certain things or not. Self-control, self-regulation, self-appraisal. self understanding. Okay. And then relationships is a lot easier for us to conceptualize, right? It's how can you apply those things to other people?
How can you feel for and towards other people and how do you interact with them? And I think it's, you can always get too heavy about this, but I think most people understand what's healthy or not, as far as that goes. And if you have any trouble, there's a handy table in the alternative model section. for personality disorders in DSM-5. As regards to trauma though, I think what I would want to emphasize is that it's obvious to me, and I think it should be obvious to everyone, that trauma, properly, proper trauma, really clear trauma, and also not so clear traumas, emotional difficulties, clearly interfere with the process of self and relationship development.
And that's the root of the personality disorders. To me, it's a slow burn trauma disorder in a way. And that's why the complex PTSD construct rings true and is so liked by some people, I think. But I just don't know if it captures the full story. And I do think it's a renaming of something that we've already been treating and writing about and working with.
Yeah, and I think to maybe expand on what you're saying in regards to a lot of personality pathology doesn't develop out of overt trauma in that it develops as a result of the individual with their temperament, as we were saying, and the environment, for whatever reason, not being able to meet the person's needs. And it can develop because... The person was too much for the environment. They were too little for the environment.
Parents don't need to... Personality pathology doesn't develop from a parent who necessarily fully neglects or abuses their child. Attunement is a really helpful concept here. Attunement is like the ability for the parent to see the child for who they are. And maybe you can help better define attunement because...
Well, first of all, there's just a match, right? There's an easier match or more difficult match. But the attunement concept, I think, actually harkens back more to the psychoanalytic concept of containment and, of course, of attachment theory as well. That's more complex. I don't know if we really know how fundamental that is or not. What if personality disorders are just a long-stretching, quote-unquote, trauma of poor attunement being passed on?
over and over? Or is it genetic? Who knows? We just know that different parents have different levels of emotional capacity to interact with or feel for the emotions of others. It feels bad when we use the word parent there, but if we say that same sentence and say that different people have different emotional capacities and a capacity to feel about other people's feelings, that would just seem really obvious to most people.
Mm-hmm.
Now, there's something I want to see if you can help explain. One thing I've noticed, if I ask someone, how was your childhood and like your relationship to your parents? If I ever get the answer, that's just great. More times than not. There's a lot of personality pathology. That's a major overgeneralization, of course. But it's something I've noticed.
Do you mean clinically or in your personal life?
How often are you asking this in your personal life? You say that, but part of, is it like TF, some Columbia thing, they say that they recommend going around and asking people, hey, Dr. Fu, tell me about your personality. Or describe the personality.
Are you sure TFP people have recommended that? Because I don't remember them recommending something like that. Yeah, I think so. I'll see. I think it's... Let's not malign the Excellent Personality Disorders Institute, just in case.
No, I'll pull it up. I think Kernberg has a lecture where he says that he recommends it to the trainees. That just almost in a fun sense, you go around and say, Dr. Fu, talk to me about how would you describe your personality? And then how would you describe the personality of one of the most important people in your life? And hearing people's different responses.
By the way, I'm going to admit that... I actually do collect normal baseline responses for my psychiatric interviewing questions by talking to friends and family, not in a purpose to diagnose them, but just to see what the general population will respond with compared to a ostensibly pathological personality or a pathological person. Personality, it's not person. Pathological, basically patient versus general population. So I do that. I didn't know that they ever recommended that.
I thought I was acting out of pocket. And what have you found? What I find is that you have to be careful because you may have a certain personality and your friends are all mostly of a certain personality. And if you don't have enough self-insight to notice that, then you won't be able to tell whether or not the responses are normative or not. If you're going to do that, you should probably have a pretty good working theory or understanding of what kinds of responses to expect.
And I still basically notice that, yes, what you're referring to there, by the way, if someone thinks that their childhood is 100% great, generally, there's probably some defensive nature in that or splitting aspect, right? What is considered mature or at least normal is to be able to recognize both the positive and negative aspects of yourself and others.
I realized that my mental energy is fading.
Yeah, we should probably close on that point. Integration. Let's integrate the trauma and personality diagnoses. Let's integrate ourselves in our memory of the past. By the way, just saw an interesting paper. There's a researcher who has demonstrated that asking people about their parents can cause them to rewrite their memories into negative ones of their parents. Now, I found that to be a pretty interesting finding because we don't know if that's because we're doing that as the people asking the question, or if by asking the question, we uncover more of the fundamental ambivalence, the mixture of positive and negative that could have been there.
Jury's out, I think.
So you're saying you're not sure. You're saying that people should have more negative views of their parents, I think, inherent in your response, right?
I think people should have more balanced views of their parents.
More balanced. That's what I'm saying. Yeah. Yeah. And yeah, you do see that for someone who's been well-therapized. They have a nuanced, balanced view. A common thing is you'll hear someone say, my parent had X-list flaw, which makes sense given this happened to them, this happened to them. They were really good at this and this for me. Yeah.
yeah myself too i think we've probably capped these at 65 minutes or something oh
there was one thing i did want to say it is funny that after talking to you and the emphasis on integration how much after our podcasts don't take this as a compliment like just the concept of just like how natural i start seeing in the world someone say this is true and then someone say no this is true and how easy it is to be like no both you guys are right yeah Just that emphasis on the idea that a lot of things aren't as conflicting as they seem.
They can actually coexist on a more expanded understanding of the situation is a pretty fundamental difference in the way of viewing the world.
Oh, yeah. Unfortunately, we still have to pick one way of moving, so that makes things tricky.
Yeah, and you're just the annoying person who goes, ah, well, you guys are right. Yeah.