Childhood trauma is central to understanding a patient, and a multi-trauma early life without a personality problem is clinically implausible. Expect irrational self-blame, ask about it within a standard frame so you do not signal that talking is dangerous, and when the problem is developmental, the solution has to be developmental too.
What we see
Abused children blame themselves and think it happened because they are bad, and there is often confusion if any part of the experience was exciting, which is common. In adults it becomes an irrational self-blame they can know is irrational yet believe almost 100%.
“It's an irrational self-blame that they can be aware is irrational, yet they can believe almost 100%, even if they're cognitively aware that it's irrational”
22:40Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 Also said in 1 more episode
“We see that kids blame themselves. They think it's because they're bad. A lot of times there's confusion mixed up if there was any experience that was exciting for them, which is a common aspect of these traumas”
21:07Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025
Trauma and personality
It is completely clinically implausible for someone with a multi-trauma, terrible developmental life from early childhood onward to have normally functioning personality.
“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”
39:50Assessment of Personality: Practical Assessment in a Short TimeframeMay 2025 Most personality disorders are probably a mixture of neurodevelopmental and trauma disorders.
“it's basically i i like to think that most personality disorders are a mixture of neurodevelopmental and trauma disorders”
54:51ADHD Again, But Juicier: Unpacking Misdiagnosis, Medication Overuse, and Cultural TrendsOct 2024 Toward the borderline and psychotic end of the spectrum, sexual abuse shows up in the histories of people with hysterical dynamics.
“Down toward the borderline and psychotic end of the spectrum, you find sexual abuse in the histories of people who have hysterical dynamics”
1:15:54Nancy McWilliams on Psychoanalytic Diagnoses, Part 2: Depressive Personality, Histrionic Personality, OCPDNov 2024Guest episode
Asking about it
Avoidance of discussing, thinking about and feeling about trauma is part of the psychopathology. Do not force anyone, but do not let the way you approach things imply that talking about it is dangerous or hurtful.
“part of the trauma psychopathology is the avoidance of discussion of trauma, thinking about trauma, feeling about trauma. And I don't want to force anyone, but I also do not want to even implicitly, through the frame of how I approach things, communicate that talking about this stuff is very dangerous or hurtful”
45:07You Tell Me | Adderall for All?, Surgeons Gone Shrink, Codependency isn't NeurobiologicalJul 2025 Trauma is massively important to your conceptualization, your understanding of the patient and what you are going to do with them.
“trauma is massively important in terms of your conceptualization, in terms of your understanding of the patient, in terms of your understanding of what you're going to do with that patient”
43:35You Tell Me | Adderall for All?, Surgeons Gone Shrink, Codependency isn't NeurobiologicalJul 2025
Treatment approach
If the source of the problem is developmental, a process of relating with other people and with yourself, then the only solution is going to be developmental.
“If the source of the problem is developmental, which is a process of relating with other people and yourself, then the only solution is going to be developmental”
52:12Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025
It also comes up on
- Borderline personality disorderSurvivors of childhood abuse often collect many diagnoses before a complex post-traumatic syndrome is recognized.
- Complex PTSDSurvivors of childhood abuse often accumulate many different diagnoses before the underlying complex post-traumatic syndrome is recognized.
- Personality disordersIn complex developmental trauma, the injury is not a fear response circumscribed to the trauma. It is a wholesale inhibition or change of the person's personality.
- Bipolar disorderTrue PTSD is not that common among people who have had a traumatic experience. With bipolar disorder and a trauma history, stabilize mood first and see how problematic the trauma still is.
- Bipolar disorderDo not treat the mood du jour. Stop the cycling, then reassess: there may still be a depressive component, such as a dysthymia tied to childhood trauma, to address without restarting the cycling.
- Criterion A traumaEncountering traumatic material in electronic form as part of your work counts. It is a small carve-out for people such as those who work child abuse cases.
- PTSDExposure is broad. Encountering traumatic material electronically as part of your work counts, a carve-out for people who work child abuse cases, and so does hearing people assaulted or killed in another prison cell.
From these episodes
- Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 · 1 point
- You Tell Me | Adderall for All?, Surgeons Gone Shrink, Codependency isn't NeurobiologicalJul 2025 · 2 points
- Understanding Anxiety, GAD, and Treatments of AnxietyJun 2025 · 1 point
- Assessment of Personality: Practical Assessment in a Short TimeframeMay 2025 · 1 point
- Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 · 1 point
- Nancy McWilliams on Psychoanalytic Diagnoses, Part 2: Depressive Personality, Histrionic Personality, OCPDNov 2024 · 1 point
- ADHD Again, But Juicier: Unpacking Misdiagnosis, Medication Overuse, and Cultural TrendsOct 2024 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.