Key moments, in order
Watch for mismatches. A high level of persistent achievement that does not fit apparently psychopathic, assaultive behavior suggests something other than a personality problem is driving it.
The alternative model is not hypothetical: it is an APA-approved DSM system, considered as valid as the traditional model. It centers pathology on personality functioning, meaning self functioning and interpersonal functioning.
Personality is a collection of habits and responses in how we react to other people, ourselves and situations: how you do things, and how you relate, think and feel about yourself and others. It is informed both by the characteristics we are born with and by our development.
Vague heuristics get a few major personality disorders diagnosed, and then clinicians assume medications won't work.
Personality is the most clinically neglected category today. What we mostly see is clinicians ignoring it, or diagnosing off vibes and countertransference rather than digging up the clinical data across the lifespan.
People rarely fit into one of ten personality styles. Most are better described by specific traits and general personality dysfunction, and for most the most appropriate diagnosis is probably other specified personality disorder, with traits of several disorders reflecting core problems in self and interpersonal functioning.
Use both the state in front of you and the course from the history, particularly the course, because a personality disorder should be present across settings and with different people.
Personality diagnosis relies on an honest, relatively thorough account of the patient's psychosocial life and development, which takes time. Any diagnosis reached quickly carries lower certainty; a diagnosis is only as good as its database.
Assess in two steps. First listen in a sensitive but non-specific way for signs of personality pathology in the visit, the interaction and the history; once enough signs have accumulated, move to something more specific.
Do a mental status exam: what they say and don't say, how they act, and how they interact with you. Practice asking yourself, for every patient, what was it like to be with this patient?
In the first years of interviewing, keeping the structure and getting through checklist questions takes your entire working memory. Reading yourself comes later.
When you start out, do everything the same way every time to build the habit, then deviate later. In the first years most of your working memory goes into getting through the structure, and that is normal.
It centers personality pathology on personality functioning, how we relate to ourselves and others. That splits into self-functioning (identity and self-direction) and interpersonal functioning (empathy and intimacy), four elements in all.
Self-direction: ask about the longest job they have had, and any gaps in school or work history and why they happened (an injury, a medical condition, not knowing what they wanted to do).
Most personalities have some adaptability. A personality disorder is a lack of flexibility in how the person responds to their environment, and that inflexibility of defenses is fundamental. An unusual belief, like astrology, is not the point.
Regular heavy drug use from a young age often indicates problems regulating emotional experience, and a persistent substance use disorder with a total absence of personality pathology is very hard to find. People with good self-direction and emotional regulation find more productive ways of coping.
Notice whether the patient can automatically access and describe other people's reactions and motivations, or mostly tells it as other people doing things to them.
Intimacy: the number and length of relationships, how they met and how they broke up. You may not have time for all of it, but you often get a sense of it along the way.
Listen for discrepancies that cannot both be true: a relationship that was absolutely perfect, and a partner who cheated a lot.
Assess these areas in ostensibly normal patients too, those whose personality functioning seems normal on its face, so you have something to compare against.
Clear trauma and less clear emotional difficulties both interfere with the development of self and relationships, and that is the root of the personality disorders. It is totally implausible for someone with a multi-trauma developmental life from early childhood onward to have normally functioning personality.
Ask open questions and let the patient talk, for example: do your relationships with people you really care about have a lot of extreme ups and downs? You are not looking for a yes or no.
Questions from the STIPO-R get you a lot of clinical data on all four elements of personality functioning.
Recurrent self-harm signals aggression directed at oneself; physical or verbal fights signal aggression directed at others.
General paranoia is a lower-level defense common in lower-level personality functioning: someone always guarded, watching for people taking advantage of them or trying to harm them.
In the moment you often cannot name the defense. Only after the appointment, with time to reflect, can you put words to what you were experiencing.
Diagnose personality to find the right treatment. If it is not a medication, knowing that prevents harm and wasted time trying to treat a personality problem with medication.
With enough data you can make the diagnosis: sufficient impairment in personality functioning by this model, present over time, after considering whether the impairments are due to something other than personality.
Psychological testing is just a tool for the same diagnostic process. The DSM-5 also has self-assessment measures you can give patients.
At level three, severe impairment, with at least two domains impaired, it is clearly a personality disorder.
In severe impairment, the capacity for positive, enduring connections is significantly impaired: on-and-off relationships, dropping people for years and then being intensely involved with them.
Patients with severe impairment have not been taught to repair ruptures together with the other person, which is one reason psychotherapy is so important.
Do not be afraid to diagnose personality, and never do it to punish patients. Do it to be a good clinician who correctly identifies what should be treated with psychotherapy and what with medication.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.