Key moments, in order
A healthy personality is the traditional picture of a mature person: emotional stability, balanced viewpoints, behavior that builds things for others. Erikson's stages are the most commonly used framework, pairing each conflict with the virtue that comes from negotiating it.
Each period brings a basic conflict (trust versus mistrust at 0 to 1, industry versus inferiority at 7 to 11, identity versus confusion at 12 to 18). Negotiating it well yields a virtue such as hope, competence or identity; failing leads to problems that continue through life.
A personality disorder at any age is not a lifetime sentence. You can stop meeting criteria, especially with treatment.
The counterpoint on age: trying to figure out identity is developmentally appropriate in early adolescence, but still doing it at 35 is not.
Stopping behavior is not the treatment approach; we are used to it only because we conceptualize the pathological side of personality.
Ignoring a problem you need to treat does harm too. It is as if stigma against OCD kept us from recommending exposure and response prevention.
Depression that comes after a breakup, or shutting down after fights with parents, and that lasts shorter than a mood episode, will not be fixed by throwing different medications at it.
Having BPD does not rule out mood disorders; people with BPD are probably more likely to have them. Once a mood disorder is treated, personality tendencies may not come out with the same severity, so monitor and reassess.
Be honest about medication. Promise it will fix the depression and the idealization wears off in a month, leaving them right back where they were. If they decline therapy, say plainly that you do not think you will find the medication that fixes these problems.
Whether something is biological or psychological has no bearing on whether it is a clinical problem.
Clinicians reserve the diagnosis for patients they dislike and give CPTSD, or nothing, to patients they like. Borderline has become code for "I don't like this person" or the most annoying patient in the hospital.
Often we are all describing the same clinical problems in different language, because of poor practice in who clinicians give diagnoses to and how they give them. The problem at the outset was not categorization but a lack of alliance-building and collaborative care between equal parties.
We do not want blame, but we do want productive change, and change will be limited, mildly or a lot, if we do not look at how the person contributes to what is going on.
If understanding yourself requires a diagnosis that most practitioners will judge negatively and read you through a hurtful lens, looking for another diagnosis is understandable.
In forensic work, especially one-off evaluations, the alternative model is not very practical to use, however much we like it.
There is more to life than trauma: there is temperament, who you are when you are born, and non-traumatic but still upsetting things that happened growing up.
Splitting into heroes and villains is the original state of mind in all of us, and we only pretend we do not do it. Idealization and devaluation are very human; what stands out is the degree.
In healthy functioning, regressions are creative and ego-mediated, and projections or regressions are owned.
Defenses are called defenses because we name them that way in a pathological context. Really, they are just what the mind does.
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.
Self-functioning is how you feel about and relate to yourself, and whether you can make yourself do things or not: self-control, self-regulation, self-appraisal, self-understanding.
Trauma, both clear trauma and less clear emotional difficulties, interferes with the development of self and relationships, and that is the root of personality disorders. Most personality disorders are probably a mixture of neurodevelopmental and trauma disorders.
Personality pathology does not require a parent who fully neglects or abuses the child. Attunement is a really helpful concept here.
Attunement is partly a goodness of fit, and echoes containment and attachment theory. Different people have different emotional capacities to feel about others' feelings; poor attunement may be passed on across generations or be genetic.
Assess personality in ostensibly normal patients too, to build a baseline. Be careful: if you and your friends share a certain personality and you lack the self-insight to notice, you cannot tell what is normative.
If someone describes their childhood as 100 percent great, there is probably something defensive or split in that. Maturity means recognizing both the good and the bad in yourself and others.
People should have balanced views of their parents. Someone who has been well therapized holds a nuanced view, naming flaws that make sense given what happened to the parent alongside what they did well.
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.