Key moments, in order
In 1980 the DSM made a well-intentioned shift to a categorical system of discrete, present-versus-absent criteria. The push for reliability and checklists treated emotions as too hard to pin down.
Depressive personality, the most common personality type in the literature before 1980, was left out because the mood disorders task force did not want it.
Borderline began as a level of personality organization, not ill enough to be psychotic but more ill than neurotic. BPD as people talk about it is only one category within that organization, which also includes narcissistic, antisocial and histrionic types.
The categories have changed how patients see themselves: people who once said "I'm very shy" now say "I have social phobia; what medicine should I take?"
Elsewhere in medicine you do not lower a fever and call the problem solved. You can describe a limp with present-versus-absent criteria, but the limp is not the disorder.
It is much more important to know what level a person is at than what their dynamics are.
At the neurotic level, the person has rituals they know are crazy, knows the rituals involve internal anxiety they have to do something about, and can make a good relationship with a therapist.
Knowing the style shapes your stance even when you do not try to change it: a patient with schizoid psychology will do better if you give them a lot of space rather than move in on them.
In the original sense, psychotic means a problem joining consensual notions of reality, and you see it in many people who are not diagnosably schizophrenic but struggle to stay in reality.
We all have primitive defenses, not just the sick patient. Primitive here is descriptive, not pathologizing: they are the ones that come up early in our experience.
Splitting shows up in ordinary life. When a partner breaks up with you, you do not reach for a balanced view of why it did not work; you go to: he is a bastard, I hate him.
What makes someone more adaptive is not the absence of primitive defenses but the presence of adaptive higher-order ones. Repression, for example, is a higher-order defense than denial.
What really organizes personality is themes and stories: the person's primary narrative, or what some cognitive clinicians call schemas.
Each style holds its opposite. The arrogant sense of being better than other people compensates for feeling worse than them, and you see both sides in every narcissistic person.
It is a big improvement on the regular categories because it is dimensional. The downside is that it was built on traits.
To really get a feel for a person, let their story affect you, feel what it stirs up in you, and hear the themes: the music behind the notes.
There are two anxiety centers in the brain: Panksepp's fear system, and the panic-grief system, which is the attachment system.
The attachment system is mediated partly by serotonin, so SSRIs help with anxiety and depression that come from separation.
Paranoid personality is dominated much more by annihilation anxiety, the fear of being destroyed, than by separation anxiety, the fear of being alone.
Paranoid patients often get the affect right in other people but the meaning wrong. See you frown and they assume you are angry at them, when you may have just remembered you owe your taxes.
The core defense is disavowing something in the self and seeing it as coming from outside. These patients have been shamed too much to own ordinary badness in themselves.
You cannot interpret the defenses; asking "do you think you're projecting?" will not work. The therapy has to help them become more comfortable with the parts of the self they need to disown and project.
Parents of paranoid people tend to discourage separation and individuation, because they need the child to be the receptacle of everything they are disowning.
Part of why they help psychotic people is that they are huge anti-anxiety drugs: they reduce terror and sometimes allow clearer thinking.
Look at the situation before calling it personality. An undocumented worker paid below minimum wage by a boss who threatens to report any complaint will get pretty paranoid, and that is not a paranoid personality.
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.