Key moments, in order
Medicalizing behavior that falls within the range of normal, even at its extreme, or behavior that is rationally driven, is a mistake. The diagnosis carries an implicit belief that the behavior is out of control.
Whether something is part of a mental disorder, whether the person did it willfully, and whether they should be held responsible are three separate questions.
Dr. Fu prefers to talk about a tendency to repeat rather than a repetition compulsion, because the older term implies people have no control.
One psychodynamic idea: people recreate painful experiences to gain mastery over something that originally made them feel helpless, because by recreating it they hold the power.
The tragedy of the need to repeat is that people usually do not master the experience but repeat the same thing endlessly.
Repetition is a basic human and neural phenomenon: habits are powerful, and what we do gets stronger while what we do not do gets weaker.
Freud wrote hypotheses, and his followers then overstated them as fact, for example attributing too much meaning to repetition as a desire for mastery.
Dr. Fu thinks people repeat simply because change is hard and biological systems settle into patterns, rather than because of an unconscious desire.
In transactional analysis the unit of analysis is the whole recurring sequence, not a single behavior or interaction.
Each person occupies a role in a pattern with a psychological payoff at each step and a big one at the end.
Before calling something a pattern, see it more than twice: twice is a coincidence, three times is a pattern.
Blowups happen even when everything in the relationship is going well.
Two common self-states in this dynamic are idealized submission and righteous resentment.
Viewing a patient only as a receiver of negative things, and not seeing how they continue their circumstances, leaves no hope for change.
Drawing the line between normal and pathological is dangerous, and it is easy for a clinician to impose their own values.
In transactional analysis a successful relationship is two people playing the same game from opposite sides, or a stable game that works for both.
Over several decades, and then very quickly after modern mass media and the internet, we started saying that even a little bit of something means the full-on disorder.
Labels first help by putting words to experience, but increasingly the label is allowing less insight and less self-understanding.
Autism is a gigantic bucket of very different pathologies. The same diagnosis covers a top-tier programmer who needs prompting for appointments and a person whose main activities besides self-care were spinning and hitting people, and a category that broad tells us little.
Talk about traits versus disorder: traits, behaviors and problems are present to a greater or lesser degree across the whole population.
Autistic traits include specific, constrained interests, trouble with social communication and cues, organizing the world into a predictable system, sensitivity to certain stimuli, liking routines and not doing well with change.
Building an identity entirely around a set of traits and a disorder can create a very different life for you and the people around you.
A single observed moment tells you about traits, not disorder, and says little about why someone did something.
Consider all the possibilities for a behavior, not just medical diagnoses such as autism or neurodiversity. Rational behavior is on the list too.
Language in autism tends to be concrete and particularly detailed, not slippery or vague.
The dividing line with personality disorders: is it inability to understand others' emotions, or lack of interest?
Aggressive outbursts in more severe autism usually come from poor emotional regulation, often triggered by changes in routine, unexpected outcomes or secondary mood problems.
Grandiosity, pride, ambition and a willingness to do what it takes to be the best are not necessarily pathological, and not necessarily the result of pathological narcissism or psychopathy.
People think of narcissism as one monolithic thing, the narcissist. It is not.
At a clinical level, look for such rigid preservation and defense of a chosen identity that it defeats the person's own long-term goals and functioning.
They feel depressed and empty when not validated or admired, and understand other people's motivations so poorly that they attune only to the ones that matter to their identity or well-being.
Work and study suffer: either they cannot do well, or they do really well until they collapse, because of the all-or-nothing tendency to idealize or devalue themselves and others.
Narcissism is a defense against a really low self-esteem. Under the grandiosity, arrogance and need for admiration is the narcissistic injury: the experience that who you really are is somehow unacceptable, covered by a false self that feels superior.
Early in life, typically the parents need the child to be substantially different from who they are: successful, never showing weakness. The child's normal naughty qualities get rejected, and the child has to be something they are not inside.
Grandiosity and worthlessness are two sides of the same coin. The arrogant feeling of being better than others compensates for feeling worse than others, and you see both sides in every narcissistic person.
There is debate over whether to define personality disorders by traits, severe traits or interpersonal functioning. A hybrid approach is probably best.
There are high-functioning psychopaths, but most are low functioning: very impulsive, and probably incarcerated.
It is not a totally separate thing. It often sits on a narcissistic structure plus superego deficits: absolutely no guilt, and on top of that a desire to get over on people, to manipulate and use them.
People want to apply personality disorder diagnoses only to people they dislike, and some clinicians use it to mean "unpleasant person." That is not what it means.
Making this about us versus them misses that these aspects are part of ourselves. The best writers on personality find the pieces inside themselves that are in other people.
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.