Key moments, in order
A personality disorder is functionally a lack of maturation and integration. That is the core pathology, so maturation and integration is the core treatment.
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.
Everyone comes with a temperament: a certain way of responding intrinsically to environmental and internal experiences. Personality builds from there.
Personality, and the pathology that comes from it, develops in particular constellations from the interaction of a broad but finite range of instinctual needs (tied to temperament) and the environment's ability or inability to respond to them.
Two people can have perfectly overlapping OCEAN (Big Five) traits and totally different life stories.
Explaining behavior by a trait is circular. A person is not doing something because their neuroticism is high; we know it is high because of what they do.
"Just personality" gets said in the emergency room after a difficult interview with someone hearing voices. And doing something on purpose is not the same as having control over it.
Most people in inpatient and outpatient clinical populations can meet criteria for a DSM personality disorder. That does not mean it is the main issue.
Clinicians say they do not like to "jump to" a personality diagnosis. Imagine saying that about bipolar disorder, an eating disorder or an anxiety disorder.
A lot of severe personality pathology is an internal struggle. These people are not manipulative or causing interpersonal problems; they are struggling inside.
In clinical work we do not diagnose to decide whether something is purposeful or whether the patient is responsible. We diagnose to inform the treatment plan and the patient's treatment targets.
We all operate at different levels of functioning and regress, breakups being a big one. Splitting the world into heroes and villains is the original state of mind for all of us; we only pretend we are not doing it.
The classic psychopaths people picture, the Ted Bundys, have something on top: sadism and high self-esteem.
Do not assume everyone who chronically harms others or violates their rights got that way from some awful experience. Many innately lack guilt and remorse, and they have to be managed very differently.
Reserve the term psychopathy for people with a true innate impairment, not just a psychological problem, in feeling remorse, guilt and concern for others.
The personality disorder categories in the main section of DSM are terrible; the Section III alternative model is very good, and clinicians should get familiar with it.
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.
Borderline problems stem from attachment and bonding, which come earlier in development than issues of the self and of how we see ourselves and others.
One stronger view: the only things we should consider personality disorders are those that fit under borderline personality organization.
In OCD the symptoms are ego-dystonic: ask why they are doing it and the patient gets upset that they are doing it.
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.