What we’ve said about Personality disorders

“a personality, in as brief as I can say it, is a collection of habits and responses that in terms of how we react to other people, ourselves, and situations, that is both informed by the characteristics we're born with and by our development”

“A big part of the definition of a personality disorder is that most personalities have some degree of adaptability, and personality disorders is a lack of flexibility with how they respond to their environment”

“trauma, properly, proper trauma, really clear trauma, and also not so clear traumas, emotional difficulties, clearly interfere with the process of self and relationship development. And that's the root of the personality disorders”

“Personality pathology doesn't develop from a parent who necessarily fully neglects or abuses their child. Attunement is a really helpful concept here”

“the injury is not to some fear response and understanding of the world issue that circumscribed to the trauma it's a wholesale inhibition or change of this person's personality due to developmental issues”

“it is totally implausible for someone who has a multi-trauma terrible developmental life from early childhood onwards to have a normal functioning personality. It's completely clinically implausible”

“So all the different subtypes, all different personality disorders are different flavors, and they can all operate in the neurotic, borderline, or psychotic range”

“If you don't understand the fundamental theory and history behind borderline personality disorder, you're going to think it's one very special entity that only a small amount of people have. Instead of it being a basically common broad spectrum area of problems that people have through development”

“It comes natural to all of us. It's the original state of mind. And we only pretend that we're not doing it”

“whether we should define disorders as traits only, severe traits, or whether it's a matter of interpersonal functioning. I think a hybrid approach is best, but I tend to try to split the difference”

“the only things that we should consider are personality disorders are things that would fit under the category of borderline personality organization”

“a personality disorder at any age is not a lifetime sentence. You can stop meeting criteria for a personality disorder, especially with treatment”

“if you're 35 and you're still trying to figure out those things, those are behaviors that are not developmentally appropriate”

“For a personality, at least, I think it's because it's opportunity development and changes in the underlying biology”

“We want to first listen carefully in a way that's more sensitive but not specific for signs of personality pathology within the visit, within interaction, and also in the history. And then once enough of those signs have been marked as present, In our minds, we go to something more specific”

“I think it's very important to make sure that you're utilizing data from both the state in front of you in visits and also the course based on the history, and particularly the course. Because, again, a personality disorder is supposed to be something that is present across settings and with different people”

“You should be doing a mental status exam, right? You observe the patient and how they act, what they say and what they don't say, in addition to the literal information that they're telling you. On top of that, you observe how they interact with you”

“the diagnosis personality truly relies very strongly on getting a honest and relatively thorough accounting of the patient's psychosocial life and their course in development. And yeah, that's going to take some time”

“if you're a suspecting personality, then you're going to want to have a deeper dive into work history, history of conflicts, firings, arrests, you know, How many times you've been in a relationship, how long does it usually last”

“You literally might just ask, do your relationships with people that you really care about have a lot of extreme ups and downs? And you have the patient talk. We are not looking here for a yes or no response”

“they'll talk about this amazing relationship that was absolutely perfect. And then as they talk about more, you'll hear real discrepancies talking about how the relationship was perfect, but the partner cheated a lot”

“some lower level defenses that can be quite present. in people with lower level personality functioning are general paranoia. It's just a generally paranoid person. Are they always kind of guarded, looking out for people, taking advantage of them or trying to harm them”

“If there is recurrent self-harming behaviors, that is a sign of a tendency towards aggression and a tendency to direct aggression towards themselves and also other directed aggression will be meaningful right fights physical verbal”

“the capacity for positive and enduring connections is significantly impaired. This is when you see the on and off again kind of quality to the relationships, right? Dropping some people even for years and then intensely being involved with them”

“it is unfortunately the case that, at least up until recently, Most people don't use a lot of drugs regularly from a younger age, and I would actually say that that behavior is often indicated of problems with regulation of emotional experience”

“people who have a lot of violent impulses that is fundamentally related to personality tends to be ego syntonic it tends to be ego syntonic you should examine when there seems to be some kind of a distress or if there's not a clear link to a secondary gain”

“personality is always active clinically, but it's also not sufficient to explain someone who is presenting more acutely. OK, it's basically rarely sufficient to explain that”

“it was a high level of achievement and persistence in achievement that did not match the kind of apparently psychopathic assaultive behavior that is usually the product of a personality disorder or a personality problem. So that was a mismatch there”

“remember, psychological testing results is just a tool. that helps you do the same diagnostic process that I just talked about. The DSM-5 also has some measures of self-assessment that you can give patients”

“you have to be careful because you may have a certain personality and your friends are all mostly of a certain personality. And if you don't have enough self-insight to notice that, then you won't be able to tell whether or not the responses are normative or not”

“Most people are probably better described as having certain specific traits and general personality dysfunction. It's in the DSM. People just don't necessarily read it”

“What percentage of you have gone to section three and read the alternative model for DSM personality disorders? And again, the general personality disorder text”

“it's alternative because it's not hypothetical. It's considered a coexisting and as valid model as the traditional DSM-IV model for personality disorders. This is a DSM system, you know, APA approved”

“if we simply look at criterion a and we look at level of personality functioning i don't know if i've made a borderline personality disorder diagnosis in the last two years okay most of the time i just point to maladaptive personality traits or problems of personality functioning”

“Now, let's go to level three. That's severe impairment. This would be clearly if you have at least two domains impaired personality disorder”

“in forensics, as much as I'm a fan of the alternative model, it's not very practical for use, especially for one-off evaluations, yet it's still so important”

“when the DSM made its paradigm shift in 1980, it decided, for various reasons that were very well-intentioned, that it wanted to make a categorical nosology or categorical taxonomy, meaning that you'd have present versus absent criteria, and they would be discrete criteria”

“the most common kind of personality type that existed in the literature, including the empirical literature before 1980, was depressive personality. But people on the mood disorders task force didn't want to have depressive personality in there”

“John Gunderson, by the way, towards the end of his career, argued that we needed to separate borderline and antisocial from the rest of the personality disorders. Those were the major personality syndromes. List those on axis one and let the trait psychologists dimensionalize everything else”

“is that personality or is it simply that they lack conscious understanding or have a lot of difficulty understanding the emotions of others? Right. Is it inability or lack of interest? That's the dividing line. We want that dividing line between autism and personality disorders”

“I see a lot of patients with personality disorders who feel the neurodevelopmental label fits them better. For a clinician to be able to easily tell that it's not a neurodevelopmental issue, there's personality pathology kind of going on”

“there is a large mutual blind spot between both clinicians and researchers who are interested in and recognize personality disorders on one hand and neurodevelopmental disorders like autism spectrum on the other hand. There's not enough coordination between these groups in research or clinical settings”

“the DSM actually specifically notes that behaviors associated with autism spectrum disorder can be perceived as symptoms of narcissistic, schizotypal, or schizoid personality. And that schizoid, sorry, schizotypal personality I'm going to say that's absolutely true, and the opposite is true too”

“a lot of what is popularly referred to as symptoms of ADHD on social media, while, yes, present in many people with true ADHD, generally speaking, what they're talking about, that symptom cluster is better attributed to depressive disorders, trauma disorders and personality”

“in older editions of the DSM, it was explicitly mentioned as one of the possible explainers that isn't ADHD for the presentation. And keep in mind that it's still discussed under the DSM-5TR under the differential diagnosis area”

“we're hearing about somebody whose difficulties across their adult life suggest problems in self-direction okay uh dropping out of school not pursuing the thing that he wanted to to begin with having a variety of different jobs and interests identity”

“We separate out social anxiety and separation anxiety from dependent and avoidant personality, even though the phenomenon is basically the same”

“Is it there no matter what's happening in one's life or is it really happening more in the context of bad things happening and bad feelings between you and other people in relationships and in how you relate to yourself”

“OCD properly should have recurrent intrusive obsessions that are paired to some kind of a mental or physically acting compulsion that is not satisfying know or minimally satisfying or requires a lot of repetition and often takes at least an hour a day of the obsessions and compulsions”

“the bipolar disorder is probably aggravating their underlying personality functioning, right? They're manifesting a lot of those dynamics because they're under a lot of stress or because they're regressed or because they're acutely and supremely irritable or paranoid”

“bipolar disorders, manic depressive illness, in my experience, even if you don't get the full blown syndrome until the 20s or 30s, it's present early on. There is irritability. There is mood changes. There's problems of concentration”

“the hierarchy, even if it's simplified and not perfect, makes sure that you don't diagnose conditions that are secondary to another condition, that you're not diagnosing ADHD before treating mood symptoms, which are leading to difficulty with concentrating. You're not diagnosing a personality disorder before treating mood symptoms that could be exacerbating personality aspects”

“I have my usual message, you know, call it whatever you want, but just give the right treatment. And if your mood stabilizer is helping, maybe they do need a mood stabilizer”

“Like you can have severe personality dysfunction, but not fit neatly into BPD or NPD. So a lot of providers get caught up on that”

“some patients use it as a defense to not look at their personality dysfunction. And I feel like the McLean screen and the conversation about traits allows me to open up that conversation earlier”

“It's not that the whole system of personality is broken. It's this one thing that's causing much bigger problems than it needs to. And then they're constantly kind of making up for it”

“Does this patient have a personality disorder that might be causing them to become depressed in the face of rejection or abandonment? They might be anxious in interpersonal situations. They might be having trouble sleeping because their relationships are up and down”

“Hyperthymia, Cyclothymia, Dysthymia, the affective temperaments, which are basically subsyndromal mood disorders that you find in the family trees of patients with major mood illness. These are very easily mistaken for personality disorders”

“I think it functionally is a lack of maturation and integration. And so that is the core pathology. And so that's going to be the core treatment”

“Behavior stopping is not the treatment approach. We're so used to that because we're trying to conceptualize only pathological aspects of personality”

“When there is a fracture, a rupture in a relationship, they have not been taught to, they are not accustomed to repairing that together with the other person, which this is an example of why the psychotherapy is so important in treatment”

“we want to find the right clinical treatments for people. And if it's not a medication, that's important to prevent harm and to prevent wasting time with trying to treat a personality problem with a medication”

“The depression occurs after a breakup. The shutting down occurs after fights with parents. And they last shorter. They're not these things that last for three weeks. So that if I keep trying to throw different medications, I'm not fixing the underlying problem”

“The basic gist is, is this person relatively healthy in their personality functioning or unhealthy in their personality functioning? And with patients who are unhealthy, you really need to tighten and have your boundaries be very, very strict”

“just as I have to respect their boundaries, I have to respect mine. And there may be times and maybe this is also like, you know, it's it's it's communion and agency and the therapist has both, too”

“a lot of patients act out their conflicts and truly because they're on. It's weird because they're unable to think about them because it's so overwhelming. They act them out”

“as the, quote, neurotic conditions went to biological treatments and CBT, then the purview of psychoanalysis and psychoanalytic treatments, I think has become more and more the personality disorders”

“Make sure you have the right diagnosis, people. Treatment-resistant depression is where personality disorders go to hide”

“make sure you have the diagnosis correct because I do fear by saying polypharmacy is the rule, not the exception, that we're giving permission to over-medicate personality disorders or have someone on lithium and Depakote and Lamictal when someone really needs to reassess the diagnosis”

“and personality is the most neglected one i'm gonna say personality is the most clinically neglected category today uh but we'll leave that side um”

“The main problem in the clinical treatment of personality, in my opinion, is clinician feelings, the counter-transference feelings about the conditions, about themselves, and about a lot of different things”

“there's a big problem today in that people only want to apply personality disorder diagnoses to the people they dislike. And they think that the people they like should not have a diagnosis”

“the patient and the providers making pretend that treatment is major depressive disorder in the back of their mind know that there's a personality disorder, but don't communicate it. And it's really setting up for bad treatment outcomes”

“So I think what really happens in practice is people go like, I've identified what looks like major depression. Therefore, I can't make any other diagnoses, nor do I need to. And so people really should be longitudinally observing, re-diagnosing, re-testing it”

“Imagine if you said that about any other diagnosable psychiatric condition. Oh, I don't like to jump to bipolar. Oh, I don't like to jump to an eating disorder. I don't like to jump to an anxiety disorder”

“studies actually show that for both inpatient and outpatient clinical populations in psychiatry. Most people can meet criteria for a DSM personality disorder. It doesn't mean that's the main issue going on”

“in the emergency room, if someone comes in and says, I'm hearing voices, and then you talk to them and they're a little difficult, it's a difficult interview. Afterwards, you'd say, oh, this is just personality”

“a lot of severe personality pathology it's it's an internal struggle these people aren't manipulative problematic causing interpersonal whatever they're struggling internally”

“in a clinical setting, we don't diagnose to decide if something is purposeful or whether the patient is responsible, right? We're diagnosing to inform our treatment plan and to inform the patient of, What are your treatment targets”

“whether or not something is biological or psychological has no bearing on whether it's a clinical problem or not. And we want to medicalize, clinicalize these problems in order to help people”

“We don't want blame, but we do want productive change, and some productive change will be limited in a mild or significant way if we don't look at how the subject, the individual, contributes to what's going on”

“there's also a harm in ignoring a problem that you need to treat. It's as if we had some social stigma against OCD and we didn't want to recommend exposure and response therapy”

“So much danger in over-interpreting things as Axis 1. And when you start thinking in terms of personality, you have more control. You have more ability to change your surroundings”

“Two people of the same DSM diagnosis will have radically different behaviors and lives. And I don't know if people understand that diagnosis is not destiny”

“Most people use vague heuristics to diagnose just a few of the major personality disorders, and then from there feel as though medications won't work”

“traditionally traditionally mental illnesses did not include things like personality disorders because the personality disorders were thought to be fundamental to the person and not independent mental illness per se okay this is not a clinical reality it's a legal reality right you could call the legal fiction even in some places”

“Yes. In theory, you can just have a personality disorder and get SSI. So it is a medical condition”

“it's a bridge too far to go to diagnosis. We don't have the data for it. I think what's more important to note is that you can watch this stuff and you can say, these are not ordinary people”

“When we make this stuff about us versus them, we really miss that all these aspects are a part of ourselves. The best writers in regards to understanding personality are the ones who can find the pieces inside of them that are in the other people”

“Your personality is the way that you are used to dealing with yourself and other people and how you think and feel about yourself and other people. And where does that come from? It comes from the things that you went through growing up and who you are as a person”

“personality is not about you being a jerk. Basically, it's what you've learned and who you are based on how you've been raised and the things that you've been through”

“Telling someone they have a personality disorder is about the most invalidating thing you can do. Right. I mean, it's it's it's it's frankly insulting. And, you know, a lot of patients aren't going to engage in that”

“I think the DSM writes its personality disorders in a way that makes it extremely difficult to communicate to patients because it's as if each diagnostic category has been written by someone quite mad at a patient”

“You're telling me that to understand myself, I need a diagnosis that 80% of practitioners are going to negatively judge me and interpret my thoughts, behaviors through this pretty hurtful lens”

“be very careful about the possibility of any diagnosis, but particularly culturally laden or emotionally invested diagnoses in functioning as a form of resistance to appropriate treatment, consciously or unconsciously for patients”

“Don't be afraid to diagnose personality. You're not doing it. You shouldn't be doing it to punish patients. You're doing it because you want to be a good clinician and you want to correctly identify which things should be treated with psychotherapy and which things should be treated with medications”