Psychodynamic | Personality Couch

Ep 51: A New Psychoanalysis of Antisocial Personality Disorder

Tue, 07 Apr 2026 02:00:01 +0000

🎬In this episode of the Personality Couch Podcast, we (licensed clinical psychologists Doc Bok and Doc Fish) dive deep into the complex inner world of antisocial personality disorder, challenging the traditional DSM view and exploring psychoanalytic theory to uncover the internal processes behind antisocial behaviors. This episode is essential for clinicians, students, and anyone interested in understanding the motivations and defenses of antisocial individuals. ⚠️Note: this podcast does not constitute a professional relationship. If you’re in need of professional help, please seek out appropriate resources in your area. ⚠️

Antisocial Personality - Outside the DSM

Tue, 07 Apr 2026 02:00:00 +0000

The first personality disorder in psychiatry was psychopathy¹, which means it has an extremely long, convoluted history that I can’t fully go into for this blog. I do think it’s necessary to clear up some terminology because it’s super confusing. First, the DSM-5-TR (psychiatry diagnostic model mainly used in the United States) uses antisocial personality disorder², while the ICD-11 (global diagnostic model) captures antisocial personality using the construct of dissociality. Then there are former names for antisocial personality including, psychopath(y), psychopathic personality³, sociopath(y), sociopathic personality [DSM 1], and dyssocial personality³. However, we currently and complacently use the term psychopath(y) to describe the “worst” of people who violate laws, like serial killers, majorly influenced by Hare’s Psychopathy Checklist.

Further, we have the confusing concept of describing behaviors versus actual personalities¹. This is akin to describing symptoms versus the disease. For example, a headache could be a symptom of hypertension, diabetes, or a brain tumor, all of which are very different. In the same way, vandalism is an antisocial behavior that could be acted out by multiple personalities such as narcissistic, paranoid, or antisocial (PS: Antisocial behavior used to be called dyssocial behavior or sociopathic behavior). This is a major criticism of the DSM-5-TR’s portrayal of antisocial personality disorder² - that the criteria are mostly behaviors, not necessarily capturing the underlying personality dynamics⁴ ⁵ ⁶ ⁷. So what is underneath the exterior behaviors of the antisocial personality? 🤔

*Please also note that antisocial (against social) does NOT mean asocial (not social).

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The Makings of Antisocial Personalities

The genetic research on antisocial personalities is tricky because it’s hard to separate antisocial behaviors from the actual antisocial personality, and genetics from environment. Robins (1966)⁴ found that having a sociopathic or alcoholic father contributed to antisocial personality, even if the father wasn’t present…but what if the impactful variable was actually the absence of the father (physically or neglect from substance abuse)? It’s a chicken or egg conundrum.

In childhood, they did not have adequate attachments, were “unloved⁴,” and suffered traumatic injustices. They likely felt helpless and powerless, not having confidence in their own power or in the power of others to help/protect them. So power becomes very important to them, and they seek confirmation of their own omnipotence or power. Let’s paint a picture. Envision a child that is neglected, traumatized, abused, etc, and inherently helpless due to age. Teachers, cops, Child Protective Services were in their life, but didn’t save them. The systems and law failed them. They are left to save the self, to not rely or trust others, to reject their helplessness and weakness, and embody the power that they need. They learn that emotions and vulnerability are weak. Action is learned, not emotions and not caring for others. They need to act. To have personal power. To save the self. Invest in the self. Be self-focused. Survive.

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The Workings of Antisocial Personalities

Because survival is a big part of childhood for antisocials, their automatic nervous system operates at high levels and eventually stays there as a baseline. This is also paired with low serotonin levels, depression, and emptiness. Then, they need more sensory and emotional input to get above that baseline for pleasurable excitement and to just feel alive. So not only do they struggle to regulate their emotions, vacillating between anger/rage and “manic exhilaration,⁷” they need intensity, like sky diving, drag racing, etc. I also suspect this is influenced by primitive envy⁵, as antisocials likely feel there’s something others have that they lack (e.g., love, connection). They “wish to destroy that which they most desire⁵.” They reject and devalue the vulnerable, squishy things in life, but they unconsciously want it. It’s hard to communicate this, but it comes out in their behaviors, like a baby can both smile and then bite mom. A pathological example of this is how Ted Bundy destroyed young women that looked like his mother, noting he needed to “own” them⁵. I think it’s really important to look on the inside of antisocials because we get so distracted by their fierce behaviors.

The Defenses of Antisocial Personalities⁸ ⁵

All personalities defend against anxieties and difficulties to adapt to the world. The main defenses that antisocial personalities use are primitive, including omnipotent control, projective identification, acting out, and dissociation.

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Omnipotent Control involves the need to exert and confirm one’s power to defend against weakness/shame. It is a defense learned in the first 6 months of life when there isn’t any understanding of separateness between infant and mother. If an infant is hungry, the infant gets milk, and the infant believes it is all-powerful. This is also an extension of primary narcissism. In an adult relationship, this could look like inconsideration: “I am not cold, so you must not be cold.” Pathologically, this could be consciously manipulating to have someone under their thumb. Omnipotent control is found in many areas where there are power dynamics (e.g., politics, business, law, religious hierarchies, military).

Projective Identification involves putting an unacceptable quality characteristic on another person, then the other person identifies with it. For example, if the antisocial person feels weak in any way (which is definitely not acceptable to them), they might act dominant/powerful with you, making you feel and identify as weak. Or if they don’t trust you, they elicit mistrust of them…or if they’re angry, they lash out and now you are angry…or if they can’t feel empathy for you, you now find yourself not able to be empathetic toward them…etc. The antisocial’s struggle to verbally express emotion can easily result in evoking their feelings in others so that others can understand. This is paired with the next defense.

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Acting Out is essentially behaving on emotions to relieve them, but usually in an oblique manner (e.g., fighting, threatening, stealing). Antisocials act, but they also need more to get to their threshold of feeling. For example, their startle response is lower and their tolerance for darkness is high. They may be stuck in their fight response, always being on guard for threats. But do they actually feel anxiety? Do they lack anxiety or just hide it? We would never see their anxiety because they act so fast due to hypervigilance and past trauma. Healthier antisocials can experience anxiety, and they either hide it or it comes out as anger or irritability.

Dissociation is separating impulses, thoughts, or emotions that are too “threatening” to the ego. This can be anything from minimizing personal experience to complete amnesia. To assess this in an antisocial is tough because they can lie and manipulate, so they may not actually be utilizing this defense. However, dissociation and abuse are linked, and antisocials have experienced abuse. Additionally, when raging, the memory part of the brain can shut down, leading to decreased ability to recall what actually happened.

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Can Antisocial Personalities “Get Better”?

Theorists, researchers, and clinicians have been in conflict about this for over 200 years, yet there is a strong stereotype that antisocial personalities are untreatable⁴ ⁶ ⁷ ¹. This is where moral judgment infringes on professional assessment. Antisocials reject society, so society rejects them⁵. However, there is evidence that some antisocial individuals can make progress⁵ ¹.

Summing all of this up, the DSM doesn’t capture the personality underlying the external behaviors. Most antisocial personalities aren’t even engaging in criminal behaviors⁶ ⁷, which goes against a lot of what we think when we hear the term “antisocial.” To look inside the antisocial personality is to see the expanse of darkness inside all humanity, and if you dig deep enough, you’ll find the seed of pain every individual has buried within. I’ll leave you with this quote from Danish psychiatrist Georg Sturup 19518:
“Don’t forget these people. They have no one, yet they are people. They are desperately lacking and in terrible pain. Those who understand this are so rare; you must not turn your back on them.”

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Antisocial personality dynamics are complex!!! If you want to better understand an antisocial individual in your life, or if you are an antisocial personality and want to explore it, feel free to reach out! If you’re in Virginia (or a PsyPact state), check out our private practice, Quest Psychological and Counseling Services for available services. If you’re a provider stuck on a case, we also offer consultations for mental health professionals!

References

Millon, T., Simonsen, E., Birket-Smith, M., & Davis, R. D. (Eds.). (2003). Psychopathy: Antisocial, criminal, and violent behavior. Guilford Press. ↩︎ ↩︎ ↩︎ ↩︎
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th edition, text revision.). https://doi.org/10.1176/appi.books.9780890425787 ↩︎ ↩︎
American Psychiatric Association. (152). Diagnostic and statistical manual: Mental disorders (1st ed.). https://www.turkpsikiyatri.org/arsiv/dsm-1952.pdf ↩︎ ↩︎
Akhtar, S. (1992). Broken structures: Severe personality disorders and their treatment. Jason Aronson, Inc. ↩︎ ↩︎ ↩︎ ↩︎
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Millon, T. (1981). Disorders of personality: DSM-III, Axis II (1st ed.). Wiley. ↩︎ ↩︎ ↩︎
Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc. ↩︎ ↩︎ ↩︎ ↩︎
Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). The Guilford Press. ↩︎

Ep 46: Did the DSM Get it Wrong? | A New Perspective on Avoidant Personality

Tue, 27 Jan 2026 02:00:01 +0000

In this episode of the Personality Couch Podcast, licensed clinical psychologist Doc Bok unpacks the historical context of Avoidant Personality Disorder (APD), exploring the ongoing debate about its classification in the DSM. This episode discusses the contributions of Theodore Millon, the controversies that arose during the introduction of APD, and the implications of trauma and sociopolitical culture on personality development. The episode concludes with proposing alternative classification systems, including the Enneagram, the psychodynamic phobic character, and avoidant personality as a problematic trait versus a disorder.

In need of psychodynamic therapy or a psychological evaluation? OR are you a provider stuck on a tricky case? To schedule with us, please visit the practice website and fill out the inquiry form! https://www.questpsych.org. Clinicians use the email listed on the website.

Did the DSM Get it Wrong?

Tue, 27 Jan 2026 02:00:00 +0000

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Is Avoidant Personality Disorder the most recently created personality disorder? Technically, it was introduced in the DSM-III in 1980, along with three other “new” personality disorders: narcissistic personality disorder, schizotypal personality disorder, and borderline personality disorder. However, the origins of these three date pretty far back in comparison to Avoidant Personality Disorder, which was only coined in 1969 by Theodore Millon¹. So that begs the questions - Why is this showing up so late in the game? Is this actually a separate personality disorder? 🤔

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The History of Avoidant Personality Disorder¹

In 1969, Theodore Millon came up with Avoidant Personality Disorder, focusing on the process of active detachment from psychological pain and social relationships (in contrast to passive detachment in the schizoid). Millon highlights historical theory that intertwines with schizoid personality dynamics, until he separated them in 1969. A prominent concept that Millon describes is Kretchmer’s hyperaesthetic part of schizoid. Kretchmer described a core schizoid component (unsociable, quiet, reserved, serious, eccentric), then a continuum in which the schizoid can drift back and forth in: aesthetic (insensitive) and hyperaesthetic (overly sensitive)² ¹. Millon separated the hyperaesthetic aspect into what is now Avoidant Personality Disorder…which elicited a lot of controversy.

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Controversy Surrounding Avoidant Personality Disorder

After the introduction of Avoidant Personality Disorder in the DSM-III, theorists had some interesting arguments in The American Journal of Psychiatry. Livesley et al. (1985)² argued against avoidant personality disorder as a separate, standalone personality disorder, calling out Millon for pulling out hyperaesthetic from Kretchmer’s full schizoid theory. They also quoted Gunderson…which I think is a pretty clear, powerful comment on the topic: “In the absence of any clinical, empirical, or even widely accepted theoretical rationale for such a distinction, it is difficult to understand why this category [avoidant personality disorder] was established.”

Millon³ responded in the journal in 1986, noting that Livesley et al.² were not members of the APA taskforce for the DSM, so they’re missing data…a fair, but egocentric point. Then Millon³ argued that he conceptualized avoidant personality disorder first, then figured out Kretschmer’s hyperaesthetic fit with avoidant…which is….suspicious. It could be true, but for myself, I’m not buying it due to the snobbish undertones in Millon’s writings.

Then in 1986, Akhtar⁴ responded to Livesley² with my favorite argument! He noted that avoidant and schizoid should be separated, but not for the reasons that Millon³ proposed. Instead, Akhtar⁴ focused on defenses, with avoidants using higher level defenses like repression, symbolism, and displacement, while schizoids tend to use lower level defenses such as withdrawal into fantasy and splitting the self off from their own needs and the world. He also argues that schizoid and avoidant personalities are structurally organized in a different way, and that avoidant personality is a personality where fear, anxiety, and phobic processes have become one with the person, intertwined with who they are (ego-syntonic)…just like depression could be a depressive personality or OCD an obsessive-compulsive personality⁴. He was essentially saying that avoidant personality is a phobic character⁵ (According to the PDM-2⁵, an anxious-avoidant/phobic personality is an anxious or timid person who struggles with safety vs. danger, feeling that they are in constant danger and must avoid it 🫣).

Regardless of all the controversy…Why did Avoidant Personality Disorder only show up in 1969?! Let’s check out what was happening in the world then. 🌎

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The Zeitgeist of the Times of Avoidant Personality Disorder⁶

Personality is influenced at an individual level with genes, temperament, and early environments, but it’s also influenced by macrolevel layers such as culture and societal events. During the 1960s, there was a changing of world order and heightened polarization across the globe on the heels of World War II. In the United States (where Millon lived) in the 1960s, JFK was assassinated (1963); the Civil Rights Act was passed (1964); riots were rampant; MLK was assassinated (1968); Nixon, one of the most paranoid leaders in America, was elected president (1969)…and we have a push for people to submit to authority or else (😨phobic), rise up and challenge injustice (😡counterphobic), or avoid it all and become a hippie (✌️blissfully avoidant). Is it surprising then, that all of the sudden, we have a personality disorder characterized by fear and anxiety, who run from psychological pain? 🤷

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Doc Fish’s Opinion on Avoidant Personality Disorder

I see SIGNIFICANT overlap among multiple theories! At the core, we have a personality that is fearful, anxious, and uncertain, and feeling inadequate because of it.

The DSM calls this avoidant, focusing on the hypervigilance to rejection and low self esteem.
Millon¹ calls this avoidant, focusing on the hyperalertness to danger and active movement away from others to avoid emotional pain.
Psychoanalytic theory (in my personal opinion) calls it an anxious-avoidant/phobic personality⁵, focusing on avoiding danger and feelings of inadequacy and indecisiveness.
The Enneagram⁷ describes a Type 6 who tends to be anxious and fearful of not having support, needing security and reassurance. They can be suspicious, self-doubting, defensive, and evasive, needing to test others’ attitudes toward them…Sounds a lot like Avoidant to me!

My conclusion is that schizoid and avoidant are separate personalities, but are not adequately captured in the DSM or by Millon¹. I actually favor the Enneagram⁷ to describe avoidant personalities with the Type 6, and think psychoanalytic theory’s phobic personality⁵ is also helpful to understand Avoidant Personality Disorder. Interestingly, Doc Bok has a different take on Avoidant Personality Disorder, viewing it as a trait. To learn more, check out Ep 46: Did the DSM Get it Wrong? A New Perspective on Avoidant PD.

Whatever your perspective on Avoidant Personality Disorder is, the symptoms of running from psychological pain, feeling anxious, struggling with low self-esteem, and avoiding others due to fear of criticism definitely exist - regardless of what you want to label it. If you desire to explore Avoidant Personality dynamics, therapy and/or psychological testing can help! If you’re in Virginia (or a PsyPact state), check out our private practice, Quest Psychological and Counseling Services for available services. If you’re a provider stuck on a case, we also offer consultations for mental health professionals!

References

Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Livesley, W. J., West, M., & Tanney, A. (1985). Historical comment on DSM-III schizoid and avoidant personality disorders. The American Journal of Psychiatry, 142(11), 1344-1347. https://doi.org/10.1176/ajp.142.11.1344 ↩︎ ↩︎ ↩︎ ↩︎
Millon, T. (1986). Schizoid and avoidant personality disorders in DSM-III. The American Journal of Psychiatry, 143(10), 1321b-1323. https://doi.org/10.1176/ajp.143.10.1321b ↩︎ ↩︎ ↩︎
Akhtar, S. (1986). Differentiating schizoid and avoidant personality disorders. The American Journal of Psychiatry, 143(8), 1061-a-1062. https://doi.org/10.1176/ajp.143.8.1061-a ↩︎ ↩︎ ↩︎
Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). The Guilford Press. ↩︎ ↩︎ ↩︎ ↩︎
History. (2025, May 28). The 1960s. https://www.history.com/articles/1960s-history ↩︎
Enneagram Type 6: The Loyalist. (n.d.). The Enneagram Institute. Retrieved January 20, 2026, from https://www.enneagraminstitute.com/type-6/ ↩︎ ↩︎

Ep 35: A Deeper Look at Schizoid Personality | Psychodynamic Perspective

Tue, 26 Aug 2025 02:00:01 +0000

In this episode of The Personality Couch, we (licensed clinical psychologists Doc Bok and Doc Fish) use a fresh psychodynamic perspective to look at the misunderstood, quiet, awkward, and socially backwards schizoid. We explore the misunderstandings and stigmas surrounding schizoids, their emotional depth, and the historical perspectives that have shaped our understanding of this personality type. Our conversation highlights the internal struggles of schizoids, their coping mechanisms, and the rich inner lives they lead, often hidden from the outside world. We also take a look at the superpower of the schizoid and how they spot others’ disingenuousness. We emphasize the unique internal experiences of schizoids and the need for a compassionate approach in relationships and in clinical practice.

Are you a clinician stuck on a case? To schedule a consultation, please visit the practice website! https://www.questpsych.org/

Schizoid Personality - A Deeper Look

Tue, 26 Aug 2025 02:00:00 +0000

The Psychoanalytic Lens of Schizoids

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The DSM-5-TR doesn’t always capture the full picture of pathology, and it sure as heck does not capture the full spectrum of personality. There’s a whole range from healthy to ill, and the DSM is only a snippet of that continuum. For the schizoid personality in particular, the DSM describes the outside shell but not the inside person (see our last blog for DSM view of schizoid). Schizoid individuals are not specimens or robots🤖. They are authentic, complex human beings! So, it’s necessary to look outside the DSM to understand the internal workings of these vastly misunderstood, stigmatized, and overpathologized individuals. Let’s take a peek into the shell!

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History

Right off the bat, schizoid personality didn’t fit in. Freud focused on the sexual and aggressive drives involved with different personalities and pathologies, but schizoids just detached from those drives, so there wasn’t really anything to work with until object-relations came along¹. Initially, psychologists noticed there was a personality that seemed on the trajectory to schizophrenia, but never actually disintegrated to psychosis (e.g. Kahlbaum’s “heboid,” Hoch’s “shut in,” Bleuler’s “schizoidie”)². Finally, through the lens of attachment, theorists were able to start conceptualizing the “split” between the self and others/the world, as well as the split between the self and one’s own needs that is hallmark for the schizoid personality³.

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The Making of a Schizoid

From birth, schizoids have a temperament characterized by being extremely sensitive and easily overstimulated, often moving away from overwhelming things like light, sound, and touch⁴ ³. They feel painful emotions when overstimulated and feel so deeply and intensely that they often suppress emotions altogether⁵. Their attachment figure (usually mom) is neglectful, intrusive, or both. The neglectful mother leaves the kiddo to turn to the self for stimulation, while the intrusive mother wants the kiddo to BE her so that they are enmeshed³. Often, there is a combination of both dynamics. Eventually, this leads to an adult who desires separateness.

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Conflict & Fears

Schizoid personalities struggle with the conflict of wanting closeness but fearing it⁵ ³. They don’t fear rejection like avoidant personalities do, but rather fear they will be engulfed, consumed, or taken over by another person to the point that they will cease to be a separate being⁴ ³…and how can one exist if they are not separate? Think about Pacman… if Pacman gets close to the ghost, the ghost is consumed and is no longer a separate being. It is eaten - engulfed, devoured, and consumed by the other. Thus, schizoids feel that others are threateningly intrusive and impinging, and they learned that their own needs for dependency, connection, and love are dangerous. So what do they do?

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Defenses & Coping

To survive the world that schizoids find overwhelming and dangerous, they essentially do what they’ve always done. They move away, separate, and withdraw⁴ ³. This can be physical, literally going away and isolating, or it can involve mentally retreating into their mind to detach from what’s going on around them. They also withdraw or move away from their intense emotions when needed, which allows them to objectively and logically analyze their feelings (intellectualization) and be deeply aware of their own psyche⁴ ³. McWilliams⁵ wrote that schizoids are: “startlingly aware of features of their inner lives that tend to be unconscious in individuals with other kinds of personality.” …so what’s actually in there?

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Inside the Schizoid

My favorite way to understand a schizoid is through metaphor, which is often their language⁴. Let’s say that all humans are boxes of crayons 🖍️who have all the same colors and amount of crayons on the inside. The outside of the schizoid crayon box looks dull and gray vs vibrant and indicative of the hues inside. Whereas other personalities deny, throw, reject, or hide some of their colors/crayons, the schizoid has access to all of them and has drawn elaborate, multicolored mental fantasies. Instead of discarding these colors as most personalities do, schizoids tolerate their black darkness, perversion, and destructive desires; grey nihilism; red potential for passion and anger…a stark contrast to their dull, boring, unassuming external box.

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That’s why it’s so important to look at the psychoanalytic understanding of schizoid personality! Being cliche, the DSM is judging the schizoid “book” by their cover, focusing on the “deficits” of the boring box, while the psychodynamic lens is attempting to peer inside.

If you’re a schizoid and reading this, I hope you feel at least a sliver of validating and understanding. If you love a schizoid, please try to care for them in a way that they need, instead of coloring on their box. If you desire support with understanding and exploring the schizoid dynamics, feel free to reach out! You can look on Psychology Today or if you’re in Virginia, check out our private practice, Quest Psychological and Counseling Services for available services.

References

Millon, T., Grossman, S., Millon, C., Meagher, S., & Ramnath, R. (2004). Personality disorders in modern life (2nd ed.). Wiley. ↩︎
Millon, T. (2011). Disorders of personality: Introducing a DSM / ICD spectrum from normal to abnormal (3rd edition). John Wiley & Sons, Inc. ↩︎
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
McWilliams, N. (2006). Some thoughts about schizoid dynamics. Psychoanalytic Review, 93(1), 1-24. https://doi.org/10.1521/prev.2006.93.1.1 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). The Guilford Press. ↩︎ ↩︎ ↩︎

Ep 16: BPD Part 4: What Therapy Really Looks Like

Tue, 03 Dec 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we dive into the complexities of Borderline Personality Disorder (BPD) treatment, in particular, the healing power of the invisible dynamics in therapy. We discuss the importance of motivation and insight in recovery for BPD, and the significance of the therapeutic relationship. The conversation emphasizes that while BPD is treatable, the journey is often non-linear and requires active participation from the patient. We also highlight the necessity of setting boundaries within therapy to create a safe and effective environment for healing. In this conversation, we discuss the importance of evaluating effort in therapy, the significance of attachment, and the challenges posed by boundary violations. Our conversation also explores the concepts of transference and counter-transference, the process of repairing ruptures in the therapeutic relationship, and the methods of facilitating insight and connections in therapy. Overall, this discussion emphasizes the individualized nature of treatment and the invisible dynamics that play a crucial role in the therapeutic process.

The Invisible Dynamics of Treating Borderline Personality Disorder

Tue, 03 Dec 2024 02:00:00 +0000

Borderline personality disorder is a hot topic recently, and Personality Couch has explored its history and presence in the media, criteria and symptoms, and suicidality/self-harm. It’s a disorder characterized by deep emotional pain…but what about treatment? Is there hope? YES!!! There are actually many treatments for borderline personality disorder, which you can Google and likely find Dialectical Behavior Therapy (DBT) as the evidence-based, gold-star treatment. Instead of telling you about all the information that’s already out there everywhere, I’m going to talk about what isn’t talked about - the unspoken dynamics happening in treatment with borderline personality disorder.

Treating borderline personality disorders is one of my specialties. I enjoy it for many reasons, including the need for an individualized approach to treatment because no two persons with borderline personality disorder are alike. The growth made in treatment is hugely influenced by tricky, unspoken dynamics that are invisible. So what are they?

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Boundaries

While boundaries can be spoken and visible, they are often unspoken and invisible. Boundaries are involved in all the therapeutic processes throughout the entirety of therapy. Boundaries are important for personality disorders in general, but especially for borderline personality disorder. This is due to the safety and validation that boundaries provide in the chaotic pain of this disorder. We can think of boundaries as the frame of the therapy puzzle.

Boundaries Outside Sessions

Some examples of important boundaries outside of sessions include following rules and policies with paperwork (i.e. must be complete), payment (i.e. must be made the day of session), and communication (i.e. goes through the administration team). The policies are needed to set a professional therapeutic environment, not just an informal conversation with an acquaintance. It’s essentially the groundwork for treatment.

Boundaries Inside Sessions

There are also boundaries that are involved inside of session work, such as attendance, communication during session, and work put into sessions. I always emphasize that the days someone does not want to attend therapy are likely the most important days that they should, since that might be when they’re depressed, angry, avoidant, etc. Not to mention there can be policy-related consequences to not attending. I also highlight that anything can be discussed in therapy (even anger, attraction, fears, aggression desires), but we can’t necessarily behave on it. For example, you can be angry and scream at me, but you can’t knock over the lamp (Please be aware that every therapist sets their own boundaries. It may not be okay to scream at your therapist). Additionally, therapy is the client’s space, and therefore, I cannot do the work for the client.

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Therapeutic Relationship

(Super important factor!)

Attachment

The relational connection or lack thereof (attachment) between client and therapist is important for treatment. For those with borderline personality disorder, there is often a quick attachment to the therapist because of their high pain, need for help(er), and need for relationship (due to fear of abandonment). The client might view the therapist as a hero, rescuer, or the best thing ever (idealization). Uncommonly, and sometimes fleetingly, the client might view the therapist as a villain, persecutor, or the worst thing ever (devaluation). When either of these happen, providers need to be careful and accept it without reinforcing it.

Because of the pushes and pulls involved in treating personality disorders, boundaries and attachment often overlap and can be quite problematic. My biggest pet peeve is when providers take up the client’s therapeutic space with clinically irrelevant self-disclosure. It’s highly unlikely that the client needs to know about their therapist’s love life, diet, or own struggles with mental health. Therapists can become too involved in their clients’ needs, especially when their client wants them to constantly meet all their needs and tell them what to do. I’ve seen some providers portray a controlling or possessive resistance when a client wants to end therapy, which means something is wrong there. Other big, bad boundary crossings include unsolicited advice regarding nonclinical matters, socialization outside of sessions, physical contact, and romantic intimacy that is acted upon. Honestly, these are all red flags! 🚩🚩🚩

Transference/Countertransference

The attachment in the therapeutic relationship inevitably leads to transference and countertransference. Because the client does not have a full picture of who the therapist is as a human being, the client unconsciously perceives the therapist to be similar to a different attachment they have a map for, usually from childhood, like their mother (transference). The client then unconsciously behaves in similar ways that they acted with their mother, which leads to countertransference. This is when the therapist has their own perceptions, emotions, and reactions to the client that often mirrors what the transferred person (like mother) felt, which is often frustration or pulls to rescue. It’s common for the Drama Triangle (podcast/blog) to show up in these dynamics!

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Corrective Experiences

Corrective experiences are difficult to explain because they are extremely individualized. It’s an experience that occurs in the therapeutic relationship that “corrects” or “heals” a traumatic or bad experience that occurred with a different attachment (usually in childhood). While I may celebrate the admission or expression of anger for someone who turns their anger inward, I might celebrate the self-containment or accountability for someone who is outwardly destructive in their anger. A more complex example would be for someone who has been parentified, I can set boundaries to facilitate corrective experiences by making sure I am the “parent” in the therapeutic relationship. I handle tracking the time, making sure we’re scheduled, etc. In contrast, if someone is regressed, I can set boundaries to not play into any dependency or “tantrums.” I might make it the client’s responsibility to make sure we are scheduled or have the boundary that I will not call them if they are late or missing a session, with the purpose of increasing their tolerance of taking responsibility for themselves.

Repairing Ruptures

Corrective experiences can also include repairing attachment ruptures in the therapeutic relationship. A rupture can happen when there is any conflict or potential for conflict between the therapist and client. This is SUPER important in the treatment of borderline personality disorder because of the fear of abandonment. I have to validate the conflict or concern without judgment, allowing the client to be upset in a way where it is also emphasized that I will not abandon the client. Sometimes, this includes me being incongruently excited and celebratory that the client has brought up their concern. Then, the repairing of the rupture includes sitting in the distress, exploring what is happening, taking accountability, and resolving the conflict interpersonally.

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Connections & Insight

Making connections and facilitating insight is also an important part of the invisible dynamics of therapy. Making connections involves putting separate pieces of a client’s story together. It’s the middle part of the puzzle, and it is similar to finding all the pieces that make up a certain design, color, or shape, and putting them together. While therapists (should) do this in their own head, it’s important for the client to make and verbalize the connections with guidance (Not rescuing. Not advice. Not answers) from the therapist. Client-led connections are much more powerful and helpful. Facilitating insight includes self-reflection, self-awareness, and looking deep into the self, and then being able to verbalize it. Therapists can call out what’s happening in the room in the moment (immediacy) to help clients with this. For example, a therapist might ask the client what is leading to the clenched fists when discussing their mother or the picking at the couch when discussing their father.

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In sum, treatment for borderline personality disorder is extremely individual with a ton of invisible dynamics. This can actually be pretty frustrating for clients because there’s not necessarily tangible evidence of growth or boxes being checked off like in some manualized treatments. So because the growth is also “invisible,” it can feel like progress isn’t being made, or maybe even feeling “stuck.” However, the healing often occurs over time without realization (ya know, since all these things are frustratingly invisible!). But then, when prompted to explore their progress, clients can usually verbalize their growth, and it can be super powerful!

Ep 13: BPD Part 1: History, the Media, and the DSM Symptoms

Tue, 22 Oct 2024 02:00:01 +0000

In this episode of the Personality Couch Podcast, we delve into the complexities of Borderline Personality Disorder (BPD). We discuss the stigma and misinformation surrounding BPD, the media’s misrepresentation of the disorder, and the need for a more nuanced understanding of its symptoms and diagnosis. The conversation highlights the emotional experiences of individuals with BPD, the criteria for diagnosis, and the importance of recognizing the spectrum of presentations within the disorder. We advocate for a reboot in the classification of personality disorders to better reflect the lived experiences of those affected by BPD.

Where Did "Borderline" Even Come From?

Tue, 22 Oct 2024 02:00:00 +0000

Why focus on Borderline? In clinical practice, borderline personality disorder is common, as the pain these individuals experience often leads them to treatment. Outside of clinical practice, every time I open social media, there’s a hot topic of “borderline-this” or “borderline-that.” It’s one of the most researched of all the personality disorders, yet there is a high level of misinformation online about borderline. Not too long ago, there was intense stigma regarding borderline personality disorder. Currently, the stigma seems to have lessened, but it still exists. It’s hard to squash a stigma that’s been around for almost a century.

Photo by Alexander Shatov on Unsplash

Stigma and Borderline in the Media

Because of the unstable nature of borderline types, it can be a good fit for dramatic TV shows and movies. But such theatrical depictions actually eclipse what borderline looks like in reality. Can you think of any classic movies or shows that portray a character with borderline personality disorder? If so, the character you’re thinking about is quite likely the villain of the story, maybe even murderous or psychopathic. That is NOT your average borderline case. There’s an episode in Daredevil … maybe season 3 episode 5, and they worked really hard to try to have a character named Dex portray borderline personality disorder. But he ended up killing his coach because his coach pulled him out of a game. Dex saw a therapist when he was a child, and the therapist wrote down “borderline personality disorder” and then later, “psychopathic tendencies.” While the writers put in some good effort, they missed the mark. It’s a great example of the exaggerated and dramatized portrayal of borderline in the media. Individuals with borderline are more apt to harm themselves, not others. Remember the Personalities that Kill episode/blog? Borderline individuals are at medium risk, not high.

Photo by Limor Zellermayer on Unsplash

Okay, so what if you just quickly Google “characters with borderline personality disorder?” The Hulk comes up a lot. Why? Because he has two “personalities?” He doesn’t remember what happens when he becomes the Hulk, so this fits much better with dissociative identity disorder and not borderline. Is it because he’s angry? Anger is part of many personalities. The Hulk does not likely meet criteria for borderline personality disorder. I also saw Elsa come up a lot. But based on what? There’s no push-pull in her relationships. She withdraws to protect herself and others (Schizoid type maybe?), and she’s not fearful of being alone. My hypothesis is that characters viewed as “crazy” are likely to be labeled borderline, and this absolutely contributes to the stigma around this condition.

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History of Borderline

To understand the history of where the psychological term “borderline” came from, we have to look back to the time when the psychological field split patients into two categories: psychotic (out of touch with reality, needing hospitalization) and neurotic (too rigid and anxious, needing outpatient treatment). Psychotic diagnoses would include schizophrenia, hallucinations, and delusions. Neurotic diagnoses would include obsessive compulsive conditions and those with high anxiety.* But, alas, not all people fit into one of these categories. Some patients were outside of psychotic or neurotic categories- somewhere in the “Borderland,” - since they were bordering on both categories. They also didn’t respond to the standard treatment for either psychoticism or neuroticism. The Borderland space eventually became understood as a borderline organizational level of personality (Kernberg) somewhere around 1967. Kernberg viewed psychotic and neurotic to be on a continuum, calling the space in between: “borderline.” From that time until 1980 when the DSM-III was published, there was significant controversy about the term borderline. Some in the psychological field wanted to create a categorical diagnosis to capture the movement of borderline organization, and some were adamantly against it. Obviously, and unfortunately, the categorical diagnosis of borderline won out and was published in the DSM-III (1980), and it is the same concept we use today. Some professionals still oppose using borderline as a diagnostic category, but the widespread acceptance of such has overshadowed the history of the term.

*In our episode on Psychodynamic Personality Classifications (as Ice Cream Flavors), you can read or listen (5:17) to learn more about this original classification system.

Photo by Ahmad Odeh on Unsplash

All of this history leads me to…. How can we actually capture a dynamic movement and put it in a box? It’s a hindrance that has resulted in chaotic information regarding what we currently understand borderline personality disorder to be. In the earlier days of this disorder, it was essentially a “trash can diagnosis,” - a label to describe the numerous patients whose acuity was too severe to be in outpatient treatment, but too high functioning to be psychiatrically hospitalized. The unfortunate irony in not “belonging” to a category is that at the core of the borderline condition is fear of rejection. The name itself thus reinforces the symptoms of this disorder. Further, the essence of borderline means that there’s movement. For example, patients can be in reality at breakfast time and out of reality from lunch to dinner time. Borderline patients have constantly shifting presentations. The varying display of borderline symptoms has likely led to a lot of the misinformation that’s out there, especially on social media.

My own preference to view borderline as an organizational level and not a category puts me on the losing side of the “borderline battle.” However, the DSM-5-TR does include a proposed dimensional model for the future, placing personality disorders on a severity continuum versus a static, categorical box. This gives me hope. Because there are many things that don’t fit in boxes, least of these, people.

Psychodynamic Flavors of Personality

Tue, 23 Jul 2024 06:00:00 +0000

If you remember from the blog, there is a categorical “axis” that helps us understand the flavors of personality within the psychodynamic lens. I call this “The Character Axis: Flavor Category of Ice Cream,” which we can visualize like this:

While these categories are heavily expanded upon in Nancy McWilliam’s book, , the , Second Edition ( ) contains even more categories and includes subtypes of personality. Also note that the PDM-2 has more personality types than we highlighted in our .

Paranoid Personalities

Subtypes: None.


DSM-5-TR	Included, but differs in focusing on the external processes, while the PDM-2 focuses on the internal processes.
Millon	Included and similar.

Paranoid personalities have a fairly stable history that has not changed much. They find their emotions, desires, and thoughts unacceptable, so they reject them and put them onto others (projection). An example of projection might be reacting to others’ behavior, when really they are the one acting that way. They often feel fear, rage, shame, contempt, hatred, hostility, disgust, and envy, which are all deemed unacceptable and are thus seen as coming from outside themselves. They can also project dependency and attraction (i.e. paranoid jealousy) and believe they are in constant danger because the world is full of others who are potential threats. They expect to be attacked and humiliated by others so they aggressively humiliate and attack first in order to lessen their anticipatory anxiety. They are suspicious and distrustful of others, overly hypervigilant in waiting for the attack and on constant alert of possible exploitation.

Schizoid Personalities

Subtypes: None.


DSM-5-TR	Included, but differs in focusing on the external processes, while the PDM-2 focuses on the internal processes.
Millon	Included, but a mix of the PDM-2 and DSM-5-TR understandings.

This is one of the more confusing pieces of psychology because the prefix ( , , , , etc) and the term “ ” have been used in so many different ways. Importantly, schizotypal personality disorder in the DSM is absent in the PDM-2 because the PDM-2 believes it is a trait common in schizoid types, not its own personality. Here, we are discussing the PDM-2’s understanding of schizoid personalities, which aligns well with but differs significantly from the DSM. The DSM focuses on the outward expression of schizoid persons: little emotional expression, indifference, lack of closeness to others, lack of pleasure, lack of interest in sex with others, preference for solitary activity, and lack of desire/enjoyment of close relationships (a deficit-based description). In contrast, the PDM-2 maintains that internally, there is actually a fear of closeness that conflicts with a yearning for closeness because they believe love and dependency are dangerous, and the social environment is intrusive and engulfing (conflict-based description). The PDM-2 also notes that both the deficit- and conflict-based view of schizoid likely exist on a “health-illness” continuum, with the conflict-based version found in higher-functioning ranges.

Schizoid personalities are extremely sensitive, easily overstimulated, and shy. Overstimulation on the outside results in overall emotional pain, and they feel their emotions so intensely and powerfully that they have to detach from them. They can do this by withdrawing physically to be alone and without others, as they are more comfortable that way. However, when this happens, they desire closeness and fantasize about intimacy. They can also withdraw into their minds, thoughts, and fantasies, detaching from their own needs and the outside world.

Psychopathic (Antisocial) Personalities

Subtypes: Passive-Parasitic, Aggressive.


DSM-5-TR	Included as Antisocial Personality Disorder.
Millon	Included as Antisocial Personality.

The PDM-2 prefers to use the older term “ ” instead of to describe this type of personality, which makes sense because, as stated in the PDM-2, these individuals are not necessarily against social norms ( ), nor are they incapable of social interaction ( ). They can actually present as charming and charismatic with a capacity to read others’ emotions accurately, but their own emotions are poor and depleted, with the exception of rage and envy, which are more easily experienced. Though they actually have a high desire for stimulation, they seek power because they want it, finding pleasure in deceiving others in their journey toward more control. Fearing control and manipulation, they believe others are inherently selfish, weak, and dishonorable. Thus, psychopathic characters act in controlling and conniving ways, believing they can do whatever they want, without regard for morality.

They are extremely aware of their environment, but think and behave from a selfish perspective, always putting themselves first. They lack emotional connection to others, and what relationships they do have tend to focus on how useful the other person is. Their indifference to others includes a lack of remorse and empathy when they harm others, though they do not find pleasure in harming others like a sadistic personality type would.

There are two subtypes of psychopathic personalities. The passive-parasitic personality can be understood as a con artist, imposter, or scammer, passively but manipulatively “one-upping” others to gain control and power. The aggressive subtype is overtly more combative, actively harming and stepping on others to gain their control and power, perhaps more often tapping into their rage.

Sadistic Personalities

Subtypes: None.


DSM-5-TR	Not included.
Millon	Included.

Sadistic personality disorder was considered in the DSM-III-TR but thrown out in the DSM-IV, perhaps because of the belief that there is overlap between sadistic personalities and antisocial personalities. However, you can have a sadistic personality without antisocial personality, and vice versa. Though some can fall into both categories. Another hypothesis is that sadistic personalities are not often seen in clinical settings, usually only forensic settings. On an interesting note: those who fantasize about and/or enact sexual sadism are not all sadistic personalities, but it is likely that all sadistic personalities have a preference for sexual sadism.

Sadistic characters desire and feel entitled to humiliate and hurt others, often feeling contempt and “cold” hatred (hatred that lacks anger). They find pleasure and sadistic glee in inflicting suffering on others, but they do so in a calm and detached manner without feelings of guilt, remorse, or empathy. They tend to dominate others due to a need for control, and elicit a predator-prey dynamic. For example, when interacting with a sadistic personality type, you might feel creeped out, intimidated, and uneasy, with a desire to flee or hide - a very adaptive response to the threat that sadistic personality types portray.

Borderline Personalities

Subtypes: None.


DSM-5-TR	Included.
Millon	Included.

Again, borderline personalities have such an interesting history. The PDM-1 did not include a categorical understanding of borderline personality, only a . However, the PDM-2 notes it has now included the borderline personality category because of the pervasiveness of the concept, especially since the DSM-III added borderline personality disorder in 1980.

Borderline personalities have difficulty handling and regulating their emotions because their emotions tend to be intense, extreme, and out of control (especially fear, shame, and rage), which impairs their functioning. Because they can’t self-soothe, they depend on others to comfort and regulate them. However, being too close to someone is also scary. They need a safe person they can be close with, but they fear being too close to them because they fear rejection and abandonment. This results in treating others in a confusing push-pull way (similar to disorganized attachment styles) of “desperate clinging, hostile attack, and dissociative-like states of detachment” (PDM-2 p. 53). Thus, they have difficulty keeping stable relationships.

Often having developmentally regressed self-centeredness, they have difficulty putting themselves in others’ shoes, believing that others are thinking/feeling what they are thinking/feeling (projection). Thus, they tend to split into believing someone is all good or all bad, which can flip flop easily. They can also flip between different parts of themselves, as their sense of self tends to be fragmented instead of cohesive. Embodying self-identity concerns, they may not know who they are and instead, usually feel an emptiness, “empty spot,” or inner void within themselves that they try unsuccessfully to fill.

Hysteric (Histrionic) Personalities

Subtypes: Inhibited, Demonstrative.


DSM-5-TR	Included but describes the demonstrative subtype. “The DSM diagnosis of borderline personality disorder essentially depicts hysteric-histrionic personality organized at a borderline level of severity (cf. Zetzel, 1968)” (PDM-2 p. 44).
Millon	Included.

Histrionic personalities have a long history, stemming from descriptions of and , and it used to be called “Emotionally Unstable” in the DSM-I (1952). Though having an unfortunate namesake and a rather dark history, histrionic personalities today can be found in any gender/sexuality/orientation (or lack thereof). They are overly focused on gender, sexuality, and power, and they fear internal overstimulation of their own emotions and desires. They often have emotional experiences of guilt, shame, and fear, but they seemingly attempt to push it to the surface, speaking in dramatic ways and being impressionistic. They can also experience symptoms if their emotions or desires become too much.

At an unconscious level, hysteric character types devalue their own gender, believing there is something problematic, weak, inferior, and/or defective about it. However, they envy the opposite gender, finding it to be exciting and powerful, but also frightening, highlighting a conflict among genders and their meanings. They often address this conflict by flaunting sexuality in an exhibitionistic manner, being seductive to gain power and defend against the perceived weakness of their own gender, while pursuing conquest over the opposite gender. While histrionic was born out of a binary gender culture, it still applies in the present day where gender and sexual fluidity is more socially acceptable. The difference is that the histrionic person may be reacting against the opposite side of the gender or sexual identity continuum vs the binary male/female category.

The demonstrative subtype tends to occur more in cultures that do not try to control gender and sexuality (i.e. Western societies), and they present as more seductive, attention-seeking, dramatic, and flamboyant. Whereas in cultures that attempt to control gender and sexuality, the inhibited subtype is more likely, presenting as naive, conventional, and sexually avoidant/unresponsive. Regardless of subtype, actual sexual intimacy is anxiety provoking and conflictual due to fear of being hurt by the powerful gender (opposite gender) and shame of their own gender. Sexual behavior tends to be completely separated from internal experiences.

Narcissistic Personalities

Subtypes: Overt, Covert, Malignant.


DSM-5-TR	Included, but describes the overt subtype.
Millon	Included.

Narcissistic personalities suffer from wounded self-esteem, an unstable sense of self, as well as an internal sense of emptiness, though they often conceal these weaknesses through a grandiose presentation. These characters also defend against their wounded self-esteem through both idealizing someone, which makes them feel special by association, or devaluing someone, which makes them feel superior. They tend to experience both anxious and avoidant attachment styles, behaving in ways that are toxic and destructive to others and lacking internalized morality. Thus, their emotional experiences often contain humiliation, shame, envy, and contempt. They spend lots of energy analyzing their own status in comparison to others. They need affirmation of their own value and importance, but cannot find it internally, so they require it externally and believe that the more they have, the better they will feel.

There has been significant research that parses out subtypes of narcissism. The DSM-5-TR describes the overt narcissism that the PDM-2 outlines. The overt narcissism usually occurs when the environment meets needs of wealth, success, admiration, and status, resulting in grandiosity, arrogance, elation, a sense of entitlement, and contempt toward others. Malignant narcissism is a type of narcissism that is blended with sadistic aggression, which is the most problematic type of narcissism. Covert narcissism tends to occur when the environment does not meet needs of wealth, success, admiration, and status, resulting in fantasizing about it, but feeling envy, shame, and depression. These individuals tend to be ashamed, shy, and avoid relationships.

Anxious-Avoidant and Phobic Personalities

Subtypes: Counterphobic (converse manifestation).


DSM-5-TR	Similar to Avoidant Personality Disorder but is also captured in non-personality diagnoses such as phobias and generalized anxiety disorder.
Millon	Similar to Avoidant Personality but also captured in generalized anxiety.

The first edition of the PDM split this type of personality into two categories: Anxious and Phobic (Avoidant), but the PDM-2 hypothesizes they are all in a similar cluster containing characterological anxiety. Though controversial, the PDM-2 notes that there is a personality component to anxiety for some people, where (similar to depressive personalities) anxiety is intertwined into who they are. The DSM-5-TR captures this as symptomatology through phobic disorders and generalized anxiety disorders; however, avoidant personality disorder is included in the DSM. Similarly, Millon assesses both avoidant personality and generalized anxiety symptoms.

Anxious-Avoidant and Phobic personalities are centered on their emotions of fear, experiencing a conflict between safety and danger. They believe they are always in danger, and they have to avoid it somehow. Phobic and avoidant personalities attach their anxiety onto a certain situation or object, which they go to significant lengths to avoid. Anxious personalities have an overall universal anxiety that they can’t pinpoint. They are reserved and shy, usually have anxious attachment styles, and feel scared when they are alone, which can often result in others feeling protective of them. They also tend to feel inferior, inadequate, inhibited, and indecisive, and they have difficulty describing and recognizing their own emotions.

The counterphobic subtype is opposite of this, as instead of being swept away by their fear, they go against it. They seek out danger and risk by rejecting then projecting their anxiety. It is uncommon to see this counterphobic presentation in clinical settings because they are not apt to ask for help. Instead, they likely put on their bravado and rush toward the threat.

Dependent Personalities

Subtypes: Passive-aggressive, Counterdependent (converse manifestation).


DSM-5-TR	Included.
Millon	Included, but parses out Masochistic/Self-Defeating types.

Dependent personalities are organized around excessive dependency needs. They feel needy, helpless, passive, worthless, and inadequate, so they define themselves in terms of others and seek comfort and security in relationships. Their main focus is on keeping their relationships and avoiding criticism and abandonment. Thus, they have a difficult time expressing anger. They feel afraid and sad when by themselves, but find pleasure in a close relationship. Sometimes to maintain the attachment and care of others, they present as younger/childlike and naive. Dependent characters view others as powerful and believe they need (but can resent) others’ nurturance. At a severe level, they stay in unhelpful relationships even when exploited/abused (self-defeating or masochistic version of dependent personalities).

The passive-aggressive subtype also feels inadequate and dependent, defining themselves through others. However, they view the other with hostility and negativity. This subtype finds their own direct anger or aggression to threaten the relationships they need, so it spills out in passive-aggressive behavior and indirect attacks on others.

The counterdependent subtype goes against their impulses. They reject their strong dependency needs, including any emotional vulnerability. However, there is usually an area where dependency needs are secretly expressed. They are unlikely to be seen in clinical settings because they reject asking for help.

Obsessive-Compulsive Personalities

Subtypes: Obsessive, Compulsive.


DSM-5-TR	Included but focuses on the external presentation instead of the internal presentation.
Millon	Included.

Obsessive-compulsive personalities prefer to function as if emotions are unnecessary, believing a lot of emotions are dangerous and need to be controlled (righteous anger is acceptable). They are very resistant to feeling out of control because they believe their own urges will result in destruction, mess, greed, or aggression. Their guilt is intense, resulting in a rigid, punitive, and harshly self-critical inner voice. They defend against feelings of guilt, shame, fear, anxiety, and anger by “undoing” or counteracting them through being overly rational, logical, detail-oriented, rigid, orderly, and organized. They are overly concerned with rules, procedures, and productivity, which impairs their relationships and ability to relax. These character types hold themselves and others to very high standards. They experience conflict between giving in to others’ demands, which results in shame and rage, or rebelling/defying others, which results in anxiety and fear of retaliation. The obsessive subtype is cerebral and constantly in their head thinking, judging, doubting, reasoning, and ruminating because their self-esteem stems from thinking. The compulsive subtype is meticulous, perfectionistic, and busy, constantly “doing and undoing” by collecting, perfecting, and cleaning because their self-esteem stems from action.

Somatizing Personalities

Subtypes: None.


DSM-5-TR	Not included in personality conceptualization. Somatizing can be found as a symptomological disorder under .
Millon	Not included in personality conceptualization.

The DSM has always considered somatic disorders as separate from personality, and Millon’s theory seems to share this belief. These individuals are more likely to be seen in medical settings in comparison to psychological settings. However, the PDM-2 notes that it is very difficult to parse out the personality piece from other somatizing and medical factors, but maintains that there is a personality influence toward those whose psychological pain is mainly expressed through bodily symptoms and concerns about the body. In fact, they often experience or an inability to verbally express emotions, though they may experience overall distress and eventual rage. They view themselves as helpless, unentitled, unheard, powerless, and vulnerable, with a fragile sense of self and a fear of dying. In contrast, they view others as healthy and powerful, as well as indifferent. In some cases, they may have learned that in order to maintain care and attachment with a loved one, they have to be and remain sick.

Depressive Personalities

Subtypes: Anaclitic, Introjective, Hypomanic (converse manifestation).


DSM-5-TR	Not included in personality conceptualization. Depressive symptomatology can be diagnosed as persistent depressive disorder.
Millon	Introjective depressive listed as Melancholic; Hypomanic listed as Turbulent

Depressive personalities are controversial in the field of psychology. While the PDM-2 and Millon (Melancholic) noted that there is a personality type whose tendency toward and experience of depression is intertwined into who they are, the DSM-5-TR has parsed that out as chronic depressive symptoms.

They have difficulty experiencing positive emotions (sometimes even rejecting them), but no difficulty at all feeling all the negative and painful ones like guilt, shame, sadness, and inadequacy. The introjective subtype correlates to Millon’s melancholic personality type. They tend to turn their (unconscious) anger inward, being self-critical and self-punitive, believing there is something fundamentally bad about them. They blame themselves for things because it’s too threatening to blame others.

The anaclitic subtype tends to be preoccupied with rejection and loss, believing that if someone actually gets to know them, they’ll be rejected. They fear abandonment and rejection, but also feel alone when they are with others. This subtype desires relationship, intimacy, and warmth, but instead feels lonely, incomplete, and empty. Existential depression and nihilism are common in this subtype. Regardless of subtype, depressive personalities are often found in clinical settings.

The hypomanic subtype uses positive energy, high self-esteem, mild mood inflation, and optimism to intensely fight against and avoid their sadness, appearing opposite of those with purer depressive features. They often don’t tolerate psychological treatment and can run from relationships to avoid being abandoned.

Note on Masochism

The term has been utilized in many ways within psychology, but all include an (unconscious) investment in suffering. While the DSM previously considered , it was rejected in the DSM-IV-TR; however, Millon still includes it in his theory. The PDM originally included masochism as its own personality type. However, the PDM-2 ended up describing the concept of masochism, but did not propose it as a standalone category because masochism can be found in various other personality types (i.e. dependent, narcissistic, sadistic, paranoid).

References

Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). The Guilford Press.
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press.

Ep 06: Psychodynamic Personality Classification (As Ice Cream)

Tue, 16 Jul 2024 02:00:01 +0000

In this episode of the Personality Couch, we discuss personality flavors and typologies from a psychodynamic lens, using ice cream as our metaphor. Unique to the psychodynamic perspective is the multi-dimensional way it captures personality. We explore psychodynamic’s three personality axes throughout the episode: the severity axis (ranging from personality style to disorder level); the organizational axis (representing movement and disintegration within personality structures); and the character axis (representing distinct personality names and characteristics). We further explore psychopathic, schizoid, depressive and manic, self-defeating, borderline/cyclophrenic, and dissociative personality structures within this framework. A note to our audience: this is a complex and deep topic, and we recommend tuning in to episodes 04 and 05 first: Personality Disorders as Ice Cream Flavors and Millon’s Personality Types (as Ice Cream flavors) first before diving in. Alternatively, you can check out our blogs with visual aides here to guide you: Blog: Psychodynamic Personality Classification (As Ice Cream)

Psychodynamic Personality Classification (As Ice Cream)

Tue, 16 Jul 2024 02:00:00 +0000

Photo by Evaldas Grižas on Unsplash

Psychodynamic theory views personality a bit differently than both the DSM and Millon. The Psychodynamic Diagnostic Manual, Second Edition (PDM-2) “aspires to be a ‘taxonomy of people’ rather than a ‘taxonomy of disorders,’ and it highlights the importance of considering who one is rather than what one has” (PDM-2, p. 2). The PDM-2 has thus expanded personality categories, which resulted in a multidimensional approach to personality. While the PDM-2 uses multiple axes, we’re going to talk about the one specifically measuring personality. Visually, it’s helpful to see how this “Personality Axis” contains other axes that work together… And as always, we use ice cream to help make this complex topic more “digestible!”

The Diagnostic Severity Axis: Amount of Ice Cream and Ingredients
The Organizational/Health Axis: State Change of Ice Cream
The Character Axis: Flavor Category of Ice Cream

Let’s look at each one and see what it contributes to our understanding of personality!

The Diagnostic Severity Axis: Ratio of Ice Cream and Ingredients

We all have a personality. The severity axis is a continuum that shows how functional your personality is to how problematic it is. Are your personality traits serving you, working against you, or even keeping you from functioning in society? It’s not categorical, because we all move along this continuum at certain times, but usually we stay in a small range of the continuum. If it’s not clinically distressing or impairing, it’s toward the Structure end of the continuum. The more problematic, the further toward the Disorder end you might be. Let’s look at it through an ice cream lens!

We might think of this axis as the ratio of ice cream to the bowl or cone. Do you have enough ice cream to fill your bowl? If you have too little ice cream, or certain personality traits, you might have a psychological empty spot that you try to fill with other things (i.e. spending, love, indiscriminate partners, substances, food). If you have too much ice cream, is it overflowing onto others or about to fall off the cone because it’s hard to balance? We can also think of the ratio of flavor and ingredients in the ice cream. Is there too little flavoring to actually taste it, or is there too much flavor? Eating a drop of vanilla extract is gross, but put an appropriate amount in the ice cream, and it’s delicious! Same with ingredients. If there’s too little of certain ingredients in your ice cream, it’s like having pretty significant personality deficits that make it hard to function in our social world. If there’s too much of certain ingredients, it’s overwhelming, and the excessiveness of certain “flavors” or personality traits don’t fit into society well either. So this axis is all about balance and functioning!

The Organizational/Health Axis: State Change of Ice Cream

Early in psychology’s journey of conceptualizing personality, there were two categories: psychotic and neurotic. Eventually, someone discovered that not everyone fits neatly into two categories (😱🤯). Some theorists called those who did not fit in either category: “Borderland.” This term was later adapted to become a continuum from psychotic to neurotic, with the space in between called “Borderline.” (Note: The borderline movement in the continuum was forced back into a category for the DSM-III’s Borderline Personality Disorder - an unfortunate move in our field).

On the continuum, the further we are on the neurotic side, the more rigid and frozen we become - sometimes even literally! The ice cream might become freezer burnt or even just become ice with its atoms super close together and structured. It’s hard to scoop out this ice cream and may be painful. The psychotic part of the continuum (melted) is when we are out of touch with reality. The ice cream has melted and is now liquid. Its original state is lost, just like reality. Then there’s the big space in between called borderline (melting) where we might start to melt. We are still ice cream, but we might be falling apart and melting when we start moving toward the psychotic end. And when we move back toward the neurotic end, the melting is refrozen and icy. We can move along this continuum because we’re not static beings. Even when healthy, we can have snippets of disintegrating or moving toward unhealthy. This organizational axis is essentially an axis of health, but we still don’t want extremes.

The Character Axis: Flavor Category of Ice Cream

The character axis is the actual type/flavor of ice cream. While this seems more categorical for the purpose of understanding and learning, it’s important to note that in actuality, you are rarely only one type of personality. In fact, it is common for literature to talk about mixed personalities. Using our ice cream analogy, this might look like a matcha ice cream with a strawberry swirl and a scorpion on top (paranoid-schizoid), a burnt marshmallow ice cream with cookie dough bites (melancholic-dependent), or a cotton candy ice cream with ghost pepper pieces (histrionic-narcissistic). The flavors are endless - just like individual personalities!

So this is a great place to remind you that while we categorize and label personality information into neat boxes in order to understand and better “consume” the study of personality, limiting yourself to fit into a box is not helpful. The study of personality helps us to identify patterns and concepts, but it falls immensely short of describing an individual person. You are your own unique flavor, and that is something wonderful!

References:

Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). The Guilford Press.

Ep 02: What is Personality

Mon, 03 Jun 2024 08:01:00 +0000

In this episode of the Personality Couch Podcast, we discuss the concept of personality, its classifications, and its impact on behavior and relationships. We explore various historical classifications of personality, including the four temperaments from ancient Greece and the Enneagram. We also touch on modern classifications such as the Myers-Briggs Type Indicator and the Big Five personality traits. We emphasize the importance of understanding personality disorders and the need for early intervention and treatment. Overall, the episode provides a comprehensive overview of the topic of personality.

What is Personality?

Mon, 03 Jun 2024 08:01:00 +0000

Why Did Personality Become a Thing?

At the foundation, we want to understand the world, and our brains are wired to make categories. There’s so many facets of personality that in order to understand, we need to group things together into similarities and differences. We actually have an extensive history of sorting and categorizing people (e.g. physical traits, culture, socioeconomic status, Harry Potter houses).

Photo by Tuyen Vo on Unsplash

Plus, personality shows up everywhere. Pets interact with people, other animals, and their environment differently. Babies are a “raw form” of personality that continues to develop but also maintains some traits. You can have two siblings raised in the same household who are night and day! Personality is expressed through interaction with the environment → which is why it’s important!

Photo by Nathan Dumlao on Unsplash

What is Personality Anyway?

The word “personality” stems from the Latin word persona, which refers to a theatrical mask worn by performers to play roles or disguise their identities. Some theorists would say personality is a reaction – it’s a way to conceal what’s going on deep deep inside of us. Others would say it reveals what’s going on deep inside of us. We say it’s possible to be both! Britannica’s definition is complex, but let’s just say that personality is “a characteristic way of thinking, feeling, and behaving,” and personality distinguishes one person from another.

Photo by Tamara Gak on Unsplash

The American Psychological Association (APA), which is our governing body for psychological practice, has a long definition you can find here. In sum, personality is the intangible and concrete pieces of YOU, which means it’s hard to study and classify…but not impossible, which is why we’re here to help guide you in your journey!

Classification of Personality

Personality is complicated! There’s no one theory that is “right,” but each theory is another way to look at the numerous facets! What are some ways we’ve classified personality over the years? Let’s start with 460-370 BC in Greece when personality was classified by your poop, by your snot, and by your blood. Seriously!

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Hippocrates coined these terms for Four Temperaments: Sanguine (Blood), Choleric (Yellow Bile), Phlegmatic (Phlegm), and Melancholy (Black Bile).
Then we have the Enneagram from who knows when? It’s been around a long time, but the beginnings of it are still in question. It contains 9 types of personality and is very dynamic (meaning it shows personality movement!), opposed to categorical.
Psychoanalysis/Psychodynamic conceptualizations of personality started early. In the early 1900s, Freud (1856-1939) became the big player, introducing aggression and libido influences on personality.
The Myers-Briggs Type Indicator (1944) was based on Carl Jung’s (1921-1971) personality work.
In 1949, Cattell developed the 16 personalities, which led to the original Big Five in 1968, then the current Big Five (OCEAN model of personality) from the 1980s onward.
In the 1950s, cardiologists (Meyer Friedman and Ray Rosenman) started to organize personality characteristics based on reactions to stress, identifying Type A, B, C, and D.
When the big book used to make mental health diagnoses (Diagnostic and Statistical Manual 1 or DSM-1) was published in 1952, there was actually no good classification of personality at the disorder level. This came almost three decades later in 1980 when the DSM-III was published with research to validate disorder level functioning. We are now on the DSM-5-TR and have come a long way! However, there’s still SO MUCH to learn!

What is Disorder Level Personality?

According to the DSM-5-TR, disordered personality “is an enduring [lifetime] pattern of inner experience and behavior that deviates markedly [differs] from the expectations of the individual’s culture, is pervasive [occurs in most settings] and inflexible [rigid], has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment [even if it’s only pointed out by others!].” If something is out of whack with personality, others notice. Signs that personality is problematic include constant ruptures in relationships or in things that require socialization, like work or school. This is a sign you or a loved one need to see a professional.

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Want more info? Check out How to Spot a Personality Disorder!

Ep 01: Introduction to the Hosts: Our Personality Journeys

Mon, 03 Jun 2024 02:00:01 +0000

In this episode, we (Doc Bok and Doc Fish) introduce ourselves and share our personality journeys and career paths! Doc Bok talks about her windy journey to personality, which includes deciding between her doctorate or a career in the FBI. Doc Fish shares about her linear journey to personality and psychology starting in childhood and her intrigue into psychodynamic work with clients. We both discuss why personality is so important, as well as different modalities and approaches to understanding personality, all the while emphasizing the complexity and nuances involved. We express our curiosity and desire to understand people, sharing a mutual passion for the detective work needed to solve the most challenging personality puzzles!

Psychodynamic | Personality Couch

Ep 51: A New Psychoanalysis of Antisocial Personality Disorder

Antisocial Personality - Outside the DSM

The Makings of Antisocial Personalities

The Workings of Antisocial Personalities

The Defenses of Antisocial Personalities8 5

Can Antisocial Personalities “Get Better”?

References

Ep 46: Did the DSM Get it Wrong? | A New Perspective on Avoidant Personality

Did the DSM Get it Wrong?

The History of Avoidant Personality Disorder1

Controversy Surrounding Avoidant Personality Disorder

The Zeitgeist of the Times of Avoidant Personality Disorder6

Doc Fish’s Opinion on Avoidant Personality Disorder

References

Ep 35: A Deeper Look at Schizoid Personality | Psychodynamic Perspective

Schizoid Personality - A Deeper Look

The Psychoanalytic Lens of Schizoids

History

The Making of a Schizoid

Conflict & Fears

Defenses & Coping

Inside the Schizoid

References

Ep 16: BPD Part 4: What Therapy Really Looks Like

The Invisible Dynamics of Treating Borderline Personality Disorder

Boundaries

Boundaries Outside Sessions

Boundaries Inside Sessions

Therapeutic Relationship

Attachment

Transference/Countertransference

Corrective Experiences

Repairing Ruptures

Connections & Insight

Ep 13: BPD Part 1: History, the Media, and the DSM Symptoms

Where Did "Borderline" Even Come From?

Stigma and Borderline in the Media

History of Borderline

Psychodynamic Flavors of Personality

Paranoid Personalities

Schizoid Personalities

Psychopathic (Antisocial) Personalities

Sadistic Personalities

Borderline Personalities

Hysteric (Histrionic) Personalities

Narcissistic Personalities

Anxious-Avoidant and Phobic Personalities

Dependent Personalities

Obsessive-Compulsive Personalities

Somatizing Personalities

Depressive Personalities

Note on Masochism

References

Ep 06: Psychodynamic Personality Classification (As Ice Cream)

Psychodynamic Personality Classification (As Ice Cream)

The Diagnostic Severity Axis: Ratio of Ice Cream and Ingredients

The Organizational/Health Axis: State Change of Ice Cream

The Character Axis: Flavor Category of Ice Cream

Ep 02: What is Personality

What is Personality?

Why Did Personality Become a Thing?

What is Personality Anyway?

Classification of Personality

What is Disorder Level Personality?

Ep 01: Introduction to the Hosts: Our Personality Journeys

The Defenses of Antisocial Personalities⁸ ⁵

The History of Avoidant Personality Disorder¹

The Zeitgeist of the Times of Avoidant Personality Disorder⁶