Daniel Knoepflmacher (Host): Welcome to "On the Mind," the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind. Today, we're going to turn our focus to the topic of personality. Why a full assessment of personality should be a part of every comprehensive psychiatric evaluation and the treatment that follows. Everyone has a sense of what personality is when thinking about ourselves or our impressions of others. But while we typically understand it in broad terms, personality is made up of several complex components, various traits that exist within a spectrum, making it hard to categorize in an organized way. Galen, a second-century Greek physician and an influential figure in early Western medicine, classified personalities according to the dominance of certain bodily fluids or humors. This resulted in four categories: sanguine, choleric, melancholic, and phlegmatic. While I'm not going to get into the specifics of those, a lot of them I think would be recognizable to us today.

While this theory of personality doesn't persist today, the idea that individual people hold enduring constitutional traits that define their personalities does. Many competing models for understanding and assessing personality emerged in the 20th century, and it's been a topic of endless interest outside the world of psychiatry and psychology. With over two billion personality tests completed online annually, the proliferation of social media posts, including four-letter Myers-Briggs types, And corporations paying for psychological testing to assess the character traits of executives In psychiatry, assessing personality should be a key component of a comprehensive biopsychosocial formulation. Yet many busy mental health clinicians skip a personality assessment when there's no obvious pathology present. And I often see trainees worrying about passing unfair judgment on someone's character, especially when that individual is enduring a period of great distress. Residents have shared with me their understandable concerns about inherent biases that might influence one's clinical impression. But without a full evaluation, personality disorder diagnoses are often misdiagnosed, misunderstood, and mistreated. And even when a personality disorder isn't present, an individual's personality shapes their experience of illness, the treatments they receive, and their relationship with their clinician.

There is no shortage of tools designed for the clinical assessment of personality. Even the DSM-5 includes two approaches, one categorical and the other dimensional.

The alternative model for personality disorders presents shifts from a categorical approach, w-which includes 10 distinct disorders, to a dimensional approach that focuses on features across all of the disorders. Today, we're going to explore the dimensions of the alternative model, and we hope to leave you with a practical approach to understanding personality that you can apply to your clinical assessment and treatment of any patient.

I have the perfect person rejoining me today on this podcast to do all of this. Dr. Frank Yeomans is a clinical professor of psychiatry at Weill Cornell Medicine and director of training at the Personality Disorders Institute here in New York City. He is an internationally renowned expert on personality disorders, whose books, podcast appearances, lectures, and teaching have been disseminated across the globe. He's also someone I always enjoy talking to, and I'm really thrilled to have him joining me again on "On the Mind." Frank, thanks for coming and joining me again today.

Frank Yeomans, MD, PhD: Well, thank you, Daniel. I'm very happy to be here. As I anticipated our discussion, it's a little bit daunting. We have a lot to go over. Your introduction framed it very well. So where would you like to start?

Daniel Knoepflmacher (Host): Well, I, I just want to say first, you know, that I, I can't think of a better person to, to talk about this. And, I hate to make a plug, but I want to remind people that it's been o- actually over about three years now that I spoke with you and Paula Tusiiani, and we did a two-part series on borderline personality disorder.

So, I recommend, uh, that people listen to that. But time really does fly when you're podcasting 'cause it, it seems like that wasn't that, that long ago. Now, I wanna get to this topic though, and, and let's start, by thinking about personality in, in its most basic form. Let's, let's define it.

What is personality?

Frank Yeomans, MD, PhD: Well, in the most simple version, personality describes who we are in the world. Like you said, all those two billion people who did some kind of personality test and all the corporations, who test for personality, the basic question is, who am I? Or from the point of view of the corporation, who is this person?

So again, simplistic version, who are we in the world? Who am I in the world? To get a little bit more technical about it, personality is the organization of enduring patterns of behavior, cognition, emotion, motivation, and ways of experiencing and relating to others that are characteristic of the individual.

So we've got a lot to unpack there. Personality organizes how we perceive and react to stimuli. I'm gonna emphasize that It involves, in particular, how we perceive ourselves and others. Now, because of this emphasis on how we perceive and how we react, personality determines how successfully or unsuccessfully we assess the world around us, specific situations, specific people, how we assess and how we adapt to the environment.

Because one of the simplest and most basic ways to think of mental health is to say it's the ability to adapt to the various and changing circumstances you find yourself in. So that's a fuller description of personality. Just before passing the word back to you, we think of different components of personality, and the first is temperament, because personality has a biological component.

The nervous system is wired differently in different people. Some people are more reactive, some people are more sort of passive. So temperament and biological constitution contributes. Then comes identity, which is what I've talked to mostly so far, our sense of self, who we feel we are. Then after identity comes character.

There's a sort of interesting interplay between identity and character. Character is what the world sees in us. Character is the external manifestation of our internal identity, and I think that's what Galen was talking about with the four humors, the character. And finally, personality involves one's system of ethical values, and it also involves intelligence and cognition, since those are part of our capacity to assess the world around us, whether we do it accurately or inaccurately.

So as you can tell from this, personality pathology has a lot to do with not adapting well to the world around us.

Daniel Knoepflmacher (Host): So, it's all very simple. Like, yeah, we can just stop right there, right? No. I, I, I think it's not a surprise that it's difficult for many psychiatrists and other mental health practitioners to integrate a good assessment of personality into their practice. I mean, this is, this is complex

Frank Yeomans, MD, PhD: Yes. Yeah. So we've got to try and sort of break it down so it won't seem so complex

Daniel Knoepflmacher (Host): All right. Well, let's, let's get to that. So, maybe a good place to start is to look at what I mentioned in the end of my introduction, which is, let's start with the DSM-5. There is a categorical model where there's 10 distinct diagnoses, sort of a cookbook approach where you list these enduring traits and, and if you have a certain number of them, you reach a threshold, boom, you've got the diagnosis.

Then there is what you described as this alternative... I mean, not you described, it's called the alternative model, um, of personality disorders, which is dimensional, a little more complex. Here there are, are dimensions that are transdiagnostic, I guess you can say, ac- across personality disorders. And really, I, I think what's important to state as well is that those dimensions are things that we all hold, right?

That it's, it's where you are on the spectrum on that dimension that determines the, the threshold perhaps for a personality disorder. So can you... I guess I'm gonna ask you a few things. Can you tell us, how we, uh, in this most recent version of the DSM-5, developed two models instead of just having one, a little bit of what that background is, and then maybe we can talk about, um, how the second model, um, is, is particularly useful

Frank Yeomans, MD, PhD: Yeah, we can go back to 1980 in the DSM-III when what is the most classic, description of-- Oh, by the way, when I talk about descriptions of disorders, I want to make sure our audience knows there's a whole field called nosology. Most people don't know the term. Nosology is the study of categories of illness and descriptions of illness.

And it's a very important field because over time, the way we understand and categorize illnesses changes according to science and what we learn and understand. So the DSM has been adapting to more recent research about personality. Getting back to the DSM-III in 1980, it was this categorical model based mostly on clinical observation and description.

So You would take a A group of smart borderline personality disorder specialists and say, "How do you describe this illness?" And you get what are the nine criteria from which the clinician can choose how many of these criteria does my patient have, and if the patient has at least five, then you give them the diagnosis.

So in that system, there were specific criteria for borderline personality disorder, schizoid personality disorder, schizotypal, narcissistic, antisocial, paranoid, et cetera. And each one of these diagnoses was considered a distinct entity, a distinct disease entity. You have this personality disorder or that one or the other one.

The problem was that most clinicians could not decide on a single personality disorder diagnosis. So the most common, personality disorder diagnoses that were written down in clinical charts were either mixed personality disorder or personality disorder not otherwise specified. In the meantime, certain researchers came along and decided to...

Well, it's not that they hadn't been there before, but certain researchers began to focus more and more on the system of understanding personality disorders in relation to what was described in the DSM. So the person I find most interesting in this body of research is Carla Sharp, who, uh, published what I consider a seminal study in, uh, two thousand and fifteen, which interestingly was the year that the DSM-V was published.

And I think her study, uh, the data from which was known before two thousand and fifteen probably had an influence on the DSM-V. So what happens is that because of a certain loyalty to the traditional system and the familiarity that most psychiatrists have with the traditional system, they kept in the ten distinct diagnoses with the diagnos-nostic criteria.

But what did the research show? The research showed that if you took a large number of people with personality disorders, in this case, almost a thousand in this particular study, and you looked at the specific criteria that each patient had distinct from the diagnosis, what were the criteria that were checked off for this person that led to the personality disorder diagnosis?

Then if you did a factor analysis of all of those criteria across the whole set of distinct diagnoses, what came out of that factor analysis? And what came out was that w- there was a, what's called a G factor or a general factor, that there's more in common to these disorders than there is different.

This was quite important to our current understanding of personality pathology. So this led to trying to refine our understanding of the general factor. And what emerged, I'm summarizing a lot, was that the core features, and this is the essence of the alternative model, the core features of any personality disorders are difficulties in one's sense of self and difficulties in one's interactions with others.

So we've got identity problems and interpersonal problems as the underlying feature across the whole range of personality disorders. I think that helps us understand the pathology better, and it provides us with a different window through which to look at our patients and assess our patients. So, that's the general shift, but tell me what it would be useful to discuss more specifically.

Daniel Knoepflmacher (Host): Yeah. Do-- Could you just, you gave us a great history and, and kind of that, that broke it down to its essence, which is, is, is those two pieces. But can you be a little more specific about what the model is in terms of the criteria, that it identifies?

Frank Yeomans, MD, PhD: Yeah. This is where it gets a little tricky and controversial. First of all, most clinicians and certainly researchers in the field of personality feel that this alternative model really represents what is the essence of personality pathology, difficulties with self and other. But the challenge is, I'm imagining some of our listeners are saying, "How in the world do I get an objective sense of my patient's sense of self and others?

You know, what do I do with the short amount of time to do my evaluation of an assessment of the patient to figure out if they have personality pathology, if it's a screwed up sense of self and others?" So we're gonna talk about that, but I also wanna mention, Daniel, that in the alternative model, what I've described so far is what's called criterion A, which is considered the core of the disorder, problems in self and ex- uh, experience of others.

There is also the criterion B, which harkens back a little bit to the old categorical model because there are five trait domains that you can judge your patient on, agreeableness versus, uh, antagonism, and so on and so forth. So I'm a little bit apologetic saying we have a system that asks you to first determine if there's pathology in one's experience of self and experience of others, and then to rate according to these five trait dimensions.

I would just add parenthetically that our European colleagues in the International Classification of Diseases don't have that criterion B. They have just gone purely with personality pathology is pathology of self and experience of others.

Daniel Knoepflmacher (Host): So that criterion B is, is also about a threshold of distress or dysfunction, meaning that if you look at those, those parameters and they're severe enough, then they meet the threshold. Am I understanding that correctly?

Frank Yeomans, MD, PhD: even criterion A is about thresholds because let's talk about identity. What is a healthy versus a pathological identity? Um, identity is a rather complex phenomenon. We don't stop and think about it that much, but now we can get a little bit to a clinical tip You're the clinician. You've got a new patient.

You try and understand them. You haven't seen them before. You want to give them a diagnosis. Maybe they've got depression, maybe they've got an anxiety disorder, maybe they have bipolar, but maybe they have a personality disorder since, um, a lot of personality disorders present, uh, as people who are depressed or anxious or sometimes, uh, look bipolar to the clinician.

So it's very helpful in your initial assessment to say, after you've gotten the symptoms, the history of development and everything you need to know, uh, in a classic psychiatric evaluation, "Could you take a few minutes and tell me about yourself? Describe yourself to me as fully as possible." That's a very challenging question when you think about it, and somebody who has a well-organized and integrated personality can say, "You know, I'm this sort of person, and, uh, what's most important to me in life is this and relationships and family, but I fit in work and career to the best of my ability, and I have a certain place for, spirituality, and I have leisure activities that are important to me, and I try to pursue these values and principles."

I mean, I'm just making this up a little bit quickly as we go along. Uh, that is a full and solid personality. If somebody does not have this solid personality, that is the main criterion for personality pathology now. They'll say, "You know, I'm a good guy. Uh, I have a lot of friends. People like me. sometimes people don't like me, but that's their problem.

I, I do my work and then I, you know, play pool or something like that." so that is a far less nuanced and complex version of the self. So that's a first pass at getting, um, an idea of a person's level of identity solidity. You can also tell something about identity solidity because people who don't have a solid core sense of self, often if you ask about their subjective experience, they sometimes report feelings of emptiness.

They don't know what their life is about. And with regard to relationships, they can report a desperate clinginess on other people because they look to other people to define themselves because they don't have that self-definition from within that's so important to have a meaningful life.

Daniel Knoepflmacher (Host): I wanna come back to identity more and talk about diffusion of identity, which you started to allude to at the end there. But before we do that, I think it's important to talk about object relations theory, because I'm hearing echoes of, of thinking about the self and other and internal representations of external, know, objects, et cetera.

Could you give us a primer right now on object relations theory and how this is really undergirding some of what you're

Frank Yeomans, MD, PhD: Yeah. First of all, let's, uh, clarify the terminology for our listeners. The object in this case is the person who is the object of your drive. That's a little bit of a technical term. The person who's the object of your love or your hate or your interest. So object is object of a certain attitude within you.

And object relations theory is a derivative of psychoanalytic theory that emphasizes the role of internal representations of ourselves in relation to others that get embedded in our mind in the course of our development. So the idea is that moments of intense emotional experience get embedded as memory traces, and they serve as sort of paradigms of how we experience ourself in relation to others.

Let me give you a simple example, because this is also gonna help the clinician who might have trouble seeing a personality disorder under a, uh, the appearance of a major depressive illness. There was a patient, a guy in his mid-30s, who'd been treated for years for major depressive disorder. He'd had a couple of suicide attempts and a couple of hospitalizations, but none of the somatic treatments worked.

Medications didn't work, ECT didn't work. Then he started an exploratory psychotherapy, a psychotherapy aimed at looking deeper into his mind. And what emerged, and it emerged in the relationship with the therapist No matter what the therapist said, the patient seemed to take it as a criticism, a dismissiveness, a negative response to him, even though the therapist in-- from an objective point of view, wasn't being negative or critical or rejecting.

So that's what we talk about when we talk about the activation of an internal representation of self and other in the here and now. This poor gentleman had as a prime internal, kind of template for who he is in relation to others as being the object of criticism and being put down, and he imposed that view on situations where it did not really apply.

So when we're talking about object relations theory, we're getting back to that aspect of personality, which is how successfully do you assess and adapt to the different circumstances you find yourself in. So a healthier guy, even with the same unfortunate history that he had of a very critical father who never gave him any positive feedback, somebody who developed their personality more fully would be able to say, "You know, maybe my gut reaction to this new guy in my life, this person I've just met, is to feel criticized and put down, but let me try to think about it, to reflect and assess all the data that's available to me now."

And then the person with the healthier identity would say, "Okay, you know, my initial presumption wasn't right. This guy's nice. He's, uh, sympathetic. He's agreeable." So the thing about object relations theory goes back to the title of one of Otto Kernberg, who's one of the, most important writers in this area.

One of his early books was called Internal World and External Reality. And the problem with personality disorders is that the person's internal world includes those representations of others that do not really fit objective reality, but are imposed on objective reality and lead to misperception and mood and relationships going downhill rather than building up in a positive way.

Daniel Knoepflmacher (Host): I think those examples of two people with the same background, I mean, you know, part of it having this hypercritical father and developing into, uh, two different people with two different personalities and two different identities, where it, it actually nods to this idea of the spectrum because that second person who maybe didn't only feel that therapist as the, the critical, uh, object no matter what was being said, the second person might still have a proclivity to feel that way, but then has a countervailing aspect of who they are that allows them to modulate and not just fall into that, more pathological pattern.

Is that

Frank Yeomans, MD, PhD: Yeah, that's the difference between personality pathology and a healthy personality, that ability to assess, to question, and to put the current experience in the context of a broad internal experience. The person with a solid identity has internalized a whole range of experiences. They know what joy is, they know what suffering is, they know what love is, they know what hate is, and they're comfortable with all those emotions, so they can assess the current interaction in relation to the whole range of emotional experience.

Whereas the person with personality pathology hasn't integrated. This gets to the fragmentation we were talking about. They either love or they hate. The r- uh, internal emotions aren't integrated. They're not mixed together. So it's a black and white world that goes from one extreme to another. It leads to terrible discontinuity in life experience, and you can imagine the impact of that discontinuity on personal relationships and study and work functioning

Daniel Knoepflmacher (Host): Well, w- we're gonna go back now, uh, to identity, 'cause I think this is, is really important. and I, I'll, I'll mention that you and I met beforehand and we talked about how we were gonna structure this and talked about six areas, one of them being identity, another one being defenses. We're gonna get to each of these.

Another being the quality of interpersonal relationships, reality testing, levels of aggression, and moral functioning. So I, I wanna touch on all of these, but let's start again with something you already began speaking about, which is identity and specifically identity diffusion. And you, you gave this example of somebody's kind of superficial, understanding of their identity as, as a sign of perhaps diffusion of, of identity.

Can you say a bit more about that? And we can even use that example of the 30-year-old, uh, man that, that you were describing. how would you assess, uh, identity diffusion? I, I say this as someone who works with residents, and I think this is something that's quite difficult because I, I mean, listen, uh, Frank, I, I switched careers.

I used to be, you know, in the film industry, then I became a psychiatrist. Eh, you know, I was a little all over the place. I wasn't sure. You know, I, I... Where, where does my, indecisions and, and vicissitudes, uh, you know, perhaps go into identity diffusion versus somebody who this is really a primary problem for them as part of their personality

Frank Yeomans, MD, PhD: don't wanna get too, uh, abstract or sort of, um, perhaps confusing about it, but I think we have to talk about different levels of identity. Like you, I changed careers. I did a PhD in French literature, and then I did the medical and psychiatric path. So you could say, well, his identity diffused. But it kind of goes back to the difference between a typical adolescent identity crisis, where they're defining themself, and for a while they don't know who they are, and they're trying to figure out who they are.

That's one thing, but that's different from identity diffusion and an unclear sense of self. So what I'm talking about when I talk about identity diffusion is the inability to have access to the full range of your emotional experience. To give you another clinical example, I was assessing this guy who came to treatment because his girlfriend left him abruptly, and he thought it was a perfect relationship that had been going on for years.

And all of a sudden, for reasons that he blamed on others, he thought there were these mean people who just wanted to take her away from him, she left him. Now, talk about identity diffusion. He described himself as adoring this woman, loving her fully, having nothing but loving feelings to her. When you did a detailed, uh, evaluation of this history of their relationship, he could have angry outbursts, he could sometimes be physically aggressive with her, and he could tell you that, but without integrating it into his sense of self.

Th- that, that just happened. She shouldn't have paid any attention to that. That wasn't me. So he's like the man I described when you ask him to describe himself. He said, "I'm a very loving man." That was his self-description. He didn't say, "You know, I'm a loving man, but unfortunately, I have this temper that gets out of control.

It can have a real, terrible effect on the relationship. I really should do something about it." So identity diffusion is the inability to be in touch with and bring together your full range of emotional experience, knowing all of your deep emotions and affective states. So when you have identity diffusion...

You know what? I actually think identity fragmentation is a better term than identity diffusion because a fragmented identity is a person who's either in a state where everything's fine or they're in a state where all hell breaks loose. There's no connection between the two. Identity integration would be when you get angry at your partner to say, "You know, I really can't stand what they just did, but they're a really good person, I know-" that, so let me put it all together.

So that's identity integration as it's experienced in relation to somebody else. In relation to oneself, it's I'm enraged right now, but I know I can deal with that if I just put myself in touch with other internal experiences that can soothe me and remind me that life isn't just about being rejected and unfairly treated.

So that's what I was referring to when I talked about putting the immediate experience in a broad context of internalized experiences where you can say, "I'm feeling this now, but how does this fit into the whole spectrum of my emotional reality?"

Daniel Knoepflmacher (Host): you're sort of describing, a preservation of the good even in these moments of intense negative affect for somebody who's better integrated or less

fragmented. I appreciate you using fragmentation 'cause that actually helps me. I think that it-- that does give a more clear sense of what it looks like in the assessment, in the clinical setting, is, is this disconnection between, between these, these aspects that we, we may all have viciss- vicissitudes, but if someone can't really give you an explanatory model or, or is blind to that whole piece of things, that suggests that they're not integrated.

Frank Yeomans, MD, PhD: just want to add another clinical tip. One thing that the residents I teach often do that they have to learn to kind of not do is fill in for a patient who is not integrated. most of our trainees luckily have pretty integrated personalities, so they can't quite get the mindset where it's just totally fragmented.

So when they encounter fragmentation in somebody, they often say, "Oh, well, I can kind of see how this might relate to that." Let me give you an extreme example, but this is an example from, you know, a clinical case. Lady comes in and she says, uh, you know, "I have these problems and I can't get along with others and I have emotional outbursts, da, da, da, da, da.

I harm myself sometimes." Kind of classic borderline presentation. And we should get back at some point to how borderline has become the paradigm for all personality disorders. But in any case, you know, she's telling me about her development, and at one point she says, uh, you know, I-- "When I was growing up, my father was my best friend."

And then, uh, later on at one point she said, "I can't trust a word my father says, you know. He's the most distrustful person I've ever encountered." And it is so disparate, you think, you know, how can that be? That's an extreme example of fragmentation when on the one hand he's your best friend, on the other hand you can't trust him as far as you can throw him.

So somebody might say, "Oh, well, maybe she was having a bad day when she couldn't trust him." No. She has two totally, sequestered and segregated experiences of this person, and that's going to influence her interactions with people moving forward. They're either totally they're her best friend or they're totally untrustworthy, and there's no middle ground and you can't put it all together.

Daniel Knoepflmacher (Host): You can't hold both at the same time that

Frank Yeomans, MD, PhD: Uh, you can't find a way to make a more complex version. My fa-- A more complex version would be, "My father was well-intentioned, but sometimes because of his own narcissistic needs, he would kinda present things in a way that wa-wa-wasn't totally honest, and he tried to preserve, like, you know, he didn't do this for us, even though he promised it earlier.

But he kinda tried to s-sort of get out of the contradiction by sort of..." I, I, I'm not finding the right words here. But what I'm trying to say is that we want our patients and ourselves to go from simplistic uni-dimensional views of others to complex views. So you go from, "My father's either my best friend or this monster," to, you know, "He was trying his best, but he had his own issues, and sometimes he had to compromise his principles."

That's a complex, nuanced view. So when we get integrated in our personality, we have complex, nuanced views of others, in this case, or of self. Like the guy whose girlfriend left him, he had this totally fragmented view, "I'm just this loving guy, and she didn't understand how much I love her." The more nuanced, complex view was what I said earlier, "I loved her desperately, but I have this anger problem.

I don't know what to do with my aggression. I've got to try to figure it all out." So we need to try to help our patients get to complexity

Daniel Knoepflmacher (Host): complexity in self and complexity in understanding of others. I, I wanna turn to defenses, which is the second, uh, category. Another important, thing to be assessing when we're looking at personality. Just to be clear, when I say defenses, I'm speaking of mechanisms that people employ to protect themselves from negative affect, from anxiety, uncomfortable emotions, distressing thoughts, impulses. We categorize them in terms of how adaptive they are, uh, from the more primitive types of defenses to the more mature. Why is this important to understand as part of personality, and how do you

Frank Yeomans, MD, PhD: Because there are levels of defense mechanisms. As you say, we all have to deal with stress and anxiety in our lives, and our defense mechanisms are our coping strategies. So there are more mature coping strategies that characterize a healthier personality, and there are lower level coping strategies that might relieve the patient of their anxiety in the moment, but don't help them adapt to the world or advance in life.

An example is a patient, uh, who came to my office for the first time, and I opened the door. Usually, I say, "Hi, I'm Dr. Youmans, and please have a seat." Before I could even say that, she pointed out the window and said, "You see that bus pulling away from the bus stop? I just got off that bus, and this woman at the bus, she was looking at me, and I could tell she hated me.

So I just looked right back at her and showed her I could hate her as much as she hated me." Now, I suppose that could be reality, but I saw in that a massive projection. I mean, I had to get to know the patient better, but my patient was a woman who was full of aggression that she didn't acknowledge in herself, always saw in others, and thus was always in belligerent interactions with others.

So that's what we call a low-level defense mechanism. The problem is outside of me. It's hard to do a very subtle, evaluation of defense mechanisms in a single psychiatric assessment. So the main question is, do they have any sense of their own role in their problems, or is it all externalized and seen as outside of them?

So that's sort of trying to get a sense of to what degree do they project and deny any involvement and responsibility versus have the capacity to think on a more mature level, "What might my contribution to the problem be?"

Daniel Knoepflmacher (Host): What would be an example of a mature defense that she might have walked into your office that you would've been able to, to assess?

Frank Yeomans, MD, PhD: if she were a higher level, she might say, "You know, I was-- I just got off the bus and then this woman looked at me, and I thought her look was really full of malice and hatred. But then I sort of had to wonder to myself, I feel that kind of often and, you know, it's not very pleasant at all.

And my question is, uh, are there really that many people out there who just look at me and take this dislike to me instantaneously? Or is there something about me that might put people off? Or am I reading something into people that might not be there?" So that's sort of a mature, reflective way of thinking.

You could call it intellectualization if you want, but it's reflecting on different possibilities versus, immediately latching onto a simplistic explanation, which did work as a defense mechanism. My patient who had no friends in the world and couldn't hold a job because of her hostile, belligerent way of being with people, seeing the aggression in others served the purpose that defenses are meant to serve.

It made her feel okay. In the short term, she could feel, "I'm okay. Nothing wrong with me." And so her defense achieved momentary relief at the expense of long-term achievement and satisfaction in life.

Daniel Knoepflmacher (Host): Natural segue to the topic of level of aggression. Otto Kernberg wrote a book about aggression in, in personality disorders. And all of us, uh, I, I'm not just speaking for myself , inha- you know, have innate aggressive drives. How does this play a part in, in personality organization and, and again, in the ways that you assess it?

Frank Yeomans, MD, PhD: this goes back to one of those aspects of the alternative model we haven't gotten fully into. I'm gonna open the text because it gets a little complicated. But after you decide if there is personality pathology, you have what's called the level of personality functioning scale, which goes from a zero.

Zero is good in this case, it means no impairment in personality functioning, to a one, which is mild impairment, and then you get up to a four, which is severe impairment. I also want to mention that our group at the Personality Disorders Institute developed a very useful instrument called the STIPO or the Structured Interview for Personality Organization.

It's actually the STIPO-R for revised 'cause it's been revised. It's fifty-five questions that help you, the clinician, and it's also useful in research, determine the level of personality pathology. So to get back to your question about aggression, one of the things that determines how severely impaired a person's personality is, is the degree to which the personality is infiltrated with aggression.

Now, you said that we all agree we have aggression within us. Unfortunately, not everybody agrees to that. Uh, I know colleagues of mine who teach have, uh, sometimes taught students I've taught later on, uh, and the students say, "Well, our previous professor didn't think there is any inherent aggression.

People are only aggressive if they've been treated badly." Now, I don't want to get into a big debate about this, but if you just look at evolutionary biology, the human species had to have aggression to survive and to, you know, continue to propagate. So, um, Well, we in the civilized world have-- I mean, hopefully the whole world is civilized, but any case.

what we have to contend with is that we live in social structures that teach us to tamp down our aggression, but we all have aggressive feelings, and sometimes they come out in more successful mature defenses. Like if you're a skilled debater, you can put a lot of aggression into your debating skills.

That's a sort of refined use of aggression. But you might channel your aggression by going to movies that are all full of, you know, violence and gore and blood and so on and so forth. sports can be a ch-- uh, authorized and, and somewhat mature channeling of aggression. Anyway, I just wanna say I'm with you that we all have some aggression.

Not everybody agrees with that. But in personality pathology, I think it's helpful to think... We've been talking about very sophisticated concepts. Let's get simplistic for a moment. Every human being, in the course of their early development, has to figure out how to manage their loving feelings and their aggressive feelings.

That's essentially what psychological integration is about. How can I combine the two? Now, going back to the constitutional or temperamental part, the biological part of personality, some people by nature have a more aggressive temperament, or some people by virtue of terrible traumatic experiences might have a more aggressive temperament.

So when you talk about those levels of pathology, the higher levels of personality pathology, when I say high levels, I mean the less pathological levels, don't have as much aggression in the basic personality makeup. The more severe levels of personality pathology have a more kind of intense infiltration of aggression.

Let me give you two examples. The lady I talked about who thought the woman on the bus hated her, she seemed very aggressive on the surface, but you know what? She really had a lot of loving attachment desires. She just was so convinced that people would always reject her that she preemptively put them down.

But I discovered in her she wanted to be close to people. She, she had strong loving urges. So in spite of her initial presentation, she wasn't that infiltrated with aggression. The aggression was part of a defensive system. Contrast that to p-- another patient of mine who got pleasure out of humiliating others, who got pleasure out of making other people uncomfortable, who got pleasure out of kind of, um, dropping hints that she might just not come to the next session because she'll be dead before she sees you again.

And I mean, you could, uh, say that that kind of statement might stem from a whole number of underlying motivations. But in this particular case, I had to help the patient see that she liked being aggressive. There was a certain pleasure and satisfaction about exercising and, uh, manifesting aggression and just living out aggression.

And when you help somebody see that, then they can decide what to do with that part of them versus having it come out in an uncontrolled and dangerous way.

Daniel Knoepflmacher (Host): What about aggression that is externally focused, as you've been describing, versus internal aggression?

Frank Yeomans, MD, PhD: that's part of what we analyze when we assess personality. Most of our personality disordered patients tend to manifest their aggression toward themselves with self-harm, but a certain number can be aggressive towards others. Now, not to get into sex stereotypes, but an interesting thing about borderline personality disorder is that in the population, not the clinical population, the general population of the country, if you take people with a diagnosis of borderline personality disorder, 50% are women and 50% are men.

You go to a hospital or a clinic and you look at the population of borderline patients, 90% are women and 10% are men. Where are the men who out there in the population who have borderline pathology but they don't wind up in the hospital? They're in the prisons because it turns out that the aggression that is expressed as part of the pathology in women is more likely self-directed aggression.

In men, it's more likely directed towards others, as in my patient I was describing whose girlfriend left him and he couldn't understand why even though he sometimes hit her. You know, it just didn't compute in his mind. It, it couldn't enter into his mind as part of who he was

Daniel Knoepflmacher (Host): I wanna turn to the next item, which actually I think maybe came up even in the example you talked about from the experience of this woman on the bus, which is reality testing. We, we teach, residents, medical students about reality testing early on, and often that's in the context of psychosis. We're talking about assessing delusional thinking. But talk about it in personality and again, how

Frank Yeomans, MD, PhD: And this is gonna get us back to the dimensional part of the picture, which we Need to elaborate a little bit more fully to show that we're all on the spectrum ourselves, the spectrum of personality issues. But when I was a resident, I always thought, "Oh, what distinguishes psychotic pathology from other forms of mental illness is a break with reality, poor reality testing."

And it seemed like an on or off switch. You either had reality testing or you didn't. But if you get into the object relations model, then you realize that there's a variability, a kind of a dimensionality

of reality testing. The depressed guy I was talking about, I could say to him, "How was your week?" And he'd think I was saying, " how did you destroy this week, you idiot? You know, how did you misuse your time since we last met?" So, um, that's a more subtle... He didn't think I'm a, you know, CIA agent or a Martian who had come to take his life over.

That would be a more full psychotic reality testing break. But I think the distortion of what's really happening out there because of the activation of the internal representation that's been embedded in the mind leads to that unfortunate, weakness. Let's call it a weakness or fragility in reality testing.

And we know from studies that if you take a population of borderline patients and you show them what have been determined to be neutral facial expressions, the borderline patients will see a negative hostile expression where other people will see neutrality and no hostility at all. So that's the kind of reality testing distortion we're talking about.

But getting to the dimensional thing, as I said earlier, we all carry within us our repertoire of embedded memory traces and internal representations. So when we enter into a new situation, we have to assess it, and sometimes we're good at it and sometimes we're not good at it. And, um, depending on different s- factors, some of which are biological, whether we're ill or sleep-deprived, some of which are external stressors, if we've just been exposed to a trauma, you or I might regress in our ability to accurately assess what's going on.

I mean, after nine eleven, you know, we were all kind of paranoid. Was that appropriate or was that a projection? so the point I'm trying to make here is that one, element I find very appealing about the alternative model with its dimensionality is that when we think that way, people with personality pathology are not another species.

They are just part of the human experience, and we're all part of that range. And depending on what's going on in our lives, you or I could regress to some form of splitting, seeing things in a black and white way. And, um, we shouldn't see our patients as these odd creatures who are so different from us

Daniel Knoepflmacher (Host): I think that's hugely important because there's so much stigmatizing of personality disorders. and I think it sometimes may influence the way trainees or clinicians are perhaps afraid to make these diagnoses. Whereas, I mean, I, I completely agree with you and see this in my own life at times of stress, of great anxiety, exhibiting several of these characteristics at, at more, more than at other times in my life and, and, uh, including reality testing, paranoia that, uh, that might enter my thinking.

Uh, and, and I guess that gets also to a point of kind of a stress model on top of a baseline level of functioning so that that's something you have to be assessing when you're looking at somebody if y- what, what is the context of the stressors in their life? Is there an underlying, depression that is coloring this versus what is that kind of baseline organization that is causing them their primary distress?

That's part of a f- a, a comprehensive

Frank Yeomans, MD, PhD: Yeah, to get back to that comprehensive evaluation, that's why after getting this symptom picture, it's really important beyond what we talked about already about identity and defenses and aggression, just to find out how a person is leading their life. We didn't talk as much about the depth and complexity versus lack or paucity of interpersonal relationships.

Daniel Knoepflmacher (Host): That was next, next, on the list. So go- g- that's number five of these six. So next, let's talk

Frank Yeomans, MD, PhD: Yeah, I mean, if somebody has personality pathology where they don't assess others accurately and don't respond appropriately, they're not gonna get close to people. They're not gonna have continuous deepening relations with others. They're gonna have superficial encounters.

They're gonna have encounters that are based on extreme emotional responses instead of complex ones. So a very important part of personality pathology is how deeply can somebody get to empathy and understanding of others versus how simplistic is their understanding of others. That gets to the second part of the dimensional model, pathology of self, but also pathology of relations with others.

So we have to be very attentive to people's capacity to enter into deep, complex, relations that have nuance and, uh, range to them.

Daniel Knoepflmacher (Host): and can you give us some examples of how you assess the quality of interpersonal relationships

Frank Yeomans, MD, PhD: was gonna get to that i-in one way, but I'll start with another way. If you go back to the guy whose girlfriend left him, he thought inexplicably because other people didn't like him. I told you, I think, that when I said to him, "Could you describe yourself to me?" He said, "I'm a very loving man."

And that was kind of the whole thing. Then when I said, "Could you describe your girlfriend, your former girlfriend to me?" He said, "Oh, she's a beautiful woman. She had brown hair and these lovely eyes, and she smiled a lot. She's always beautifully dressed." And he didn't, like, say a lot more. So once again, even though it sounds simple, ask for a description of the self and ask for a description of somebody else who's important in the person's life.

And the detail versus, uh, simplicity of those descriptions tells you a lot. But the other thing to do is just to say, it only takes a few minutes, "What are you doing with your life? How's work?" You find out if they're invested in work, if work is meaningful to them. "Are you in a relationship? What's that like?"

What do you do for leisure time?" You can find out a lot whether somebody is able to just engage in the world at a deep and meaningful level, or if the whole world is kind of at a distance and they aren't fully engaged. So that's another way to get a sense of what we're looking for.

Daniel Knoepflmacher (Host): Let's go to the six, which I think is maybe something that people may feel more uncomfortable with 'cause it has the word moral in it, but that's assessing moral functioning as a parameter for, for

personality organization.

Frank Yeomans, MD, PhD: That's very important. I had the same reaction when I was learning this whole model. I thought that seems like a different, uh, kettle of fish. It seems a little judgmental. But we're not saying what moral system a person should have, but we're just saying that part of a healthy and integrated personality is a coherent sense of moral values.

And it, perhaps can't escape being a little judgmental sounding, but it seems to help people lead a healthy life to think there's something in the universe that's kind of a little bigger than they are, that they're not the whole sort of reason for the existence of the universe. So it, it helps to have a kind of a moral guidance system, something by which you judge yourself.

It's the difference between guilt and shame. You know, we all try to guide ourselves to behave according to our values, and if we fail and feel guilt, that's because of a personal discontent with ourselves. Shame is only if somebody else catches us doing what we don't think is right, and we don't really care about our relationship to our values.

So I would say that a coherent and harmonious moral value system is a subset of the identity coherence. And it's also to distinguish, people who... let's put it this way. It's to make sure we know whether we're dealing with somebody who has antisocial pathology or not, because unfortunately, about a percent of the population has antisocial pathology.

They do not have a moral compass. They do not care about anybody but themselves. They have no interest in others except to the extent they can use them and exploit them. So even though trainees are uncomfortable with this question, and then we should get to the issue of how to describe personality disorder to our patients, I was just saying last week, uh, in a class, say to the patient, "You know, I don't know you, and I just want to know all about your life.

Have you had any encounters or run-ins with the law? Have you had any instances of having, uh, issues of any criminality that might have been part of your experience or been accused thereof? You know, do you tend to be honest or you just say a lot of white lies?" That's sort of couching it in a little bit of a softer way.

But once again, our trainees are nice people, and they don't want to offend other people by suggesting they might have, unattractive traits. But let's face it, you know, our patients might have unattractive traits, and you don't want to be blind to them.

Daniel Knoepflmacher (Host): I, I'm gonna name all six of these, these aspects that we just described. One is, uh, the identity, defenses, reality testing, aggression, interpersonal relationships, and moral functioning. So you're looking at all of these different parameters. You can arrive, uh, with the help of some of these other diagnostic tools, which, which we described, uh, from the DSM at the diagnosis of borderline personality disorder versus narcissistic personality disorder or another personality disorder.

If, if you wanna learn about either of those two, then listen to earlier episodes on borderline personality disorder with, with Frank Yeomans or on a- another episode on narcissistic personality disorder with Diana Diamond. But let's say you've come to the conclusion that there is a personality disorder.

How do you discuss this

Frank Yeomans, MD, PhD: Yes, I hope listeners have stayed with us up to now because this is really important. Because so many trainees and people in the profession who are far beyond being trainees don't think it's okay or nice to say to the person, "You know, I think you are, uh, experiencing a personality disorder. I think we can best understand your difficulty through the lens of what we call a personality disorder."

Both research and a lot of clinical experience have shown that patients do better if you discuss the diagnosis with them. It's not insulting them. So anyway, after you've done this evaluation, including everything we just discussed, if you feel, you know, my patient has been treated for depression all this time, but I think there's an underlying personality disorder, say something like this.

This is my recommendation. Now, this is for classic borderline personality disorder, then we can go into narcissistic, which is increasingly common, it seems. So, having got to know you so far, the best way I can put together the problems you're having in life is through the lens of difficulties with some f- of your personality functioning.

Notice I'm not saying outright you have a personality disorder. I'm saying you have difficulties in personality functioning, which is in sync with the dimensional model. So, you know, then you can say, "We all have a personality. It's complex in certain ways, but let's boil it down to a basic, uh, few ideas.

Personality is the way we spontaneously think and feel and react, how we experience ourselves and how we experience others." Alternative model in plain English. So having listened to you, it seems like there's difficulties in your experience of self and others. You know, kind of a lack of clarity, a lack of consistency, a discontinuity, shifts back and forth that have led to dissatisfaction, unhappiness, frustration.

Now, that's what I would say to anybody who had a personality disorder, and I think that's pretty palatable. If somebody has more classic BPD, I would say among the different difficulties with personality, to be specific, I think you have what we call borderline personality disorder. Some patients react badly because they've heard of the stigma.

Some patients are very well-read about it. You get the whole range. But whatever the person says, you say, "I'd like to give you my impression of it because there's a lot of misunderstanding of it." And I put it this way. I say, We can think of borderline personality disorder in terms of difficulty in four areas of life.

The first is how you experience emotions. You tend to experience them in a very extreme way. You can be very high. You can be in the lowest depths of depression. There isn't a lot of mid-ground. There isn't a lot of peace and harmony in your emotional life. It's kind of like you're going through life on an emotional rollercoaster."

You can be a little more detailed with the patient. Then the second area of difficulty is in relations with other people. They tend not to have a lot of harmony and satisfaction. They tend to have discord and conflict, and you're either going from one relation to another, or you're sort of in the same relationship and sort of having good times and bad times, but never really settling down.

So there's the emotional area, the relationship area. The third area has to do with certain behaviors. I always say to the person, "It's kind of unfortunate because this behavioral part of the picture is usually what gets the most attention and what people see as the defining part." Now, the behaviors are dramatic.

They might be self-harm, they might be overdosing, they might be s- cutting oneself, they might be substance abuse, they might be promiscuous, unsafe sex, they might be eating disorder. And those are all dramatic and serious behaviors that need help and attention. But I don't think they're the core of the disorder.

I think they're the surface manifestation of a deeper problem, which gets us to what the central issue is in my mind. I think the central issue is not having a clear, solid sense of who you are. Life is very challenging. We're always, you know, as we go through life, there's this difficulty and that difficulty, and we have to deal with one situation after another.

Life is not a piece of cake. So, it helps dealing with all of the different slings and arrows, if you will, that life can throw at us to have a solid core sense of who you are, what you believe in, what you want from life, and, uh, what you're committed to. And if you don't have that, and if you don't have an emotional stability where you can ground yourself in a solid sense of emotional core, if you just get buffeted about from one extreme state to another, then life becomes a terribly distressing challenge, and you have all of the preceding problems: emotional, relational, and behavioral.

So I'd like to ask you to think about how this sounds to you, and if it makes sense, then we can use that understanding to decide what kind of therapy to embark upon.

Okay. NPD is trickier I tend to favor using the term narcissistic personality disorder when discussing it, but you have to be a little more savvy clinically because depending on the fragility, if you've decided-- And we should talk for one second, even though hopefully people listen to you and Diana, we should talk for one second about the main difference between NPD and BPD.

If you decided the problem is NPD, and notice how we're deviating a little bit from the dimensional model 'cause we're going back into categories. I wanna say before we end, we're never gonna totally abandon categories because they are like a shorthand. They're pattern recognition, and clinicians need that.

Clinicians are busy. They need to recognize patterns. Anyway, let me go into this main difference between BPD and NPD. Both conditions are rooted in the identity fragmentation, in the lack of identity consolidation and integration. But the borderline personality disorder patient experiences that directly.

I'm all over the place. I react extremely to the last thing that happened to me. The narcissistic patient Protects themself from that inner distress of fragmentation and not having a solid core sense of self. They protect themselves by kind of unconsciously developing a narrative that provides an explanation of who they are.

It's just that the explanation doesn't hold up in reality. That's what happens with a lot of these failure to launch young adults. "If I were to go to college, I would just, you know, be so successful, but I can't get out the door." So the grandiose fantasy is, "I'm really smart. I just have this social anxiety that keeps me from getting into the situation where I might achieve."

So what happens is that the narcissist hangs onto their grandiose fantasy that defines them in a way that protects them from that disturbing rapid shifts from one internal state to another, but it doesn't allow them to interact effectively with the rest of the world because the rest of the world doesn't support the narcissistic fantasy.

Anyway, so if you've diagnosed this kind of situation, you go through the same initial, you know, I think it's best to understand your difficulties in terms of problems in personality, functioning, experience of self and others. Now, sometimes I do say, "I think you have what we call narcissistic personality disorder.

Don't jump out of your seat 'cause I know that sounds bad, but let me explain. It's not what the general term means in plain English. I'm not saying you're an arrogant, grandiose, obnoxious person." The way we understand narcissistic difficulties in psychiatry is that it's a defense against really deep feelings of concern about inadequacy and doubts about how you're functioning and who you are.

So I'm just saying that while we have to honor the way you've presented yourself to me, we have to wonder about how well that sort of version of yourself, how well that serves you in life, and if there might be underlying distress that we should get to know that we might be able to help you resolve.

But if you sense that your NPD patient is so narcissistically fragile, and I've had this happen, where using the term narcissist is just such a narcissistic injury. They say, "You're calling me a narcissist. You don't know anything about psychiatry. I don't know how you even got your degree because I'm the least narcissistic person in the world.

I'm humble and wonderful, and everybody loves me." So, if you are afraid that the narcissistic injury of the very term would lead to that kind of defensive reaction, you might say you have difficulties in personality functioning. It's hard to kind of engage in the world. And I think we might begin to look at that difficulty in terms of some ways your mind works.

My impression is that your sense of who you should be, here I'm talking about what we call the ego ideal in technical terms. Your sense of who you should be, your kind of North Star of who you should be in the world is so extreme and demanding, it puts so much pressure on you that it's impossible to function.

That what could be a desirable trait, a very high level of standards that becomes exacting and Well, just demanding, uh, on your functioning, that that internal system, as laudable as it could be, may have become so extreme and exaggerated that it's paralyzed you. So we might wanna start by thinking about an internal system of vision...

And here you're talking about the grandiose self without calling it that. Your idea of who you should be, how you can or cannot relate to that, what the balance is, and how to find a better equilibrium within yourself

Daniel Knoepflmacher (Host): Frank, I could spend another half an hour, uh, riffing off what you've just said, um, questions, thoughts, et cetera. But unfortunately, we don't have another half an hour, so I, I'm gonna have to wrap this up. I'm wondering, um, if you could boil down into just a s- a simple, uh, important thing that you wish every psychiatrist, including residents who maybe who are just starting out, understood when it comes to assessing personality in their first encounter. What do you think is the major take-home

that they, that they need to always keep in mind?

Frank Yeomans, MD, PhD: It's to be more curious. Don't take the chief complaint as the diagnosis. We're all busy. We're all rushed, especially during residency training. So if a patient comes in and you say, "What brought you here today?" And they say, "I'm depressed," don't just say diagnosis is depression.

Have that be what, instigates in you a kind of a whole flowchart of what the next question should be. Is this person depressed? Then you go through the whole series of neurovegetative symptoms. If they don't seem to have those, then you start getting curious about their personality functioning, and then you go into that whole kind of assessment you and I just went over for people who've been listening to us today

Daniel Knoepflmacher (Host): Well, your curiosity is clear. I mean, your passion for this work comes through, and it's just always so enjoyable talking to you, not just about this topic of which you have great expertise, but just in general. So thank you, because I always learn something, and I'm sure everyone who listened today learned something as well.

Thank you so much, Frank, for, for sp- taking the time to come here and speak with us today

Frank Yeomans, MD, PhD: Thank you, Danny. It's always a pleasure and it's a great service you do. I appreciate it

Daniel Knoepflmacher (Host): And thank you to all who listened to this episode of "On the Mind," the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms, including Spotify, Apple Podcasts, YouTube, iHeartRadio, and others. If you like what you heard today, please give us a rating and subscribe. That way you can stay up to date with all of our latest episodes. And if you leave a review, that will help others learn about us and, and be sure to tell your friends. We'll be back again next month with another episode. So until then, wishing you good health in body and mind.

kids health promo: Every parent wants what's best for their children. But in the age of the internet, it can be difficult to navigate what is actually fact-based or pure speculation. Cut through the noise with Kids Health Cast, featuring Weill Cornell Medicine's expert physicians and researchers discussing a wide range of health topics, providing information on the latest medical science.

Finally, a podcast to help you make informed choices for your family's health and wellness. Subscribe wherever you listen to podcasts. Also, don't forget to rate us five stars.

disclaimer: All information contained in this podcast is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition. We urge you to always seek the advice of your physician or medical professional with respect to your medical condition or questions. Weill Cornell Medicine makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information featured in this podcast, and any reliance on such information is done at your own risk.

Participants may have consulting, equity, board membership, or other relationships with pharmaceutical, biotech, or device companies unrelated to their role in this podcast. No payments have been made by any company to endorse any treatments, devices, or procedures. And Weill Cornell Medicine does not endorse, approve, or recommend any product, service, or entity mentioned in this podcast.

Opinions expressed in this podcast are those of the speaker and do not represent the perspectives of Weill Cornell Medicine as an institution.