Psychiatry & Psychotherapy Podcast - Identity Diffusion

Episode Date: September 16, 2025

In this episode, Dr. David Puder and Mark Ruffalo dive into the history and theory of identity diffusion, from Kernberg's structural model and Gunderson's work on BPD to Akhtar's clinical descriptions. We explore how identity diffusion shows up in patients' lived experiences—feelings of emptiness, fractured self-image, lack of authenticity—and what these struggles mean for psychotherapy. You'll also hear practical insights into treatment, including empathetic confrontation, fostering continuity of self, and amplifying moments of authenticity. Whether you're a clinician, student, or simply curious about the complexities of identity, this conversation sheds light on one of the most important yet misunderstood dimensions of mental health.   By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog.

Welcome back to the podcast. I am joined today live in my office here in Winter Park, Florida with Mark Ruffalo. He is a world famous psychotherapist who has been on the podcast before. We talked about splitting borderline per seizing disorder. I would say you're becoming one of the most preeminent borderline per seizing disorder experts on Twitter on X. Got a little bit of a following there, yeah. quite the following. Yeah, and it's been fun to correspond with you. And today we will be diving into something I've been curious about for years. And I really haven't taken the time until recently to dive into the history of it.

Identity diffusion. And I was reading it this week and I was thinking to myself, why is this so hard to understand? Like, why is it hard for me to get my, mind around it. And if you have yourself kind of in that phase while you're listening to us, you may come back to this thought that I have that I'll share with you right now. You're learning about something that is not defined. The very nature of identity diffusion is the lack of definition. It's like we're learning about something that is the not something. It's like a stem cell awaiting

to be having some identity, but there's no identity yet. So how would you like start it up? Yeah, no, I agree. I think that, you know, as we're talking today, I'm probably going to be working through my own ideas and thoughts on identity diffusion, which sort of lack of cohesion, which is ironic because of the nature of the,

syndrome or the problem itself. And so, yeah, it's something that I think is really hard to grasp, even for experienced clinicians. Yeah. And so let's go through a little bit of the history of it. I notice you're also, you have Gunderson's book Open, and we also have an article by Salomon Akhtar. and so yeah where do you want to begin yeah i think it was ericsson who was the first to use the term identity diffusion and later work uh by otto kernberg linked the presence of this problem to severe character disorders or personality disorders notably borderline narcissistic and schizoid personalities you know that the

I think the only reference in the DSM to problems with identity is found in the diagnostic criteria for borderline personality disorder. But Gunderson didn't really think that identity diffusion was a very useful diagnostic criterion because it's not really specific to borderline personality disorder. And so he didn't find it all that useful in discriminating different types of pathologies. and differentiating BPD from other problems. So, you know, a lot of what I'll talk about today with you is really in the context of borderline psychopathology, which has become, at this point in my career, my main area of interest and focus.

But you also see this problem in other severe disorders. It's also notably lacking in other personality disorders, like obsessive-compulsive personalities, histrionic personalities, and really I think it's, in that sense, it's useful to differentiate the borderline personality patient from the histrionic personality patient,

which can look, they can look sort of similar, but the borderline patient evidence is identity diffusion. So it was Erickson, Kernberg, Salman Hocktar, in 1984 writes a paper, the syndrome of identity diffusion, identifying, I believe, six clinical features of the syndrome.

I think later he adds a seventh feature. Maybe we'll get into that. That's a little bit of the history. Yeah. I think that pre-Kernberg, there was really a thought of, you know, neurosis, psychosis, right? Like two differentiating groups of people.

Helene Duch 1942 described an as-if personality which mimicked normal behavior but lacked genuine core self foreshadowing this kind of later notion of fragmented identity Bruehler 1911 reported schizophrenic patients

saying that they often had lost their individual self highly a profound disturbance in identity this kind of crisis and then you have this mid-century ericsson identity um he talked about ego identity this multifaceted construct involving a conscious self of personal sameness and you know there's a lot of in his writing like what is normal crisis of identity in adolescence like every adolescent has a crisis of identity starting to

differentiate from their parents starting to get in touch with their friend group where what they believe in contrast to what their parents believe in contrast to what their friend group believes trying on different types of identities so some of that's very normal sure and then yeah i i agree this otto kernberg 1967 seminal paper called borderline person or borderline personality organization talked about psychotic, neurotic, and then this borderline level, which is between, which one of the seminal characteristics is diffuse identity, fragmented identity, unstable identity. And he observed that these patients could not provide a coherent description of themselves or significant other, and they exhibited contradictory like self-concepts,

chaotic instability and goals and relationships. So this kind of like started there, right? Yeah, yeah. And, you know, a little bit of the history, you know, for years there was this group of patients who weren't overtly psychotic, but they would regress very transiently in brief, into psychotic states where they might hallucinate, become transiently paranoid.

These were the same patients who would really worsen with classical psychoanalytic treatment where they were on the couch four or five times a week. They would, classic paper by night, described them as falling apart on the couch. So these were patients that were just hard to classify diagnostic. And so I believe it was Adolf Stern in the 1930s who first used the term borderline cases, two words, borderline cases, to describe patients who were somewhere in between psychosis and neurosis. And so it was Kernberg in the 60s writing about borderline personality organization. And then Gunderson in the 70s identifying a specific syndrome of borderline personality disorder, which eventually makes its way into the in 1980.

And so, you know, Gunderson argued that the concept of BPO was far too broad to be very useful clinically and only about one in ten patients who meet Kernberg's definition of borderline personality organization have borderline personality disorder. And the way that you treat someone psychotherapeutically with BPD is quite different from how you might treat someone with NPD. And so Gunderson argued that, well, the concept of BPO is far too broad. And while it does identify a group of patients who are organized in a certain way and rely on certain defenses, it's not very pragmatic.

It's not very useful clinically. And that there is a distinct syndrome that is valid, coherent, with a predictable onset, course, and treatment response that we ought to call borderline personality disorder. So that's a little bit of the history. So, you know, problems with identity are very common in BPD again, but they occur in other psychiatric disorders as well. But I think you described it pretty well.

You know, we, in healthy or normal or neurotic people, There's, you know, a sense of cohesiveness to who we are. I think Akhtar in this paper sort of describes, you know, the healthy individual as, you know, as being able to maintain a sort of core sense of self amid change and with the passage of time, sort of regardless of what's going on in life, I still maintain a core sense of self. And then there are patients who come in, and I'm sure you've seen these types of patients, who will actually say explicitly, I don't know who I am.

I'm not sure who I am or something to that effect. And when I hear a patient say that, I start to get interested in these issues of identity. And that often opens the door to an understanding. Or if they show up very different in different contexts. Or, I mean, we all do to some degree, right? we all have like a social veneered different contexts different degrees of revealing this but when there's huge incongruencies in how they show up when they when there's um very different feelings towards different people you know as well as well to themselves like do i hate myself do i love myself

you know this kind of splitting is kind of like an identity yeah crisis as well um one thing i wanted to say was for those of you who are listening you were like this isn't isn't really a thing, like identity diffusion isn't really a thing. Borderline level of functioning isn't really a thing. When I, like, have started to go down this road of like, actually, this is a really helpful construct. And there's actual ways of testing this, right? And once you have a good way of testing it, that's like very consistent.

You know, one person tested, the next person tested, very consistent. Kronbach alpha is very high, right? So for this one, based off of Kernberg's model, there's the inventory of personality organization, IPO, and there's the structured interview of personality organization. And part of the facet of what it's looking at is identity diffusion. So this is kind of like a subdomain. And you could think of like borderline level of functioning as primitive defenses and identity diffusion. and you can have this in different types of personality disorders.

And so when Gunderson moved it all to BPD, I think it did a little bit of a disservice to kind of like an understanding that you could be narcissistic with borderline level of functioning. You could be schizzoid with borderline level of function. You could be paranoid personality disorder with borderline level of functioning. And I think it's actually really helpful

to think in these categories. And when I've looked at the STIPO, the structured interview of personality organization and the different studies that they've done, they've done different types of things to look at different severities. And actually, this is like really helpful to understand what we're dealing with.

Yeah. And to have empathy and compassion, I think. You can have intact reality testing and identity diffusion and primitive defenses, and this is what this has proven to be true. Yeah, yeah, yeah, yeah. I think, you know, there's so much confusion

about the terminology, and I think you're absolutely right. I mean, borderline level of functioning, borderline personality organization, it absolutely captures something that really exists. So I believe, you know, Gunderson argued that, borderline personality disorder is sort of the prototypical disorder at the borderline level of functioning and incorporates, in essence, much of what is seen at borderline level functioning.

And so there's, you know, there's, it's really unfortunate that there's, there's, you know, two different concepts with the same name borderline. And I'm, I think that, I definitely think we ought to retain this concept of BPO, but some have argued that maybe we should rename it disorders of self or something of that nature to differentiate it from borderline personality disorder, which is what most people know nowadays, and has become the most widely accepted use of that term. So there's unfortunately a lot of confusion around it, though. Yeah, and I think, of course, every single one of these people have contributed vastly to our understanding.

So it's like, but let's zoom in to Salomon Akhtar, and let's go through the different domains of identity. entity diffusion. And I have written down some notes here, but maybe we could go one by one and just kind of like explore the different aspects of this. How's that sound? Sounds great. So, and I, there's something really valuable in my mind, if you're reading, if you're listening to this and you're like that you find some value in it, this is a paper you want to read. This one and as well, we're going to go through another, a second one. So, you know, as always, I'm going to write up some details on the podcast notes.

And this one, Salomon Akhtar from 1984, very worthwhile. Another one, Karstein Jorgensen from 2022, which I've actually corresponded with him. Very cool. Yeah, he's, he's, is exciting. So that one is really amazing. We'll get to that one second. And that one will go through a group of borderline patients that he did a qualitative interview,

extensive qualitative interview around identity. And he found commonalities. And so he, and I think that's a really powerful way to look at a concept and to look at like, what are things that are common between one group and another group. And it validates this as a concept. as well, like further validates that this exists. And so there's really like multiple levels of validation

that make me very confident that this thing exists. One is the IPO inventory of personalities organization, the STIPO structured interview personality organization, and all the data that's come from that, the years of these tests being run, and then studies like this. But let's go to Salomon Akhtar, because I think there's a really nice look at this.

Okay, his first one is contradictory character traits. What jumped out at you? And then maybe I'll read a part. Yeah, I think that there's a section in there where Akhtar talks about how patients with identity diffusion have to rely very heavily on the immediate behavior of other people in order to read them. And he links this to sort of an inability to integrate cognitively and affectively the observed behavior of others into a dynamic composite conception that would reveal the constant aspect of the other's personality. So because the patient is lacking a coherent sense of self, they also lack an ability to construct a cohesive, sort of narrative of what another person is about. And so they rely excessively on the last interaction

with the other person. And so you see this very, very commonly in borderline personality disorder. So, you know, this is, you know, the contradictory character traits, you know, this is paradox. And so, you know, tenderness towards others, coexisting with extreme indifference towards them.

Extreme love, alternating with extreme hate. So this is very closely and intricately tied to Kernberg's and Klein's notion of splitting. And so, you know, you also see individuals who lack a sense of vocational sort of purpose. So Actar in the paper talks about people who they simultaneously. sort of want to become a physician and also a movie star. And so there's this ill-organized ego identity. And so... And one thing I might mention is like, nowadays, that would be a lot more normal.

You know? And as you're listening to this, you may go like, oh, I'm a little bit like that. But then realize, like, to have identity fusion, you have to have more of a global. It has to be more global. Yeah. Okay. So, yeah, with this one, it's like marked tenderness towards others can coexist with extreme

indifference, naivity with suspiciousness, greed and self-denial, arrogance and timidity. So you get these kind of like juxtapositioned character traits, right? Yeah. Yeah. Yeah. I think that's, I think that's it. Yeah. So, yeah.

With this, you can see how it could be difficult if you're, if you're a therapist, as you're listening to them, do I empathize with which side? And I would say you could empathize with both. You could say, it sounds like on one hand, you feel warm towards your spouse, but on the other hand, you feel completely angry. You know, like when there's multiple emotions going on at the same time or multiple experiences, self-experiences, you can empathize with the juxtaposition, with the contradictory traits. Yeah, yeah, yeah.

And a bit of, you know, confrontation in the sense of pointing out the discrepancy to the patient, not necessarily interpreting, but pointing out to the patient that they engage in these very contradictory or self-contradictory ways, their views of themselves, and others vacillate pretty readily and predictably, depending on the subjective experience of the other person. And so pointing that out to the patient, as ACTAR notes in the discussion part of this paper, rather than interpretation, is more helpful, I think, for these types of patients. I would say pointing it out, but in a way that actually decreases shame. And so we pointed out as a way of having compassion. Yeah. Of course, it can be really difficult to have a multiplicity of fluctuating experiences of another person or of ourself. Yeah, and I think when people hear the word confrontation, they think of it in sort of the everyday sense, not in the strict definition psychoanalytically.

And, you know, confrontation is completely compatible with empathy and, you know, and caring about the patient and warmth. you can engage therapeutically in this way and still confront the patient. Or it's another way of saying it, which would be, it's increasing their reflectiveness of themselves. We aspire towards increasing reflective function, and we know that people with BPD have around on average, a lower score on reflective function around 2.7. It's an 11 point scale from negative 1 to 9.

So they're around 2.7 when they start, but they can increase it. And so it's by an increased knowledge of themselves and their self-experience that they actually increase it. And realizing that you don't hate them, despite their maybe multiplicity of mixture of their own things that they feel a lot of shame about, they may imagine you hate them,

they may imagine you're critical of them. When they find that you actually care about them and you're curious and you're interested, but you're also compassionate, I think that's when they can make a shift to seeing themselves in a more compassionate light as well. So, okay, so number one was contradictory character traits and number two is temporal discontinuity in the self.

So what does it mean to have discontinent? continuity in the self, temporally. Yeah. The capacity to remain the same amid change and with the passage of time is how Akhtar describes it as the hallmark of a sound identity. That seems to make a lot of sense to me that despite the ups and downs in life, what I'm going through, I remain more or less the same person. Let me read this quote here from this.

the past, present, and future are not integrated into a smooth continuum of remembered, felt, an expected existence for these patients. They experience themselves as a very young and at the same time, old, beyond rejuvenation. I feel like I'm almost a toddler, and then I also feel like I've lived three lives, right?

It's like that kind of. of level of like temporal discontinuity. Yeah, yeah. And so in the last paragraph there of that section, Akhtar describes sort of what it might look like, and he writes, keeping chronological photo albums, writing personal diaries, chronically searching for one's roots,

and excessively reflecting about external events are often used as defenses against the disturbing, subjective sense of temporal discontinuity in the self. trying to, you know, use these methods to develop some cohesive sense of who I am in the world. It gives you kind of a new way of thinking about people who maybe excessively document and journal and like this kind of like desiring to ground themselves into time and into memory, right? And that being said, I recommend journaling.

I recommend having reflectiveness. But you could see how for him, it's like there's a compensatory mechanism here that you see some people. Okay, number three is lack of authenticity. He writes individuals with identity diffusion, display feelings, beliefs, and actions that are caricature-like. In a given situation, they act as someone else. they know would act, not in a manner that is genuinely their own. They lack originality and readily acquired gestures, phrases, ideologies, and lifestyles from others.

Yeah, this is the essence of Helene Doecious, I think it was 1948 paper on the as-if personality. Sometimes I refer to this as like the chameleon-like effect. The patient very quickly adopts the interests, hobbies, manner of dress, of the other person. In a sense, trying to develop some sense of who I am by mirroring what people around me are doing. So sort of touching on the concept of the false self,

I remember very early in my career, I started to see a patient who, in retrospect, probably had a borderline personality disorder, a male patient who, after a few sessions would come into my office wearing bow ties. And for anyone who knows me, I sometimes wear bow ties and the style of Aaron Beck and John Gunderson and some other people. But anyway, this was a man. Oh, so you're mimicking. Are you adopting their identity?

Yeah, I guess you could say that. But the patient started to come in and had never revealed to me, had never worn a bow tie before in his life, but all of a sudden he started to show up to our sessions wearing bow ties. And at the time, I didn't really know what to make of it. I couldn't make heads of tails of heads or tails of it. But now, of course, in retrospect, I think that there was some identity problem here. he was seeking some identification with me

to anchor himself in the world. And so I think this is sort of what Actar is touching on here. I think it's probably going to get worse. And I think it probably already is there. It's like when you act as someone else, right, genuinely not your own, think about like all of the influencers now and people, youth adopting mannerisms

of the influencers, tics, sometimes mental illness, characteristics, sometimes like adopting how they talk, mannerisms, dress. There's like different levels of this, right? So there's like probably a healthy level, which is like, you know, your patient wanting to be a little bit more like you. But then there's like, you know, when the person doesn't have any groundedness underneath it, You know, like we can all aspire to be a little bit like our mentors.

That could be probably a good thing. Sure. But then to adopt, you know, like I know exactly what Dr. Tar would say in most situations. Yeah. But I'm not going to do it, right? Because, like, I can hear what you would say in some situations, right? Probably not as accurate as you would say yourself. I think this is a really important point that's so confused.

And, you know, all of this, I mean, all of these things we're discussing today exist on a continuum with normal, right? And so, you know, and all defenses exist on a continuum with normal, or rather, they can be used by all persons. It's a matter of degree and whether they're used to the exclusion. of healthier defenses, right? So, but that, you know, the dimensional nature of these traits doesn't negate the, you know, pathological nature of their excess, right? So sometimes I like to say that, you know, hypertension exists on the same continuum as normal blood pressure, but, you know, people die of hypertension. Hypertension is a pathology, right? So just because something exists on the same spectrum or continuum as normal doesn't mean that an excess of that trait is not problematic

or a sign of a pathology. Or maybe people don't die of high blood pressure. Yeah. But people die of things that high blood pressure leads to like a stroke, right? And so, you know, when I, with this, maybe they're not dying of identity diffusion, but maybe they're also suffering, not knowing who they are or not. having someone attuned to their experience in a way that tries to get to, like, what's really going on for them? What do they really enjoy? What boundaries have they had where it's like maybe they were in a relationship that pushed them and took away their personhood and they adopted many of the things of this other person they were dating up to a point. Usually,

they've stopped it at some point. It said, no, no, no, I'm not going past that line. For some patients, that's where I get excited for them. I'm like, yes, that's you. That's your value. What do you value that's underneath that? Oh, I don't value being used or abuse. Maybe they were abused to some degree,

but there was like some level at which they said no. And that personhood would like reach out of the abyss and was like, absolutely not, I will not go past that line, right? And that's a great, so we're like, we're searching for the person. Of course, I think, you know, to humanize this, you know, for a moment,

you know, the lack of authenticity. Well, you know, why is a person engaging in this, you know, as if type of way where they're mimicking the behavior of other people? Well, they want to be accepted. They want to be loved. They want to find a sense of who they are through this process of identification. And so, you know, sometimes especially reading some of the older psychoanalytic literature, you know, the humanity can sometimes get a little lost, you know.

But yeah. And I would say like going back to like conformity tests. So the Milgram experiment is a great example of how we are wired to. towards conformity. So you know, someone comes into a research room. The person says, okay, we're going to run a test. It's a memory test. You're going to shock this guy when he misses a question.

And you have this person standing there saying, yes, please, please continue. Please shocking him. Yes, it's necessary for the research. 70% of the time people go through all the way and shock to the person all the way up to, like, you know, the max voltage, right? 70% of the time. They go all the way through. Sometimes they feel very uncomfortable doing it, but they do it because they want to conform.

So, like, I would say the majority of human experience is conformity. And it's the exception that you have someone who truly is willing to not conform, right? And go out and to disagree and to take a stand. I would say we need to increase our ability to not conform. and they ran, they reran that test. I don't know if you saw my X tweet on this. Uh-uh, no. They re-ran it with a computer instead of a human saying to the person,

please continue, please continue. Yeah. We need to complete the study. Okay. And so in this specific group, they split the, you know, one group had the computer, one group had the researcher, and guess what the difference was? What was it? Guess.

Oh, I would say people were less, less, likely to conform to the computer. They both conform the same. The same, interesting. In this specific group, it was 90% complete conformity in both groups. Wow. Which I'm thinking, like, and if you think to yourself, well, I would never conform to a computer, we have algorithms feeding us information now.

If you're on any short form video platform, and the algorithm is a computer feeding you. information. Do you conform? Do you just believe it? Or do you, after each video, reflect and say, well, I don't know if I agree with that completely. Okay. So lack of authenticity is probably much more difficult. Winnicott talked about this with the false self. Yep. Kind of this idea, and I love Karen Hornay, who came afterwards, really brought this to life. It's this idea of this idealized persona that we may create in our mind that we need to be. That's not our true self. So looking for authenticity and looking for that true person. Anything you want to move on that before we move on in the next one?

I think that's all. The next one is called feelings of emptiness. And so I think this is really where the pain. The other ones maybe like it's like we're seeing this, but this is where like a lot of the pain is. It's like a sense of inner emptiness under the absence of any social contact. So it's like without social contact, I feel hollow. I feel like a shell.

In loneliness, there's often a longing for a fantasized person or experience. But in this, there's a lack of capacity to fantasize for a person or experience. So that's a very different emptiness. Yes. Yeah. Yeah. And so I think that. the work of Gerald Adler and Dan Bowie in the 70s and the 80s,

they talked about intolerance of aloneness as being very central to borderline personality disorder. And then Gunderson wrote a paper in 1996 on the intolerance of aloneness. And I think this is very similar to what Octar is describing here with feelings of emptiness. So the idea is that for these types of patients, when they are alone, there's such a feeling of emptiness, they are unable to evoke a sustaining internal object, the representation in their minds to get them through these periods of aloneness. So they rely very heavily on other people, self-objects,

if you will, to sustain them emotionally, to hold them and to soothe them. They can't do it themselves. So there's a constant searching often in these types of patients for a sustaining presence, you know, as a result of these feelings of emptiness. There's an intolerance of a loneliness. And it differs from, you know, from loneliness, which normal people can experience. But there's something very different about the quality of aloneness in patients with identity diffusion and borderline personality problems.

Let me read a quote here. a particular deadening of inner emotional experience occurs. Few fantasy objects can be created, and a sense of self begins to crumble. Compulsive socializing, bulimic episodes, drinking, drug ingestion, impulsive sexual encounters, and even provocative behaviors ultimately fill one with rage, are various measures that are used,

to ward off feelings of emptiness. Self-mutilation, seeing blood flow out of oneself, may be a more regressive way to combat inner emptiness. Yeah, and sometimes I use the metaphor of a container without a bottom, a bottomless container. So, you know, Actar is talking about filling this container in these patients, but it just empties right out. There's this compulsive socializing, as he calls it, a need to maintain social contact and communication with others who are used to sustain them.

Gerald Adler talked about a diffusion of self-objects for patients who will rely on multiple people, multiple others to provide them with a sense of holding soothing. And so, yeah, this is a major problem that I think really is quite prevalent in borderline personalities and differs, again, from loneliness. Yeah. Loneliness can be mournful, but you may have fantasies and there may be many emotions, whereas this, there's this compulsion to fill the void, compulsive socializing, bulimic episodes, drinking, drug ingestion, self-mutilation, multiplicity of sexual partners.

It's like I'm trying to exit out of this feeling of emptiness. Yeah. And some patients will come right out and say something to the effect of, I feel empty on the inside. I feel hollow. Not all patients are that sort of insightful about it, but my experience is that some people will actually just say this directly. and I just feel empty on the inside.

Okay. The next one is, according to ACTA, gender dysphoria. You want to break this one down? Well, to ACTA, this is a problem in individuals with identity diffusion. He writes, a cohesive gender identity is concordant. with one's biological sex and shows harmony between core gender identity, gender role, and sexual partner orientation. This translates into an overall gender appropriate demeanor, including attire, gestures, roles, social priorities, sexual behavior, and interpersonal relationships.

And so I'm not sure how well this has aged in the 41 years since this article was published in 1984. But, you know, Kernberg as well continues to talk about problems like this in severe character pathology. It does seem to be the case that individuals with gender dysphoria do have a higher prevalence of certain personality disorders. And so there might be some merit to this idea, even though it's a bit controversial or very common. controversial to talk about nowadays. And I would say what we're looking for here is we're looking for the global picture, right?

If this is a part of a multiplicity of these different domains of identity diffusion, then you may not overly focus on the gender portion, right? So I think in our culture, in our time, you know, there may be an inordinate focus on something, which is like, okay, maybe this is a bigger part of cluster B or borderline level

of functioning. And so I can try to treat the cohesive picture of this person is struggling with identity. Yeah. This is an identity crisis. I think that's such an important point is that, you know, and, you know, that's why you know, we have to look at the global picture and not focus on any one indicator. And so, you know, is this part of a larger picture of identity confusion? Or, you know, do you see these other signs or symptoms in the patient?

Or does it seem to be something that exists separately from these other problems? Yeah. And I would say if we get to more of the qualitative study, I think we can talk a little bit more about this. So maybe let's skip ahead to the next paper. Because I feel like this is such a hot topic to discuss. And we're not trying to make a big statement here. We're trying to say, like, look, there are some people with identity diffusion.

It can be in every domain of their identity. And gender, sexuality, sexual interest. sexual expression is all part of that. And so, yeah, let's keep going. Is there anything else from this article that you want to touch on before we move on? No, there was just one last criterion that Axtar describes, which is inordinate ethnic and moral relativism, which I think, because we're going through the rest of them,

I think just deserves to be mentioned. But, you know, he argues that individuals with identity diffusion display a peculiar power of ethnicity, this lack of an important historical, cultural basis of identity results in a peculiarity or a peculiarly polymorphous sense of ethnicity, which becomes evident in one sense of history, cultural norms, group affiliations, object choices, lifestyle, and child-rearing practices. It's a very interesting argument to me. Akhtar was Indian, I think he did his psychiatric residency in India, and then my have done a second here in the United States.

And so I'm wondering how influenced he is by his own ethnic identity. But he argues that individuals with identity diffusion lack any sense of ethnic or cultural or often lack a sense of ethnic or cultural identification. And so it's an interesting point. Yeah. And I think to myself, like, okay, the history of human kind was listening to myths, religious stuff, and they were rooted in myths or religion largely for, you know, forever, right? The oral traditions of mythology and the character traits that are

passed on as like, these are valuable character traits, right? Let's think about the Iliad and bravery, think about the Odyssey and hospitality. As I read these myths, I think to myself, like, these, Okay, so for thousands of years, people were hearing these stories, and it was grounding them in a sense of like, these are the things that we value as a culture, right? So every culture has values and things that they value and that roots and grounds them. He makes an interesting statement here towards the end. He says, the absence of inner morality increases the need for direction from others and sometimes involves a heightened vulnerability to isoteric religious cults. And I think it's an interesting say, man.

Very, very interesting. And I've long thought, you know, anecdotally that people who get caught up in cults, they're searching for something. They're searching for a sense of belonging. They're searching for a group, a community. And so it makes sense that if someone's lacking an ethnic identity or a cultural identity, they may go looking for it in weird places and get themselves caught up in all sorts of bad situations with cult leaders and the like. I think about some of the cults that I've studied, they've used things like LSD to kind of like create an increased identity diffusion. And then, um, oh, that's fascinating actually. Yeah. And so I think that the propensity of increased openness, right? We know that it's associated with, with psychedelics.

I'm more hesitant to recommend something even like ketamine to someone who struggles with dissociation for treatment resistant depression or something like that. So I think this is something that we need to be thinking about as well in this burgeoning field that could get heavily commercialized in the next decade. Yeah, good point. So, okay, shall we go to the next paper?

Yeah, let's do it. Okay. Right. So this is a paper called How Does It Feel to Have Disturbed Identity, the phenomenology of Identity Diffusion in Patients with Borderline Persia disorder, a qualitative study by Carlston-Jorgensen, Reich Boyd, Boyd, 2002. So a couple of interesting things in the intro, he talks about normal identity. And one thing he is that Kernberg said that commitment in intimate, mature relations in which love and sex need not be split off from each other.

That was kind of an interesting statement to me. This idea of normal identity has merged sex and love and they're not split off from each other. But I've definitely met some patients where it's like sex is not, like sex can only be done outside of any attachment. Yeah. And if I think, if I understand Kernberg correctly here, it's not that healthy people are incapable of sex without love. They certainly are capable of it, but that they are capable of integrating sex and love.

And that they can go together. Yeah. So he argues that, you know, healthier and around. person is able to engage in casual sex, but is also able to integrate sex with love. And I think that's a vital point. Yeah. He talks about how normal, so normal and consolidated identity involves a stable and coherent self-image, having a sense of inner core, continuity, and sameness of the self-other

time and across different social context. We've talked about this and capable to make stable communities. So I was thinking we could go through some of the core things that he found. So he was looking for, so basically in 16 patients with borderline personality disorder, I think it's very important to note that these patients actually had BPD. They were known to have BPD. They were getting treatment for BPD. And so he was looking at these 16 adult women, average age of 27.6 years, so about 27 years old.

And only two of them had comorbid narcissistic personality disorder. They did the inventory of personality organization that I had talked about earlier. They came up with an interview that was guided by Akhtar, Kernberg, other questions. on identity. We won't go through the questions that they gave, but you could look at that. And then he gave them, I think there was like,

on average, about an hour and a half interview and read the transcripts multiple times, looked for things that were common between them. And yeah, anything else on the kind of the methods and the intro before we get into the commonalities? No, I think some of the questions are interesting.

Okay. Yeah, go for it. Yeah, let's just read through some of them. You know, can you tell me a little bit about how you feel when you're together with other people? How does it feel to be you? How do you feel when you're alone, touching on, you know, emptiness and intolerance of aloneness? How do you see your own future? What do you imagine life will be like in five or ten years from now?

Could you tell me what sex means to you and what it means in your life? So, you know, from the first article, that we talked about the ACTAAR article, you know, there's an attempt to capture, I think, the different domains, sexuality, emptiness, contradictory character traits, splitting, and the like. So I thought it was a good questionnaire for the study. That's great, yeah.

And so then they looked at Table 2, they described the different themes and categories that emerged and how often they were present or not present. And most of them were present in each of the people. And if they weren't present, it was often just insufficient data. But very rarely were they not present, which I think goes to show that if you have patients with BPD and you dig into identity diffusion, across the board, they're going to have

a lot of these domains. And so things like, don't know who I am, using facetting. thoughts, self is broken, self does not fit in, inner emptiness, doesn't know what I want, don't know what I want, contact to stabilize identity, relational paradox, sex as self-regulation. It's pretty much in all of them. Yeah, yeah. And again, you know, Akhtar, you know, 40 years ago, syndrome of identity diffusion, all of these domains really fit in pretty neatly to what he described in 1984. And so, yeah, it's when I was looking at the data, it's actually quite striking to see that these things were present in a very, very high percentage of the study participants. You know, meaning, in essence, like you said, that if you have a patient with borderline personality disorder, there's a very high likelihood that they,

evidence these problems, these problems with identity. One thing I will mention is that this population, they scored high in identity disturbance in the IPO that I talked about. They scored on average 78.4 standard evasion of 10.2, demonstrating a very high level of identity disturbance. So this was a sample that had a high level of identity disturbance in them. Now, I don't think they picked them because of that. I think they picked people who had Borderline versus Sautil or who would be a part of this thing. But they did have high level of identity diffusion per other tests. And I think that's important.

Like if you wanted to run an IPO on people, I don't think that would be that hard. And they didn't score high in identity diffusion, then they probably wouldn't have identity diffusion, right? So, okay, that was one of my thoughts. I think it might be good to kind of go one by one through these and give a couple of the quotes, just so we can give some, like, meat to what this means. And once again, if you're struggling with us at this point,

trying to get your head around it, remember, this is something that you, it's like hard to get your head around because it's the thing that is diffuse. It's like, number one, I don't know who I am. So this is fluctuating and disintegrated self-image. So they said things like, there is no me.

This is exactly my problem. And it's terribly confusing, not being able to navigate who I am, what I really truly think and feel and what my view is on things. Here's another quote. What I am saying is something I really mean. if what I feel is something I really feel, the thoughts I have in my head about who I am, are they even true, really?

Here's another one. I don't feel that I can wholeheartedly say one single thing about who I am. Yeah, very common statements for those of us who've treated and worked with borderline patients. And, you know, I think, you know, this, sense that there is no core me.

Some people have linked, you know, self-injury and cutting to attempts, unconscious attempts by the patient to recognize or realize that they are in fact still alive and that I'm in possession of a body, which is an interesting conceptualization. But... Well, it's interesting, but it's also like it's suffering to not. know that you are alive. It's awful. It's horrible. It's a horrible feeling. And it's a horrible feeling to not feel like there is any you. And we rightfully suffer with them in the not knowing often in sessions. It's like it is so painful to not know where you are, where you start,

where you begin. Yeah, right. And that's a good point. I mean, the countertransference reaction to a patient who struggles with identity in this way is a feeling in me, I don't really know who the patient is either. And I'm having a hard time making sense of what's going on with the patient. Or another one I've heard from a lot of, especially people who haven't had a lot of training on countertransference like nurse practitioners. I know a lot of them are getting it after they get through their program, but in their program, they're not getting a lot of that. they'll say to me things like,

I don't, I come out of this session and I think to myself, am I? Like, what am I? Who am I to treat this person? Am I good enough to treat this person? Do I even know who? So it's like you have to imagine when someone's, when you're sitting with someone who really doesn't know who they are

and who it's like a common countertransference could be that you, don't have a sense of your own professional consolidation. And I see it coming out with people with like this insecurity about their own abilities, their own person. Yeah, very, very good point projection, projective identification and a professional sense of insecurity or a sense of incapacity. I'm not good enough to help this person. and I don't know, I don't really know what I'm doing. And perhaps in treating other patients, the clinician feels pretty skillful and pretty competent.

And so I think that's the point you're getting at, yeah. Yeah, so maybe it's like, for you as a professional, if you're listening to this, and that's a feeling you have when you treat some patients, it's like you have to step back and you have to say, like, okay, what am I feeling from this person? And then how do I use that to give them empathy? or to increase their reflectiveness, you know,

I think it's painful specifically. It's this emptiness that's painful. Yeah, and using the countertransference also to understand what plays out in the patient's outside relationships. If the patient's making me feel this way, well, then the patient's probably making others in their life feel this way, and that might contribute to the interpersonal dysfunction that we see in the lives of these types of individuals.

Okay, so we're going through the, I don't know who I am. I have never known who I am. How it feels to know who I am is confusing to me. That kind of like line was common with these patients. Because of that, sometimes there were statements like, I am completely dependent on the person I am currently dating. This kind of like utilizing the other for self-definition. As an anchor, yeah.

I'm going to anchor myself to that person. And my entire sense of self depends on whether this person is present, cares about me, loves me, is in communication with me, et cetera. And without this person, I fall apart. You know, and I hear, I've heard people who are narcissistic who talk about dating. and they actually look for this type of person that they can mold into their own image. And sometimes they talk about why they date young people.

And it's like, oh, bro. Yeah. Like, it makes me angry. But then also one thing that they'll say is they never show any weakness. And I used to be confused about that. I brought it up with Sue Johnson. And it finally occurred to me, why?

Do you know what I'm going to say? No. Because when a narcissist, shows weakness to a borderline that they're dating or someone with really bad identity diffusion, they may go into devaluation quickly. And so they have to stay in the idealization because that's where they feel good.

Yeah, yeah, yeah. This unconscious dance between these two personality disordered individuals is very fascinating, right? Because they're each playing a role for the other unconsciously, right? The narcissistic individual is providing the borderline patient with a strong, solid, at least outward appearance of someone who's very strong and solid and knows who here she is and that sort of thing, right? And the borderline patient gives the narcissistic individual, at least in the early stages of relationship, idealization. And what does the narcissist need and want so greatly is to be idealized?

And so there's a very complicated, complex sort of dance there that goes on, I think, sometimes interpersonally, which is not to say that normal or healthy individuals can't find themselves in relationship with personality disorder people. Certainly, that's probably the rule or the majority of, of these types of situations. But when you have a situation with two people who are severely characterologically ill, you have quite a situation on your hands. You know, it's really, really painful

to watch a dysfunctional relational dance where they're in this. And, you know, by the way, if you're in any relationship, there's going to be a dance, right? the Sue Johnson withdrawer, pursue, or dance, right?

That's always there. Someone doesn't feel quite enough. See, I'm not entirely sure that that's always there in healthy relationships. I would argue that in healthy, in two healthy persons, when one person leans in,

the other person leans into, and there's, there's a coming together, there isn't this follower, Chaser, you know, withdraw, sort of dynamic. I think that's the ideal. And I think a relationship can stay there for a while. But I think inevitably, most relationships fall into a dance of sorts where there's

some level of disconnection. I think it's rare to find a super highly connected relationship. That's probably true. Yeah. Like one that's very life-giving. Yeah. Once in a while, you'll see it. And you'll be like, wow.

Yeah. My sense is that, yeah, I mean, relationships can be at times difficult, but I don't think they have to be inherently difficult. Sure, absolutely. I think sometimes people who say, well, relationships take work and relationships are hard. I think sometimes that's a defense against their own pathological modes of relating. You know, healthy people tend to have pretty stable, you know, relationships. They tend to feel good about their relationships. relationships most of the time, and there's a good flow, and they feel connected. And so I'm really, you know, sort of against this notion that has become very popular that relationships are somehow inherently difficult. I think for some people, yes, relationships are inherently difficult, and those people often have at least some pathological personality traits, if not full-blown personality disorders. But I think well-adjusted people get along with their partners most of the

time and there's a good flow to things and there's a sense of comfort and and and certainly there's disagreements but so yeah this has come into the pop culture and the pop psych world quite a bit and I'm not entirely sure that I agree with these notions but yeah that's it's a good topic well maybe maybe my um my repertoire of patience that I've seen over the years tells me otherwise That being said, when one partner is very well connected to the other, treatment usually goes a little bit different. You know, the issues more discreet, time limited. I have this one couple, and it's like the most supportive, loving couple,

one of them's bipolar. Ah. And they're getting through it, you know? Yeah. But it's so much harder when there's, you know, like with, personality disorder comes chaotic interpersonal relationships so they don't have these longitudinal monolithic relationships that have gone on for decades like if you're wondering if you have identity diffusion and you have great friends that you've had for decades meaningful relationships

you're probably lower risk yeah and my experience with borderline personality disorder patients is that They can maintain long-term relationships. And I see this sometimes in my practice, but often the partner or the spouse is not what Gunderson would call the major object. They're not the fixation. The patient often has someone else, a friend, a family member, that their interpersonal world is centered around. And so they can sustain, perhaps in a marriage long term, where the, where the, partner is actually not the favorite person or the major or the primary object and so and sometimes they pick that partner for that reason as a higher level of stability that's right that's exactly right

they pick the partner for that reason unconsciously usually sometimes consciouslyly yeah okay that's interesting some digressions here good digressions okay number two fake it till you make it using masks and facades to stabilize the self. So some of the women said that they try hard to look and act normal, in some cases in an attempt to be socially accepted, in other cases, mainly to hide feelings of inner vulnerability, sadness, and what they see as bad or unacceptable parts of themselves. Interestingly, he's gone on to write a book, Jorgensen, on shame,

and the use of shame and psychotherapy. So you can kind of see some of the potential reasons for that. Am I good enough in the imagined eyes of the other? One participant described always trying to be the sweet girl, always pretending to be very happy, very, very sweet to others, even in situations where she's angry and feels like being and doing something completely different. I keep up this facade. Here's another quote.

I have many different facades. Behind them, there's chaos, not knowing who I am or how you're supposed to act on the outside. I have no problem appearing calm, in control, completely integrated, but inside I am going 150 miles per hour, trying to figure out, am I doing the right thing? Am I giving the right answer? What appears in these statements is a self that is haunted by anxiety and constant fear of being exposed. to be as defective, phony, and inadequate, and ultimately of being rejected, should the mask slip, which it often does.

Reflections? Yeah, lots of good stuff here on the fake it till you make it stuff, you know. You know, it's kind of like painful to imagine this person feeling so inadequate. that they need to be someone that they're not to fit in. It makes them feel like an imposter, I would imagine sometimes. And we're talking about with the people that probably love them the most. Or maybe they pick partners that will be very conditionally loving,

which is sad too. Maybe they had parents that were very conditionally loving. That's also very sad and difficult. And, you know, as a provider, they will imagine that I will be conditionally carrying towards them as well. And so they will project all sorts of ways of being and things that they have to do in order to appease me. And it's kind of a superpower in a lot of their domains of life.

They can be incredibly successful, reading people and melding who they are to fit various people's necessities. And yeah, and they find themselves in very narcissistic oriented relationships where they can be a certain way, show up a certain way, and get accolates and get appreciation. And that can be stabilizing for a time, but inevitably potentially leave them very empty. So I'll often say to a patient who has this, I'll say, if you feel like you can tell what I want to hear and that consciously goes through your mind, can you share that with me? rather than trying to appease that part of me because I know, like, we all have bias. Like, every therapist has probably things

that they want to hear more or less, right? Sure. I've seen this in patients who have a flight to health very quickly on in treatment because they imagine that that's what I want for them. But when I look at them, they look like they're really suffering. Like, it doesn't look like they're better.

It's a good patient. Was that? They're the good patient. They come in and you've cured them in two or three meetings. Right. They fly right into health, right. So I want to be the good patient for you, doctor. I've had patients who do good behaviors, imagining that I want them to do those good behaviors.

And we as professionals need to not be naive that this is a good reason to not talk about certain topics and preferences. I don't talk about my political preferences online ever because I probably have some patients who will read that and want to adopt or maybe they'll have some vitriol. One way or the other is probably not a good thing. Sure. But they could look at my books out there. I've had patients to look at my books

and start to include different aspects of my books into what they're saying. And I'm like, are you doing? doing this because you're trying to connect. And some people are very skillful at connecting. Sure. That's awesome. Sure. Yeah.

And so we always have to ask ourselves why, you know, what's going on, that's driving this and motivating this. But you make a really important point and that all of the stuff that we're talking about here that exists intra-psychically within the patient's own mind or in their outside relationships plays out in therapy too. And I mean, it's such a basic point for people psychodynamically oriented. But to others, you know, this is often not talked about.

It's not mentioned. So, you know, this is going to play out in the transference and the countertransference, what happens between you and the patient. And it becomes very, very useful information to inform diabetes. to understand what plays out typically in the patient's outside life. And so all of it occurs with us too. Yeah. One thing, I think that it's important for us to talk about how it plays out in our relationship

with the patient, because if you aren't psychodynamically informed, and I would say it's not like you can just read books and understand this. It's like supervision and seeing patients and that experiencing it yourself and reading books and more supervision. It's like slowly you get goggles and eyeglasses that see this as it plays out, right? One of the people,

Yeomen's recently said, if you want the transference to be evoked, try to reinstate the frame. Yeah, yeah, you just have to stay neutral. You just, I mean, if you, well, I don't know. Even if you, like, I'm probably, you know, different people

have different degrees of warmth, right? or I'm probably, I try to be more on the warm side. I would hope, I would imagine myself to be that way, right? You seem that way, David. If I truly am warm, I try not to say something that isn't true. Yeah. Because I feel like that's also a facade of sorts, right? Okay, one thing I was thinking about was my use of microexpression.

So I read microexpression on people's faces. Like if you flash a little bit of frustration when I say something that you slightly don't agree with. I think you did this the last time. I was here actually. I think you may have just flashed an expression. And I think what that does, though, is it helps me get to their true self. So it helps kind of like reroute me from my experience

into like what's going on inside of them. And I think it's true. I think it's like a piece of true knowledge, you know? Yeah. Like a dream. Dreams are like true knowledge. Because there's only one dreamer. It's not you and the person interacting.

Like they are in their own mind in the dream. You know, okay. Let's keep you on. So painful feelings of self as broken, defective, unvulnerable. Here's some quotes. I feel like there's a hole in the middle of my soul that nothing can repair. I am always the odd one out. The others think I am wrong.

It goes on to the body, their feeling of their body. and I've seen this with patients. It doesn't matter how attractive or unattractive. It's completely unrelated to how tall or short. They may say something like, I hate my body. I always have. I can't remember a time when I didn't hate my body. I am fat.

I'm too short. Well, everything. I'm not happy with any part of my body and never have been. One woman said, the greatest wish is to be born as a man. And this body and this body, and this mind's soul would fit together. I'm deeply dissatisfied with my body.

Different parts of my body are disconnected, like Lego bricks that don't fit together. And I would say like just like with body dysmorphia, sometimes you have patients with body dysmorphia that have lots of these thoughts. And it could be like linked to this bigger issue of identity diffusion, right? If they have surgeries,

one plastic surgery, two plastic surgery, three plastic surgery, a lot of these patients still have body dysmorphia. So if you have a patient like this, they're still going to have identity diffusion, unless you treat identity diffusion, you know? Yeah, lots of interesting ethical questions there with plastic surgery and the like, which, you know, are interesting to think about.

But, yeah, I mean, I think this is linked to self-destructive behavior, in these patients, self-punishing behaviors, masochistic behaviors. I feel so bad about myself that I deserve to feel pain. And so I think we can link some of the sadomasochistic behaviors that we see in these patients to these painful feelings about themselves. It's like I hate myself, I hate my body, And then what feels natural for me is to have other people hate my body or hate me.

And so it's like I'm going to search out maybe relationships where the person will have some large amount of hate towards me. And that can be masochism. That can be a masochistic sort of relationship, right? Here's another quote. I am like a broken bucket with a small hole on the, bottom where the water keeps running out because somewhere, because something is missing, and I have no idea what might plug the hole. And so you can see that the desperation, the agony, the pain in that hate, right? And so you might ask, how does this play out like in your relationship?

Well, if they have hatred towards themselves, they could project onto you that you will hate them, get you to identify that and then maybe you do end up hating them. And then as a provider, you may have a hard time hating a patient. That may be something that you can work through in supervision, you can get to the other side of it, you can work through a mixture of emotions

that you have towards another human being, right? We all have a mixture of emotions. Thoughts on that? Yeah, yeah, no, no. I mean, hate in the countertransference, Winnicott, you know, I think, yeah, there's, you know, there's just the sense of defectiveness, sense of brokenness that leads these individuals into bad situations unknowingly often and unconsciously. And just this, you know, this really core sense that I am just bad.

there's just a badness about me. It must be a horrific way to go about life. It must be very, very painful. But you're touching on projected identification too, which is the eliciting in the treatment situation of feelings within the therapist or the analyst that the patient's own feelings are dumped into the therapist and then the therapist begins to experience them

and if they act on them, then it's projective identification. And this occurs unconsciously. Very, very, very difficult thing to experience, something that really requires expert consultation and supervision often, and it becomes very murky, becomes very clear, are these my own thoughts, or are these the patience? Am I, you know, there's a coerce, quality to projective identification.

Gabbard talks about this. It can feel like I am feeling and experiencing something that I've never felt and experienced before. This is uncharacteristic of me. Why am I feeling these things? Why am I acting this way? Normally, I am patient and I'm warm and I try to approach each patient. with empathy, but all of a sudden I feel myself, you know, thinking about, you know, about kicking

the patient out of my office or I'm looking at my watch. I can't wait for the session to be over. Or I feel like I want to, I want to erupt. I want to yell at the patient. How could you say that or how could you be thinking that way or something like that? And of course, a skilled therapist doesn't do those things, but we feel them sometimes. And so, that's sort of the essence of what you're talking about there. Yeah, and I would add, one, I've referred a provider to you, which I think you were able to help them, even in one session. You can help someone like, when they've gotten pulled into this really deep,

you can help them kind of understand what might be going on and why this is, and just even knowing that this is a thing, I think, very helpful. Yeah, it's not taught, you know, my friend, colleague. When you get pulled into it, though, and if you're listening to this and you're like, oh, that's never happened to me, it's like, okay, but when it does, remember back to this talk, come back here, listen to this again. I've heard it described before as feeling like you're in shark-infested waters, and I think it's a pretty damn good metaphor for this type of experience if you've never had it before as a clinician. But yeah, I mean, I just want to quickly add, you know, this stuff, unfortunately, isn't taught at the graduate level very often, if at all.

Because here's the thing is like a lot of the teachers that are teaching in a lot of programs, they're not treating severe. If they're treating anyone at all. Severe patients. Often they're just researchers. Often they're just researchers, yeah. I picked the residency that I went to because every person that I would work with was working 40 to 80 hours a week

and had been for decades. For me, that was like, it was kind of a workhorse program. I chose to go there for that reason because it was like, I was going to get this mentorship of people that have actually done this. I've rotated at another program.

It's like I would have a guy teaching for the week who had been doing research for the last 50 weeks of the year, year. So if you haven't gotten this, you're getting it here. I'm glad that we can give it to you here in a small dose. Okay. I want to wrap it up in like five minutes. Okay. So this is my goal. So hang with me here, guys. Number four, feeling that the self does not fit in, the self is not experienced as an integrated part of social communities. Okay. I'm not going to go into that. We've talked about that quite a bit, but this feeling that I'm not belonging, I'm a lone wolf.

I'm, I'm, if I'm around other people, I are, I feel rejected. Okay. And some of that is maybe happening. Some of that maybe is part of the projection, right? And maybe that's part of like the difficulty of a feeling, a sense of self, so you can't feel a part of a group. This ties into what Akhtar was talking about the cultural stuff, the ethnic relativism, right? I don't really feel like I'm a part of a group. I don't really feel any sense of connection to my ancestors or to a larger, you know, a group, you know, to which I belong. You know, I've been reading a book on Hitler, and I think Hitler had some of this identity diffusion. I mean, this guy was practically homeless

for a big portion of his life, artist. And the war, World War I, he was kind of described as this odd guy, like wouldn't join in the laughter, reading books on the side, but when he was able to talk about politics and he disagreed, he would go into these rages in front of people.

And there were some people that really listened to him and gravitated towards him. And I think over time, the war, gave him an identity. Yeah. And the anti-Semitism gave him a subgroup. And the political stuff and the, his knowledge,

because I think he was fairly bright, gave him things to talk about that led to people following him. But he was a very odd interpersonal person. Yeah, yeah. I'm, I don't know if I've told you this, but I'm in a one-year training program with Otto Kernberg right now on personality disorders. and, you know, Kernberg's written a little bit,

and he's spoken a little bit in this program on Hitler. You know, for those who don't know, Kernberg had to flee Europe as a young person because of the rise of Nazism, and Kernberg is Jewish, and he went to Chile and did his psychoanalytic training in Chile and then came to the United States. But anyway, Kernberg has argued that Hitler suffered,

from the syndrome of malignant narcissism. So borderline level of functioning. So he had reality testing intact. He had identity diffusion. He had primitive defenses. But in that, a very pathological narcissism. Yes. That is, you know, so malignant narcissism is Kernberg's term for, in essence,

a combination of narcissism and with antisoly. social behavior. Psychopathy, yeah. And yes. But he did not think, or he does not think that Hitler was a psychopath or that Hitler had antisocial personality disorder because to Kernberg, Hitler had the capacity for some non-exploitative human relationships. He was capable of a love relationship with Ava Braun.

And so he is, so Kernberg argues he has this, had the syndrome of malignant. narcissism. It's an interesting, just an interesting historical point. So I ran him on the PCLR, the hair psychopathy checklist, and he scored 30 out of 40, which puts him right at that edge of psychopathy. Yeah, interesting. He, he scored lower, and like, usually people with psychopathy will have a multiplicity of sexual relationships, but he did not. So I would actually say that I think he had some psychopathy. Yeah, I think that's captured. I'm, I think that's captured by malignant narcissism. I'm reading the book where it talks about his friendships,

and he didn't really have any long. A lot of these friendships, the people were very passive that he was able to relate to. Interesting. And I think that a lot of his relationships were not based on a normal connectedness. Yeah. But I think later it was based on more like ideology. Yeah, yeah. I don't know enough about his relationship with Ava Braun.

Yeah. He had some German Shepherd dogs and apparently was devastated. He was more devastated by his dog. About the dog, he killed the dog the night before he killed himself, my understanding is. He didn't have psychopathy to a level of like harming animals of like, but there was some, but he was very dehumanizing. I mean, so. Oh, absolutely. Yeah. this i hope i hope i didn't um you know okay so i have one more thought on him and then let's move on his father was actually very um stern and would like um would try to steer him in the right direction through pretty strict discipline maybe some like spankings or stuff maybe even worse right he would leave his dad and his mom would coddle him. And so I almost think with that, you know, like he had no...

It's a perfect setup for splitting. It's a setup for splitting, right? And so you could hear that and you could say like, oh, Dr. Peter, do you have empathy for someone like hitting their son? Or are you saying that the mom should not empathize with the son? And I would say, no, no, no, you're misconfusing. me here. Okay, you're not understanding the situation. If a father disciplines a son for something that the son should have been disciplined for in the proper amount, and then the mother

negates that through coddling, not empathy, because empathy would properly be saying like, hey, you had aggression, your father was trying to steer you in the right direction, right? Empathy would be congruent to the situation. This is not empathy. This is coddling. So coddling is like, it's like overly nurturance to something that doesn't need to be nurturing. Yeah. Okay. So hopefully I can parse that out. It leads to splitting, right?

Yeah. So, okay, enough on Hitler. We'll get further in the book and I'll have some more thoughts. So, okay, I wanted to touch maybe on the last one, because I think his take on sexuality was interesting. And all but one person had issues with sex. using sex to distract the self and regulate painful self-states, painful confusion around sexual needs. So almost all women, almost all women have used sex as a way of gaining acceptance and recognition from others and avoiding abandonment.

Quote, most of my life, I have used sex as a way to be accepted and recognized as good enough primarily in one night stands or having sex made the other person feel happy. Personally, I could easily do without it. Here's another quote. Sex is a way for me to be affirmed as being good enough. Others have used sex as a distraction, quote, a means of handling emotional problems, end quote. One woman contemplated what she is looking for in sex. I don't know what I'm looking for.

Maybe I'm looking for some artificial form of care, love, tenderness. I don't know. I think attention is what I'm looking for. Yeah, and so I think what you're seeing here is that the sex is, it's about much more than sex, right? And I guess an argument could be made that sex is always about more than sex, but in these individuals, it's magnified, right? It's an extension of a desperate, a desperate desire for connection.

Correct. A desperate emptiness that we've already talked about. Yeah. It's a coping strategy. It's a way of helping someone else feel better about themselves. So it's like instead of like their own identity, what they would desire, it's like this is me merging with the other person's desires and giving away my own sense of self. And it's different from, I think, in normative functioning, it's nice to feel desired.

We all like that. We all enjoy that. But in this subset of patients, it's not just nice to feel desired. It's needed and sought compulsively, often with a number of objects, a number of people, over and over again. And the person really never feels satisfied, filled up, and good enough. And so I think sex is like a manifestation. It's like a playing out. It's like an acting out of some of the distress.

It's a powerful way to connect with other people. And it's utilized for that. But in a way that doesn't lead to the desired outcome. Sometimes. Yeah. And I think it's something where, as a clinician, you know, how do I have empathy for the person for the yearnings underneath, for the yearnings for connection that feel thwarted for the yearnings to find a sense of self to rediscover sexuality?

What is sex for them in a meaningful way, right? as they start to get in touch with more of their personhood, more of what they would desire, not more of just what they would submit to the desires of others for other satisfaction. Like, what would they yearn for? And they described a lot of the people with kind of like an asexuality almost,

like because they're so distanced from desire. Yeah, yeah. And sex is meaningful connection. And so, and I guess the last point I want to make on this is there's an inherent self-destructiveness here as well. The risky, impulsive behavior, you know, sometimes it's very, very apparent to the clinician, but the patient themselves doesn't necessarily see this type of behavior as self-destructive. And Gunderson talks about this a little bit. I think it's an important point, is that what might be glaring. hearingly obvious to us when we look about,

look at this patient's life and what they're doing may not be apparent at all to the patient themselves. Yeah, and I think like the doctor side of me is always a little bit cautious with the higher, more higher risk behaviors that can lead to lifelong consequences, right? It's I want to, I want to not increase the shame that someone might feel, but I also want to help a person person not have consequences that could lead to lifelong suffering if at all possible.

So, okay, well, let's wrap it up on this one. This is, hopefully this has been meaningful. Hopefully this has been helpful for you guys listening to this. Hopefully you can jump on X. I might post the whole video, the whole audio actually on X. We didn't record any video today. So that people could put comments or there should be some place that you can throw up a comment or something that you vehemently disagreed with us or you felt like we were really off

track you can just let us know you know because that's what that's what we do on Twitter or you can put up a kind thoughtful comment on something that was helpful yeah those aren't that common I like yeah um but it's really meaningful to have you down really appreciate you coming absolutely it's been real this is this is good this is a good conversation I feel like if we there were things that we did not get to, right? And so if you could get these two papers, check them out yourself, spend some time reading them. If you had any strong disagreements with us, maybe that's the first step. Read the articles, front to back, and you can come up with disagreements you have for them, juxtapose of different disagreements you have with us. You can have some nuance between the

differences, right? Okay. All right. Thanks, David. We'll leave it there for today.