Mark L. Ruffalo
@MarkLRuffalo
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Psychoanalysis, psychopathology, history of psychiatry; faculty in psychiatry at @UCFMed and @TuftsMedSchool; clinical interest in BPD and psychosis; DPsa
Joined September 2019
"It is in the nature of paradox that 'equations' based on it do not work out. Where paradox contaminates human relations, disease appears." - Paul Watzlawick.
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I am becoming more and more convinced that politics is merely a playground for psychopathology, an outlet for the most vile forms of narcissism, rage, and aggression, and a socially-sanctioned vessel for groupthink and splitting.
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It should not be controversial to state that in many cases, "lived experience" actually *detracts* from one's ability to objectively consider the nature and severity of a given condition, especially mental disorders.
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The ability to disagree with others without feeling personally attacked is a mark of healthy object relations and psychological maturity.
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A fairly common phenomenon is a person achieving some level of fame and then giving strong opinions on topics well outside of their area of knowledge or domain of influence. Psychiatrist Robert B. Millman termed this "acquired narcissism." Plenty of examples on social media.
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I do not believe it is a coincidence that the explosion of interest in treatment-resistant depression (TRD) has coincided with increasing neglect of issues of personality and personality functioning. It is likely true that a significant percentage of what is called TRD is.
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Some basic facts about trauma and psychopathology. These have emerged from years of empirical research and thus do not represent opinion. 1. Children who lack genetic vulnerability do not develop psychopathology. 2. Childhood trauma is not a *cause* of any mental disorder; it.
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The need for accurate diagnosis in #psychotherapy: A warning from the life of Carl Rogers, one of the most famous psychologists of the 20th century. Early in his career, Rogers was treating a young woman whom he later recalled was "borderline psychotic, on the edge of
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We are headed for a real showdown over the possible inclusion of CPTSD in DSM-6. My concerns (enumerated in a recent article with Joel Paris, M.D.):. 1. The diagnosis of CPTSD is frequently used, at least in practice, to avoid diagnosis of BPD. 2. This means that patients who.
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A very common statement from new patients I see for consultation, sometimes said verbatim:. "I don't want you to simply validate and support me. I want to know what's wrong with me.". Somewhere along the course of the past 30 or 40 years, the role of the therapist went from, to.
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For the next two weeks, until January 26, the entire archive of Psychodynamic Psychiatry is open and free to access for all.
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I am going to say something decidedly anti-psychoanalytic, but I am of the opinion that classic bipolar disorder is basically a disease of the nervous system, effectively cured in many patients by lithium. These patients should always be referred for pharmacotherapy.
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How do we differentiate between #bipolar mood disorder, cyclothymic temperament, and #borderline personality disorder? This may be among the most important questions in clinical psychiatry and psychotherapy. There are two fundamental symptoms present in #BPD that are not.
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If research in human psychology has taught us anything, it is that some people, on the basis of their internal object representations, are really in need of an enemy.
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I was very happy to learn today that I have been promoted from Adjunct Instructor to Adjunct Assistant Professor in the Department of Psychiatry at @TuftsMedSchool.
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"Diagnose the fewest conditions needed to explain the clinical picture." - DSM-II (1968). Timeless advice. Largely forgotten today.
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I would like to add some historical nuance to recent discussions here on depression and SSRIs. A significant broadening of the construct of "major depression" occurred with DSM-III and the subsequent discovery of the novel antidepressants in the 1980s. A very heterogeneous.
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Some therapists exhibit what has been described as a "good mother" (Gunderson, 1984) or "withdrawal from reality" (Kernberg, 1965) countertransference, in which there is a denial of the patient's aggression and a joining with the patient in externalizing the sources of the.
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What is going on with #ADHD? My take (inspired mostly by my Tufts colleague, Nassir Ghaemi):. To understand this problem, one needs to know a little bit about history and how the psychiatric classification system works. Many mental disorders present with problems with attention,.
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While #attachment theory has become a popular lens through which to understand human problems, it often offers an incomplete model of understanding. Sometimes, attachment style is simply a euphemism for a severe disorder of personality. While attachment theory helps explain how.
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Children are born with innate temperaments, which are genetically and biologically mediated and differ from personality. This is why, as any parent will tell you, some kids are simply easier or harder to parent than others. It represents a significant error to mistake an.
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Core issues in borderline psychopathology, according to major theorists/paradigms:. Kernberg/TFP: excess of aggression.Linehan/DBT: emotional dysregulation.Gunderson/GPM: interpersonal hypersensitivity.Masterson: difficulties with mother/separation-individuation.Adler:.
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In this new piece at @PsychToday, I offer some thoughts on complex PTSD, arguing that the construct suffers from two fatal flaws and should not be included in DSM-6.
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Beginner: DSM categories "carve nature at its joints.". Intermediate: Psychiatric diagnoses are subjectively determined and socially constructed. Advanced: Although imperfect, psychiatric diagnoses point to real phenomena that exist in the world.
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Two issues that have long plagued psychoanalysis are:. 1.) apophenia, which refers to the tendency to see meaningful connections where none exist (ironically, a symptom of some forms of psychopathology), and. 2.) the related problem of psychoanalysis being a "closed system,".
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Yesterday, the brilliant Lois Choi-Kain, Director of the Gunderson Personality Disorders Institute at @McLeanHospital, said something so simple but important: "Trauma is an etiology, not a diagnosis.". Why is this such an important concept? Because when we generically diagnose.
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The entire archive (over 2,000 articles) of Psychodynamic Psychiatry is open with unlimited access for the month of May. (I have an article in the current issue.)
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The intrapsychic translation of "I disagree with you" to "I hate you and must destroy you" is the source of much of the world's conflict.
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Beware of totalizing narratives of psychopathology. For years it was unconscious conflict. Then it was biology. Now it is trauma. None of these things could possibly account for all psychopathology, given the various types of problems we classify as mental disorders.
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"You do not absolve the parents of any causal role in this. But you want the borderline patient to recognize that they were probably a difficult child, and the parents, who had their own difficulties--those difficulties were exacerbated. That might be a difficult pill for some.
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"The most important cause of severe personality disorders is severe chronic traumatic experiences, such as physical or sexual abuse, severe deprivation of love, severe neglect, unavailable parental objects as familial dispositions that can lead to the development of personality.
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You can learn a lot about people by watching how they react to opinions they strongly disagree with.
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When a person is unable to acknowledge certain painful aspects of self, they may act in ways that induce these feelings in others. To this, we give the name "projective identification.".
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A core element of narcissistic pathology is the patient's entering into all human contacts with a fundamental belief that there is always a winner and a loser. Life is one competition after another. This plays out quite predictably in the patient's transference.
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My paper titled "Heads I Win, Tails You Lose: Interpersonal Aspects of Borderline Personality Disorder" has been accepted by the Bulletin of the Menninger Clinic. It is an honor to publish in that journal, which for so long served as a leading outlet for psychoanalytic theory.
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@hubermanlab Rare clip of Schwartz acknowledging that he is just regurgitating Freud while claiming that he has invented something new.
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Misdiagnosis of borderline personality disorder as a bipolar spectrum disorder is a common, and costly, clinical error. In this new piece at @PsychToday, I offer two pointers to differentiate the two--one from Kernberg and the other from Gunderson.
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"The question often arises--when a couple fights so much why do they stay together? The answer, of course, is that they stay together because they fight so much. The message is that it is preferable to have an external negative object on which to project the internal negative
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The first step in psychotherapy is a clear conceptualization of the pathology the therapy aims to treat. Without this, the therapy is aimless, and patient and therapist just end up stumbling around. This is why Kernberg emphasizes the need for accuracy and clarity in diagnosis.
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The spectrum of antisocial behavior, from most to least severe, according to Kernberg:. 1. Pseudopsychopathic schizophrenia.2. Antisocial personality disorder proper.3. Malignant narcissism.4. Narcissistic personality disorder with antisocial behavior without excess of aggression.
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Kernberg today on the differential diagnosis of suicidal ideation:. Suicidal impulses and fantasies are quite common. The most basic and fundamental question is: Are the suicidal ideations with clinical depression or without depression?. If they are chronic and without.
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A classic in self psychology. My Chicago friends will enjoy this one. I have grown increasingly fond of deficit models of psychopathology, especially narcissistic and borderline disorders.
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Clinically, this is often narcissism hiding behind the facade of chronic "depression and anxiety.".
"The second form of narcissism, covert narcissism, is marked by largely unconscious feelings of grandeur and openly displayed lack of self-confidence and initiative, vague feelings of depression, and an absence of zest for work"
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"Abandonment depression" was James Masterson's term for the primary affective state of borderline personality disorder. In the wrong hands, this is often (but of course not always) the type of patient who "fails" multiple trials of antidepressants, is treated with polypharmacy,.
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In this 2010 paper, Fred Busch argues that psychoanalysis is being eroded by powerful ideological forces: "We increasingly view our patients as primarily trauma victims rather than also *victims of their own mind.* We seem to view our primary goal as comfort via understanding
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Classic paper from 1988 on "deliberate misdiagnosis," which, as the name implies, reflects the practice of knowingly and intentionally rendering an inaccurate psychiatric diagnosis. My sense is that this is a pervasive practice today, rationalized by some clinicians to avoid
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A good rule of thumb is that when a person starts engaging ad hominen, you have already won the argument because they don't know what to do with your ideas.
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The differential diagnosis of attention symptoms in adults is lengthy and includes: mood illness, cyclothymia, hyperthymic temperament, primary anxiety states, and disorders of personality, including hysterical, histrionic, and borderline personalities. This is not to mention.
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If you don't know the history of psychiatry, you will think you will have discovered something that, in all likelihood, has been described by many people before you--often psychoanalysts. There is very little that is new under the sun. But lots of money in believing there is.
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I am very pleased that my paper, "Some Observations on Paleologic Thinking in Borderline Personality Disorder," has been accepted by Psychodynamic Psychiatry. The paper proposes that interpersonal dysfunction in BPD is mediated, in part, by a type of prelogical reasoning process
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Postmodern critiques of psychiatry tend to assume that psychopathology exists only insofar as we name and describe it, or that it is mythical, metaphorical, or "co-constructed.". But anyone who has experience with severe psychopathology knows that these problems exist in the real.
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Perhaps the most important thing to understand about psychiatric diagnosis is that the map is not the territory. The fallibility of our classification systems does not mean that psychopathology is not real.
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I may be a psychoanalytic psychotherapist, but it is a remarkable fact that Kraepelin's 1899 distinction between the two major mental diseases--schizophrenia and bipolar disorder--continues to stand the test of time. A testament to his genius.
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You know, it's okay to say "I'm not really sure" or "I didn't study that so I don't have much of an opinion about it" or "Here are my ideas but don't take them too seriously because I don't know for certain.".
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Incredible new open access study in Schizophrenia Bulletin of over 170,000 patients on types of delusional themes encountered in psychosis. Twenty-one different themes were identified, with the most common being paranoid, referential, and familial.
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A very powerful unconscious motivator for illness in some cases is continued dependency on a helpful, caring object. In some cases, this is the therapist.
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This 2008 paper by Gunderson and Lyons-Ruth provides perhaps the most comprehensive theory of #borderline personality disorder to date. They write, "This paper offers a theory with supporting evidence that the preborderline child has a genetically based hypersensitivity to
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"Masterson proposed that the mother of the borderline individual was herself a borderline who encouraged symbiotic clinging and withdrew her love when the child displayed strivings toward independence. The situation was complicated by an absence of the usual counteracting pull of
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Excited to announce that James Barnes @psychgeist52 and I have agreed to publish side-by-side essays on diagnosis in psychotherapy, where I will be defending diagnosis from an ego psychology-object relations perspective and James will be critiquing diagnosis from a relational.
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Christopher Lasch called the 1980s the era of narcissism, but we may very well be living in the era of identity diffusion. From Akhtar, S. (1984). The syndrome of identity diffusion. American Journal of Psychiatry, 141(1), 1381-1385.
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It is often a futile endeavor to try to convince with logic and evidence someone who insists on reasoning with emotion.
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Introducing the Association for the Psychoanalytic Study of Psychopathology, an organization dedicated to the psychoanalytic understanding and treatment of mental disorders. Join us here:.
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"Our work with [the patient] consists of two parts: what has been done to him and what he does to himself." - Anna Freud. When the therapist focuses solely on the former, the patient loses an important opportunity for growth and change. Simultaneously, the therapist gratifies his.
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This year marks 50 years since John Gunderson identified borderline personality disorder as a distinct psychiatric syndrome. To mark this anniversary, I have co-authored, with two undergraduate students, a manuscript entitled "Fifty Years of Borderline Personality Disorder: A
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In this new paper published last week in Psychodynamic Psychiatry, I apply the double bind theory to the study of borderline personality disorder.
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One of the major unintended consequences of DSM is that people learn only what is in it. They generally learn nothing of the century of psychiatry and psychoanalysis which preceded it.
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My forthcoming paper in the journal Psychodynamic Psychiatry (vol. 53, issue 2), covering a historically rich and clinically relevant area of psychiatric theory.
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"We must begin to love in order not to fall ill, and we are bound to fall ill, if, in consequence of frustration, we are unable to love." - Sigmund Freud (1914).
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This is an absolutely remarkable paper by the late Michael H. Stone, following some patients from his private practice over 50 years. Some patients he kept in touch with by telephone once or twice a year. It is the longest longitudinal study of BPD ever conducted.
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For those interested, I will be presenting a two-hour lecture on the psychodynamics of #narcissistic personality disorder #NPD on March 5, drawing mostly on the work of Otto Kernberg and Gerald Adler.
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A quite predictable development in the treatment of narcissistic patients is the emergence of a power stuggle between patient and therapist, a consequence of the narcissistic tendency to see only "winners" and "losers" in every human interaction. In some cases, the patient "wins".
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Common paradoxes in human communication, adapted from a forthcoming paper in Psychodynamic Psychiatry.
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A senior psychoanalyst once told me that his former boss, a prominent department chairman in psychiatry, once bragged that his "analysis didn't touch [him]," meaning, in essence, that there was nothing in him for it to "treat.". This is an intriguing comment to me, and it of.
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Ronald Pies and I will soon publish the PRiSM (Psychopathology Refracted into Seven Modalities) psychiatric diagnostic instrument. PRiSM aims to reduce polydiagnosis by capturing psychopathology across seven functional domains. While PRiSM will not yield specific DSM diagnoses,.
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Reading Salman Akhtar's (1992) book Broken Structures and he makes the argument that theorists who have not trained in hospitals (or have otherwise not spent significant time working with psychiatric inpatients) tend to underestimate the severity of personality disorders,.
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I am convinced that the most prolific scholars in psychoanalysis--the ones who published 30 books and 500+ peer-reviewed papers--did nothing but write, teach, and see patients. Literally nothing else.
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There is something particularly paranoid about a psychological theory or worldview that holds that all of psychopathology is explained by the failure of other people. It is as if all of the bad is "out there" in the world, and internal determinants are denied. It is also.
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One of the most egregious errors in contemporary research on psychopathology is that researchers tend to conflate symptomatic improvement after initiation of a new treatment (often what psychoanalysts would call a "flight into health") with treatment efficacy or cure.
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I recently completed training through @McLeanHospital in General Psychiatric Management (GPM) for borderline personality disorder, and I highly recommend the course for anyone and everyone involved in treating BPD patients. GPM provides a cohesive model of BPD as a disorder of.
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If a patient has pneumonia with a fever and a cough, we don't diagnose pneumonia, a fever disorder, and a cough disorder. Yet, this is precisely what we do with psychiatric diagnosis--what Mario Maj called the false co-morbidity problem.
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"In some cases, there is an objective form of countertransference in which the therapist reacts to the patient in the same way that everyone else did. Winnicott noted that some patients would be so provocative and contemptuous that everyone, including the therapist, would respond.
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This 2005 study by Allen et al. in Comprehensive Psychiatry found that patients with borderline personality disorder reported significantly more contradictory communication from parents than did normal control subjects. This aligns with Masterson's contention that children who go
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This important 2008 review by Taylor and Fink argues compellingly for restoring melancholia--a classic, profound, biologically-based form of depression--as a diagnostic entity to differentiate it from all of the other forms of depression that are now clumped into the fictional
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This 2019 study by De Panfilis and colleagues in Italy found that patients with borderline personality disorder react to others' fair and accepting behavior as if it were unfair, frequently responding with punishing, hostile attitudes. This is likely due to the discrepancy
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To paraphrase Robert Langs, it is better to learn the basic ground rules of psychotherapy first and then flexibly adapt them to the needs and challenges of each clinical situation than to naively think that the rules don't matter or that all that matters is "the relationship.".
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Kernberg speaking this morning about a rare condition called pseudopsychopathic schizophrenia, in which the psychosis involves extreme aggression and antisocial behavior. When these patients are treated with antipsychotics, they actually become *more dangerous,* as their reality.
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I will be presenting "The Psychodynamics of Narcissistic Personality Disorder" on March 5 via Zoom for @Executive_Links from 12:00 to 2:00 pm EST. If interested, here is the link to register:
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Spend enough time in certain psychotherapy circles and you will realize that some people actually don't believe in science or truth. Everything is relative and contextual. These ideas have infiltrated the culture so deeply that they often exist unconsciously (a la Thomas Kuhn).
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Replace "trauma reaction" with "the consequence of a complex gene-environment interaction, including adverse experiences, some of which might have been traumatic (broadly or narrowly defined), and my own idiosyncratic reaction to these circumstances.".
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The psychoanalysts who have had the greatest impact on contemporary practice are those who subjected their ideas to empirical study and inquiry. Figures like Kernberg and Gunderson exemplify this shift, moving beyond dogmatic acceptance of theory to helping build a psychoanalytic.
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I am honored to have been selected as Chair of the upcoming Psychotherapy Special Report at @PsychTimes. I look forward to helping put together an excellent issue covering various topics related to psychotherapy and psychiatry.
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In this new paper in the Bulletin of the @MenningerClinic, I advance the hypothesis that borderline personality disorder is fundamentally a disorder of paradox or self-contradiction.
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"In general, the occurrence of any mild or brief ego-dystonic psychotic-like experiences in the absence of severe, widespread psychotic symptoms at any point in the patient's past life is a strong indicator for the borderline diagnosis." - John Gunderson.
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