Music 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 personality sort of, I would say you're becoming one of the most preeminent borderline personality sort of experts on Twitter on X. Got a little bit of a following there. Yeah. Quite the following. Yeah, 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 started out? 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 a cohesion, which is ironic because of the nature of the syndrome where the problem itself. And so, yeah, it's something that I think is really, really hard to grasp even for experienced clinicians. Yeah, and so let's go through a little bit of the history of it. I noticed you're also, you have Gunnerson's book Open and we also have an article by Salomon Aqatar. And so yeah, where do you want to begin? Yeah, I think it was Erickson who was the first to use the term identity diffusion. And later work by Otto Kernberg linked the presence of this problem to severe character disorders or personality disorders, notably borderline narcissistic and schizoid personalities. 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 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, the evidence is identity diffusion. So it was Erickson, Kernberg, Salman Haqtar 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 neurosis, psychosis, like two differentiating groups of people. Helene Duge 1942 described an as if personality, which mimicked normal behavior but lacked genuine core self foreshadowing this like kind of later notion of fragmented identity. Brueller 1911 reported, it gets frenetic patients saying that they often had lost their individual self, highlighting a profound disturbance in identity. It's kind of crisis. And then you have this mid-century Erickson identity. 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 kind of their friend group friend group where what they believe in contrast to what their parents believe and 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 Odokernberg 1967 seminal paper called borderline Personalities, 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 themself or significant other, and they exhibited contradictory, like self-concepts, chaotic instability and goals and relationships. So this kind of like the started 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 and briefly 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, describe them as falling apart on the couch. So these were patients that were just hard to classify diagnostically. 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 the roses. 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 SM 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 disorders. That's a little bit of the history. So, 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. We, in healthy or normal or neurotic people, there's a sense of cohesiveness to who we are. I think Aktar in this paper describes the healthy individual as being able to maintain a core sense of self amid change and with the passage of time, regardless of what's going on in life, I still maintain a core sense of self. 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 understand. 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 her feelingness. But when there's huge incongruencies in how they show up, when there's very different feelings towards different people, as well as themselves. Do I hate myself? Do I love myself? This kind of splitting is kind of like an identity crisis as well. One thing I wanted to say was, for those of you who are listening, you are like, this 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, I have started to go down this road of like, actually, this is a really helpful construct. There's actual ways of testing this, right? Once you have a good way of testing it, that's very consistent. One person tested, the next person tested, very consistent. Cornbuck 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 schizoid with borderline level of function. You could be paranoid personality sort of 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 personalities 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 in identity diffusion and primitive defenses. And this is what this has proven to be true. 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 it's really unfortunate that there's two different concepts with the same name borderline. And 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, you know, so it's like, let's to Salomon Actar. And let's go through the different domains of identity 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 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, this second one. So, you know, as always, I'm going to write up some details on the podcast notes and

this one, Salomon Actar from 1984, very worthwhile. Another one, Karstein Jorgensen from 2022, which I've actually corresponded with him. Yeah yeah, he's, he's, uh, 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 has a construct 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 STI, PO, structured interview, personality organization, 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 an actor because I think this is a really nice look at this.

Okay, his first one is Khan Tritiquity Character Traits. What jumped out of you and then maybe I'll read apart. Yeah, I think that there's a section in there where Aktar 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 others' personality. So, because the patient is lacking a coherent sense of self, they also lack an ability to to construct a cohesive narrative of what another person is about. So they rely excessively on the last interaction with the other person. You see this very, very commonly in borderline personality disorder. contradictory character traits, 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 Cline's notion of splitting. And so, you know, you also see individuals who lack a sense of vocational sort of purpose. So Actar and 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 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 it's you to be 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, naivety 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 it. Yeah.

So, yeah, with this, you can see how it could be difficult if you're a therapist, as you're listening to them, to 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. 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. And a bit of 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. So pointing that out to the patient as Octar 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 not to, but in a way that actually decreases shame. And so we pointed out as a way of having compassion.

Yeah.

Yeah. Of course, it can be really, it can be really difficult to have a multiplicity of fluctuating experiences of another person or of ourself. 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 confrontation is completely compatible with empathy and caring about the patient and warmth. You can engage therapeutically in this way and still confront the patient.

So it is another way of saying it, which is increasing their reflectiveness of themself. We aspire towards increasing reflective function, and we know that people with BPD have a burn on average, a lower score on reflective function around 2.7. It's an 11 point scale from negative one to nine. So they're around 2.7 when they start, but they can increase it. And so it's by an increased knowledge of themself 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 like 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 discontinuity in the self? Temporally. Yeah. The capacity to remain the same amid change and with the passage of time is how act hard 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 and expected existence for these patients. They experienced 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 level of like temporal discontinuity. Yeah, yeah. And so in the last paragraph there of that section, Octard describes, you know, 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. So trying to 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 this kind of like desiring to ground themselves into time and into memory. Right, Now 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 what act, not in a manner that is genuinely their own. They lack originality and readily acquire gestures, phrases,

ideologies, and lifestyles from others.

Yeah, this is the essence of Elaine Dewey's,

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 bowties. and for who who knows me I I sometimes wear bow ties and the you know style of Aaron Beck and John Gunderson and some other people but anyway There I Yeah, I guess you could say that but but the patient started to To come in and never Reve revealed to me, it 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 or tails of it. But now, of course, in retrospect, I think that there was some identity problem here, and he was seeking some identification with me to anchor himself in the world. And so I think this is sort of what Acta 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, ticks, 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, you're 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, but then to adopt, you know, like I know exactly what Dr. Tarr would say in most situations. Yeah. But I'm not going to do it, right? Yeah. Because 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. All of these things we're discussing today exist on a continuum with normal, right? And so, 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. So, but that, the dimensional nature of these traits doesn't negate the pathological nature of their excess. So sometimes I like to say that hypertension exists on the same continuum as normal blood pressure, but people die of hypertension. Hypertension is a pathology, right? So just because something exists on the same spectrum or continuum is normal, doesn't mean that an excess of that trait is not problematic or a sign of a pathology or or maybe people don't die of high blood pressure.

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