On Breakups, Apropos of Nothing
Unrelated to any current events, your author muses on the challenges of breakups for those with psychiatric disorders.
I've been doing a lot of work recently! My readers may have noticed that the Frontier Psychiatrist is no longer a daily publication, although it is published fairly frequently. In part, it's because I have a new relationship. Two. One of those relationships is with my car. Yes, I now have a car. Because I moved to Connecticut. I'm driving a Rivian around, and it is a great car. But you can't write a newsletter article and drive a car at the same time, without substantial risk of death. If you want a Rivian, also, here's my referral code. It gives you $500 of free stuff with the car, like a tent.
Also completely unrelated to anything, it's an electric car, but not a Tesla. I previously drove a Tesla. I no longer drive a Tesla. Because I drive a Rivian, and you could too. Using the above code. All of that is related to factors, including liking a larger area for the storage of things. Also, it was appealing to not risk a brick with Nazi iconography dropped on my car by a psychotherapist. That's inappropriate behavior. I'd prefer not to have that take place to my vehicle.
The other relationship I have is with the exciting work I'm doing in my employment, which involves getting a lot of publications out and bringing products to market. These things are exciting to me.
However, when you don't have a good relationship, or when you once had a good relationship and then it ends in a breakup, it's a significant issue. It can make everything feel bad. However, for some people, breakups can be an even bigger deal and can occur more frequently. For people with psychiatric problems, frequent breakups can be a symptom of having a psychiatric disorder.
There is a range of psychiatric disorders that we call personality disorders. The name sounds pejorative, and I apologize for that. I didn't get to pick it, and I don't have a better name. But I can say that the concept is pretty helpful.
For people with personality disorders, the impairments are not primarily in mood, anxiety, or perceptual disturbances, although those problems can co-occur. The problems are across four domains of personality functioning.
These are identity, self-direction, empathy, and intimacy. And just like you can have a problem where your mood is constantly depressed, and you can't have a good sense of how great the world could be, or you hear things that aren't there, in the case of auditory hallucinations, it's possible to have profound impairments in those four domains. Let's look at what that might look like in the context of a breakup.
Let's say you have a best friend. The best friend is pretty new. For folks with a personality disorder, they may have a rapid onset of very close friendships, for a time. The problem for those with personality disorders is often not that they can't get close, but that they can't stay close. Many of us, without profound personality disorders, will have friendships that last over many years. Sometimes, one might not even see one’s friend, and then you get a phone call, and it's as if you pick up where you left off.
For people with a less solid sense of who they are and what their relationships with other people consist of, it can be hard to continue to feel close to somebody if they're not immediately around you all the time. And so people with these impairments in identity— “I don't know who I am without you,” —or intimacy, “all we ever do is hurt each other!”—the relationship can start hot and heavy, they can spend all their time together, and even if it's not a romantic relationship, even friendships can be deeply intimate. The problem, of course, is that they can be unstable. Doomed to failure. Just imagine spending every minute with another person? For most of us, that sounds like it would be tough to keep up over a long period of time. Most people need some space, including us, and ramping up a relationship more slowly, so it has time to grow and breathe, is a good idea, in general. People with personality disorders don't tend to do this. They go all in on a relationship, until they go all out on it. Historically, we referred to this as alternations “extremes of idealization and devaluation.” You're either everything to me, or you're nothing. We're either gonna be together forever, or I'm gonna slash your goddamn tires.
And if that's not an impairment in functioning in your life, I don't know what it is. It's really hard to have so little sense of yourself, in the context of a close relationship, that you lose yourself. And the only way you can feel like you're reconstituted again is to push that other person away, and take dramatic, frantic efforts to devalue them. Maybe you'd even do it publicly. Maybe you'd even go to the Internet to disparage them or to defame them, maybe you'd even sabotage their business interests?
These things are all possible for someone with a personality disorder. Sometimes, two people, both of whom have personality disorders, we get together. In the beginning it makes sense to both parties, they're used to these extreme relationships. They get really close, they spend all their time together, and then something goes wrong, and now everything has to end. And keep in mind these individuals have problems knowing both who they are, and how they are with other people. So that evaluation of the other plays an important role in the maintenance of the sense of oneself—my friend is the bad one, I'm the good one, and I'm gonna prove it to you, world.
To be clear, these are profound impairments, this really screws with your life. It would be a lot easier for all parties if they could take it slow and maintain relationships over time, rather than all or nothing. And the inability to do so is what makes this pattern of interpersonal chaos disorder. If they could have stable relationships over time, it wouldn't be a disorder; it would be a pattern of personality functioning that is healthy.
The opposite is, of course, profoundly unhealthy.
It's worth noting that there are other problems that commonly occur with personality disorders. Reckless drug use, for example, is a common pattern of behavior. “Sexual promiscuity,” a term I kind of hate because it sounds very judgy, is also a common symptom. To clarify this a little bit, it's sexual behavior that's not healthy for the person. It's not supposed to be judgmental, but there are people who have inadvisable sex, even for them. They're not having sexual relationships because it's a good idea, or because they find it pleasurable, and enriching to their life, all of which is important and healthy; they're having impulsive relationships. Maybe they're having children they didn't plan on? Maybe they're having unprotected sexual intercourse; they should probably take appropriate steps to prevent outcomes that are not in keeping with their goals in life.
There are many ways in which sexual behavior can be perfectly healthy, and there are many ways in which sexual behavior can be unhealthy. And the symptomatic sexual behavior I'm referring to in this context is sexual behavior that is a problem for your life. That's what makes it part of a disorder.
Substance use, similarly, isn't necessarily a disorder. I'm having coffee right now, that's a recreational substance, but I can stop anytime. I'm having it only in the morning, for example, so it doesn't impair my sleep at night. I'm not having severe tachycardia from drinking coffee around the clock; I'm not having caffeine intoxication. Other substances have signs or symptoms of abuse, and usually, that's the inability to discontinue use even when it becomes clear that it's problematic. If you break your arm while drinking because you fell over when you were too drunk, that's problematic. Suppose one routinely falls and injures oneself, and can't stop, even if it becomes clear that there's a pattern of physical injury. In that case, that's another example of addictive behavior, which is its own disorder, but commonly occurs with personality pathology.
It can be common for people who have personality disorders to turn to substances, or the next relationship, or to other problematic behaviors, in the context of a breakup.
Breakups are hard for everybody. They're not supposed to be easy. But the ability to have a relationship, and to have it end in a healthy way? That's functioning well in the world. And if every relationship ends in a huge explosion, it's a signal that there may be a role for assessment and treatment. There are effective treatments, even for the most severe personality pathology. Just last month, a remarkable paper was published by my colleagues at the Anna Freud Centre on the treatment of antisocial personality disorder. They were able to reduce aggressive behavior male violent offenders by using mentalization based treatment for ASPD.1 Mentalization based treatment is already demonstrated effective for borderline personality disorder, along with dialectical behavioral therapy, schema focuses therapy, transference focused psychotherapy, and other approaches like good psychiatric management which can help individuals with personality disorders live more functional lives. One of the things that is special about personality disorders, or at least more common, is the profoundly interpersonal nature of the impairment. Given empathy and intimacy, our areas of impairment, it's often impairment with other people, who don't specifically have that disorder, that causes problems for the rest of us, as they were, that can be seen. Depression can cause suffering for you and your friends and family, but narcissistic, borderline, or antisocial personality disorders can cause suffering for others as well. We all suffer when somebody with a personality disorder suffers. Almost by definition, the impairment also affects those around them. So I would argue it's in the public interest to make sure we have great treatments for personality disorders available broadly, and to educate the public, like I'm doing right now, that personality disorders exist, and that effective treatment exists. None of them, unfortunately, are drugs. Even ketamine, a rapid-acting treatment for treatment-resistant depression, is unlikely to be helpful as a first-line treatment in severe personality disorders.
Thanks for reading this totally off the cuff and utterly unrelated to anything article. After I finish it, I'm gonna check the news, and see what has been going on in the world, because I feel like I've been living under a rock!
Fonagy, P., Simes, E., Yirmiya, K., Wason, J., Barrett, B., Frater, A., ... & Bateman, A. (2025). Mentalisation-based treatment for antisocial personality disorder in males convicted of an offence on community probation in England and Wales (Mentalization for Offending Adult Males, MOAM): a multicentre, assessor-blinded, randomised controlled trial. The Lancet Psychiatry, 12(3), 208-219.
Did you base this chart on me? It’s ME!