MARK RUFFALO: Welcome everyone to this episode of The Carlat Psychotherapy Podcast. I’m Mark Ruffalo, editor-in-chief of The Carlat Psychotherapy Report, and I’ve got with me today a guest, Dr. Nassir Ghaemi, of Tufts Medical Center and Harvard Medical School. Dr. Ghaemi is director of the Psychopharmacology Consultation Clinic at Tufts, a leading expert in bipolar illness and lithium therapy, and has written extensively on the philosophy of psychiatry. Today, I’ve got some questions for him about psychotherapy, about the diagnostic hierarchy in psychiatry, and a few other topics. So, welcome to the podcast, Dr. Ghaemi; it’s great to talk with you today.

NASSIR GHAEMI: Thanks, Mark. It’s nice to be with you.

MARK RUFFALO: So, my first question for you is, you have argued in some of your writings that the oft-repeated claim that medication plus psychotherapy is better than either alone is untrue and that it should not be generally accepted. Can you tell us why you make this point?

NASSIR GHAEMI: Well, my claim is not that it is untrue inherently; my claim is that it’s not true inherently. The view, that it’s obviously true is either unproven or demonstrably false. It could be, though, that in some cases the combination is helpful, and that’s something that needs to be proven and has been shown in some things. For instance, it depends on what condition you’re treating. Let’s take a simple example, like acute mania. There’s no research that shows that adding psychotherapy to the antipsychotics for acute mania is more effective than antipsychotics alone so that one example is enough to disprove the general thesis. Even acute depression, depending on what kind of depression you’re looking at; in acute bipolar depression, antidepressants don’t work at all, so adding psychotherapy to antidepressants doesn’t make that any better; neither of them are proven effective. Acute unipolar depression, which is a place where people often talk about this, there is some evidence that the combination can be more effective than antidepressants alone in some studies, but then not in other studies, and if you dig into that research, my general summary of it would be that— and most people don’t make this summary, but I think this is a correct interpretation— that is underappreciated. When you look at very severe depressive episodes, the combination of CBT (cognitive behavioral therapy) plus antidepressants has been shown to be more effective than antidepressants alone. But when you look at mild depressive episodes, it has not been shown to be effective – more effective. Interestingly, though, in mild depressive episodes, CBT is as effective as antidepressants. So, it’s not that you need to take both; it’s that you could take either one, but adding both doesn’t add anything. Whereas in severe depression, antidepressants are more effective than CBT alone, but when you combine both, they might be more effective. So, it really depends on what you’re talking about, what’s the syndrome you’re treating, what does the research show; that’s my view. It’s not generically more is better, which is, we can get into it if you like, it’s really a reflection of a deeper philosophical belief among many people in psychiatry in the so-called biosocial model and the view that more is better, and eclectically people combine and add interventions on a general theory like that, but that theory itself is questionable, and as I said, I think it’s better to base those judgments on actual research and evidence rather than belief systems.

MARK RUFFALO: Yeah. So, looking at the illness or the condition and the research specific to the identified problem rather than making a broad claim?

NASSIR GHAEMI: Right, because if sometimes people can just be treated with one treatment, why give them two? You know, maybe they don’t even need medication; maybe psychotherapy alone would be enough. So, there’s no reason to inherently over-treat people, both for costs and also for harms – side effects and stuff.

MARK RUFFALO: Which really leads me to the second question that I have: You mentioned eclecticism, and I was recently taking another read of your text concepts of psychiatry — which I recommend to everyone listening; you've criticized eclecticism in psychiatry and argue that it can lead to undisciplined and unscientific practice in some cases; can you share your general thoughts on this topic and what this means, specifically for psychotherapy, as a treatment, and as a discipline?

NASSIR GHAEMI: Right, well, I think it leads to anarchy, and I think that's the way psychiatry is now. We live in an anarchy, there’s no ruler, there’s no guidance, there are no laws, everybody just does whatever they want to do. And people will defend that and say, Well, that’s great. People are free to treat however they want to. It may be great for the clinician who just has a belief system and wants to get paid for it and pay his mortgage, but it’s not great for the patient who basically can be treated by different people in so many different ways with no rhyme or reason to it; that’s why in a recent Gallup Poll, a random selection of Americans gave mental health clinicians a D or an F grade in 60% of cases. Only 1% gave us an A. 90% gave us a C or less – the biggest groups being D and F. So, we may like it, but our patients don’t like it, and ultimately that’s the important thing.

MARK RUFFALO: What I see so often in the psychotherapy world is that eclecticism becomes a justification for throw anything at the patient and see if it sticks. It’s just a very unprincipled stance, and it’s unsupported by the research literature, which looks, obviously, at specific treatments for specific problems.

NASSIR GHAEMI: Right, well, the whole concept of eclecticism is unscientific or antiscientific, so it wouldn’t be something that you would look to research for; it’s a theory; it’s an ideology. And it really grows out of (if I could put this briefly) the larger context in our modern culture in the last 40-50 years is a postmodernist belief system that’s relativistic about truth. So, people don’t think there is such a thing as absolute truth in science or in religion or anything, and so nothing is forbidden, and anything can be done.

MARK RUFFALO: Sure, and I think that “anything goes” type of approach has hurt us in psychotherapy.

NASSIR GHAEMI: Yeah, I think from the perspective of psychotherapy, what’s interesting about this is this postmodernist, relativistic, eclecticism has allowed psychotherapy to happen – you know, anyone can do anything so, they can do psychotherapy. But it also doesn’t justify, so when push comes to shove and people say, Well, why are you doing psychotherapy? or, Why are you doing this psychotherapy? Usually, with this kind of thinking, you really don’t have an explanation except for I like it or In my experience, it works. And you know you can’t get insurance companies to pay for that if that’s relevant; you can’t get the government to subsidize it often. It is important, separate from the inherent reality of it’s good to know the truth, it’s also practically important to be able to justify what you’re doing, which we really don't.

MARK RUFFALO:  Much of your work and your career, to my understanding, has been on bipolar illness, manic-depressive illness; as an expert in mood illness, can you tell us a little bit about what role, if any, psychotherapy plays in the management of bipolar disease?

NASSIR GHAEMI: Well, in the case of bipolar disease, like schizophrenia, these are the two conditions in psychiatry that are diseases, that really are almost completely genetic in their etiology, and they don’t happen unless you have the genes; they are completely biological in their cause. They are a medical disease like any other medical disease. You would think that, therefore, medical or biological interventions would be the most relevant, and they are relevant. But, nonetheless, there is a role for psychological interventions for both conditions in both cases – schizophrenia and bipolar illness. It’s been shown that certain kinds of psychotherapy added to the right medications do improve the course of the illness to some extent, and in bipolar illness, specifically family-focused therapy developed by David Miklowitz, PhD and colleagues, which reduces expressed emotion, seems to reduce the life-event stressors that trigger mood episodes. Cognitive behavioral therapy probably can do the same thing. Interpersonal therapy has been studied. So, there are various therapies that may reduce the likelihood of life events causing mood episodes essentially, based on ameliorating the patient’s experience of those life events. That’s probably the main role for psychotherapy for bipolar illness. It is not a treatment of the disease. It is not really a treatment of an episode; it’s more the course of the illness to reduce the likelihood of severity of episodes in relation to life events.

MARK RUFFALO:  Yeah, and you mentioned there that you put in the category of psychiatric disease schizophrenia, bipolar illness. And I’ve read some of your work, you know, Kraepelin’s distinction between psychiatric disease and clinical picture or clinical entity, and we’ve come to agree that there’s probably a core set of DSM diagnoses that reflect biological disease entities. And then the other things that are included in the DSM: the majority I would submit of the diagnostic constructs that we use are more in line with what Kraepelin would call sort of a clinical picture or a clinical entity. You know the etiology of these problems is largely psychosocial, not as inherently biological as these disease states. Would you add anything at this point in time to schizophrenia and bipolar illness in that latter category? Would you say melancholia? Would you say obsessive-compulsive disorder?

NASSIR GHAEMI: Yeah, you know I insist on the disease concept even when we talk about psychotherapy because I want to get away from the eclecticism that you can believe whatever you want to. And I think it’s important to our field to admit if there are such things as diseases of the mind that express themselves just like psychiatric symptoms and also to admit that there are not. And it’s not really legitimate to say everything is not a disease, or everything is a disease; we should be able to, which it is and which isn’t, and in fact, as you point out as I’ve argued, even if you accept the disease concept if you look at all the different clinical presentations of psychiatric clinicians probably 90% are nondiseases, so even the diseases there’s a small group, but that small group is really important. Schizophrenia is 1% of the population, bipolar is 2%, so we’re talking about 3% of the general population have these diseases, and that’s a lot of people, and it's important to diagnose and treat them well. I will say that I don’t think that DSM has identified these diseases at all, or well, maybe schizophrenia, but when I say that bipolar is a disease, I don’t mean that the DSM definition of bipolar is the valid definition of that disease. My view of it is that manic-depressive illness is the disease, not bipolar illness, and manic-depressive illness includes what DSM calls bipolar illness; it also includes at least half of what DSM calls so-called major depressive disorder, which would include people like as you mentioned with the melancholic depressions, but also people with mixed depressions which is not defined in DSM. So, I would say that the two big diseases are schizophrenia and manic-depressive illness – not schizophrenia and bipolar. And the manic-depressives includes the people that used to be called recurring unipolar depression and bipolar, so that’s one group. Other than that, I think other disease entities that might exist include OCD properly defined – not OCD as a symptom when you’re manic, or depressed, or psychotic, which is a common mistake. My reading of this literature is that only about 20% of the people diagnosed with OCD actually have primary OCD; the rest of them have OCD secondary to mood illness or other things. So primary OCD, yes; usually starting in childhood, chronic, unrelated to mood illness, and unrelated to psychosis; that is a disease and autism, even though people love diagnosing it now as a spectrum in the mildest cases. Certainly, in the classic, severe cases, autism is a purely a genetic disease. And there are probably two or three others. So, I would say, you know, a half a dozen I could come up with. And if you look at the old research diagnostic criteria from the 1970s, which was the only time in psychiatry — in modern psychiatry — that we ever tried to list diagnoses based on their validity – not their reliability, which is what DSM is. DSM is a dictionary; let’s all agree to call it. These clinical pictures, as you said, in the German tradition they called it – yeah, we see patients like this, let’s just define them. Okay, fine, but the fact that we see patients like this doesn’t mean that they are diseases; that’s something that science and research has to show. It doesn’t even mean that they are psychologically caused, they might be spiritually caused who knows, you know? So, yeah, we have 200 clinical pictures; that’s DSM. There are probably more, but the research diagnostic criteria said let’s just list the ones not that we see the clinical pictures, but the ones we know are valid. That means that there is evidence based on genetics and course of illness that these symptoms really are different than other conditions. And they only came up with about a dozen diagnoses. In terms of valid diagnoses, we might have a dozen. In terms of valid diagnoses that are diseases, we might have half a dozen, and then we have about 200 clinical pictures, which we don’t really know what they are.

MARK RUFFALO: On that basis, would you make a broader argument that psychiatry as a discipline ought to get back to the study and the treatment of these core diseases, that this ought to be the primary focus of psychiatry as a medical specialty?

NASSIR GHAEMI: Our group has proposed in writing that we should go back to clinical research diagnostic criteria as the basis for future diagnosis in place of DSM. Get rid of DSM, stop the reliability focus, and change the focus to validity, and then we would have maybe a dozen or so diagnoses that we would make. And the rest would be not diagnoses that are definitive but just various viewpoints that people could have. And they could keep thinking about. And I think we should focus on the valid diagnoses. Now, they are not all diseases – like PTSD is a valid diagnosis, but it’s not a disease; it’s an injury. You could argue that antisocial personality, and maybe borderline personality, are valid and appropriately defined, but they’re not diseases in the same way that schizophrenia or bipolars are, not purely genetic; they have a lot of environmental components to their etiology in early childhood, especially probably. So, yeah, I think we should focus on these valid diagnoses, some of which are biological diseases, some of which are psychologically caused, and the dozen diagnoses would provide – I mean, in reality, I think a majority of clinicians do engage with these dozen or so diagnoses most of the time anyway, and the other 200 labels are just made up and are worthy of dropping, I would say including ADD, which I do not think is a valid diagnosis at all in adults or children.

MARK RUFFALO: But, yeah, I would agree. I think the vast majority of the people that I say they probably … I think we are probably treating these maybe, 8, 12, 15, you know, core problems sometimes without even realizing that these are the issues that the patient has. It leads to my next question about diagnostic hierarchy, and this is something that frustrates me a great deal. I often see patients referred to me — sometimes by psychiatrists — who come to me with four or five or six different diagnoses, and my understanding of the history of psychiatry is that this really is an artifact of the DSM classification system, that historically, the idea was that the patient really, can have only one mental disease, maybe they may have a couple of mental diseases, but this idea that a patient may have five or six, seven different disorders of the mind is really a novel idea in psychiatry, I think, right. So, you know this is one of your major contentions; can you just tell us, you know, in general, why you think a diagnostic hierarchy in psychiatry is important? What it means? What is a diagnostic hierarchy, and give me an example of an egregious error in this area, if you don’t mind.

NASSIR GHAEMI: In general, in medicine, the approach it has taken is the so-called differential diagnosis approach. The patient presents to a doctor with usually a number of symptoms: fevers, chills, and night sweats, and then the doctor makes a differential diagnosis of the kinds of conditions that can cause those symptoms: bacterial infections, viral infections, other things. And then he goes through that list and rules them in or rules them out. If you know the cause, that’s the best way to go, but often you don’t know the cause. And the way you do it is there are some diagnoses, you know, valid diagnoses, that cause lots of symptoms, and you want to rule them out before you diagnose smaller conditions that cause fewer symptoms. So, a doctor doesn’t say, You have fever disorder or chill disorder or night sweats disorder when you go to him with pneumonia. But in psychiatry, we say, You have ADD, generalized anxiety disorder, and MDD when someone shows up with cyclothymia. And the cyclothymia causes the manic and depressive symptoms, which make people have poor attention, poor sleep, mood being down sometimes, and anxiety. And instead of diagnosing the illness that causes each symptom, we diagnose the effects of each symptom. And then we give them three labels and say, Oh, poor you, you have three disorders. And then, we give them one pill for each disorder, which is really a pill for each symptom instead of treating the underlying cause. With one pill, we treat the effects with three. So polydiagnosis, polypharmacy, more harm to the patient, and only in psychiatry is this done; the rest of medicine does not function this way. And the reason is again DSM. DSM-III, DSM-IV, the leaders of those groups taking an eclectic, post-modernistic, relativistic approach said, We don’t know what causes anything, so we can’t say that you should rule out this before you diagnose that. The only exception they made was schizophrenia. So, they explicitly told people to make as many diagnoses as they could just based on all these symptoms, and because the symptoms are listed in ways that they overlap, then people will make multiple diagnoses. So, for instance, half the symptoms of GAD are the same as the symptoms of MDD; if you diagnose one, you’re going to diagnose the other. And that leads to this false co-morbidity problem that people have been debating now for decades.

MARK RUFFALO:  Sure, sure. I want to now turn to some specific disorders and just get your thoughts. So, if you're seeing a patient clinically, you’re trying to figure out whether this patient has cyclothymic temperament or a borderline personality, can you give us some tips that you utilize yourself in trying to make this distinction because there’s a quite significant overlap, I think misdiagnosis when it comes to borderline pathologies and mood illnesses. I think it goes both ways. So, can you help us clarify this?

NASSIR GHAEMI: Yeah, I think I need to take a step back and first explain briefly the concept of validity and the criteria we use for that. So, it’s not enough to look at symptoms, which is what the vast majority of what DSM does. We know in general in medicine that you can have the same illness with different symptoms or different illnesses with the same symptoms overlap. You can have chest pain, and it can be pneumonia, or it can be a heart attack. You can have a headache, and it can be a brain tumor, or it can be an endocrine problem. So, you can’t go by the symptom to say what the diagnosis is. And so, in psychiatry, DSM does that because it claims that it’s “atheoretical”; it doesn’t know the causes of things, but really, it’s just being post-modernistically relativistic. It doesn’t want to know the causes of anything. And the validity is based then, not just on symptoms; you have to have other sources of evidence. In medicine, we have pathology as the ideal source: appropriate laboratory tests and so on, imaging. In psychiatry, we don’t tend to have that. The other two sources of evidence besides symptoms and pathology would be course of illness, how the illness goes over time, when did it start, at what age, is it chronic, does it improve, does it not by natural history. And then genetics; in the case of diseases that are genetic that can be helpful. Of course, many conditions are not genetic. So, these are the four validators: symptoms, genetics, course of illness, and biological markers if you have them. No, in terms of differentiating cyclothymia and borderline personality, the symptoms won’t do it for you because they overlap; we have mood lability in both cases, and everyone debates that, and that’s a waste of time, and it’s DSM falsehood that’s ruining the field. In terms of biology, biological markers we don’t really have the testing for that, but we do have course and genetics. Cyclothymia is genetic; it’s part of manic-depressive illness which twin studies show is almost completely genetic – 90% genetic in cause. Borderline personality is not primary genetic; it’s about half genetic based on the twin studies, half environmental. So, if you have family members with bipolar illness severe unipolar depression, then that makes the patient much more likely to have cyclothymia than borderline personality disorder. So, if you turn to course of illness, patients with borderline personality have sexual trauma in two-thirds of cases as defined by DSM definitions, which does not require sexual trauma. But if you look at older definitions, it’s probably even higher than that. And in cyclothymia and manic-depressive illness, it’s 20%, which is population baseline, so it’s three times more likely or more if you have borderline personality. In terms of self-cutting, which is another course kind of symptom, but also course history, you see that with borderline personality in two-thirds of patients; again, cyclothymia hardly any. So, if patients have these other features of self-cutting or early sexual trauma, they are much more likely to have borderline personality than cyclothymia. So, the answer is forget the symptoms, look at the course and the genetics, and differentiate it based on those features.

MARK RUFFALO:  That’s very helpful. And lastly, you know your comments on adult ADHD. Actually, our comments, I’ve written a piece with you on this topic. You know they’ve garnered a lot of attention, and since we're talking mainly to psychotherapists here, for the general practicing psychotherapist, what do you think it’s important for them to know about this disorder, ADHD, recent trends in this regard? It seems like every other adult patient that I'm seeing now is coming in and saying, I have adult ADHD. I’ve been told by my psychiatrist I do, or I’ve gone online, and I took a 10-minute screening test, and they wrote me for a stimulant. What’s important for the average practicing psychotherapist out there to know about what’s happening with adult ADHD right now in our society?

NASSIR GHAEMI: Yes, well, I know I think the interest in the diagnosis is expanding because DSM-5 in 2013 expanded the definition, and this is exactly what the DSM leadership wants. They basically want to manipulate the society to believe in psychiatric diagnoses the way they want them to believe. So, they expand the diagnosis, and then people believe in it. It’s a very much of a herd mentality. I think the issue with adult ADD is that it basically takes a symptom or a set of symptoms: executive dysfunction and poor attention, and it makes a diagnosis, whereas executive dysfunction and poor attention happens with a bunch of other diseases or diagnoses – legitimate ones like depressive states, manic states, and psychosis, and even anxiety states – they all impair executive function and reduce attention. And so, if you had adult ADD, and if there was such a thing, you’d have to show that it existed in people who don’t have those other conditions. And this gets to the diagnostic hierarchy concept. When you look at the research on that in studies like the National Comorbidity Survey 80%, at least 80% of people diagnosed with adult ADD were also diagnosed with a mood illness; another half of them were diagnosed with an anxiety condition. So, it’s almost impossible to find people that meet so-called adult ADD definitions who don’t have mood illnesses and anxiety. Now, the ADD experts will say – they reverse the causality; they say the ADD causes the depression and the anxiety. Well, they have no proof of that; that’s just their belief. About half of them have mania. How does ADD cause mania? There’s no one who legitimately would claim that. So, I think that the diagnostic hierarchy approach is one reason to doubt it. The other thing is when you look at prospective studies of adult ADD, the claim is that these are children who have it, who continue to have it into adulthood, and it happens in 3% of the population. There are prospective studies that have followed children into adulthood, multiple ones, and they have a control group, so you know who does and who does not have it as children, and you know who does and does not have it as adults. You get the 3% number, but the interesting thing is the majority of them, like 80%, did not have it when they were kids. So, it's not adult ADD when they are distractible and have poor executive function and so on as adults because they actually didn’t have it when they were kids. They have poor executive function, but it’s not so-called adult ADD. So, when you look at the course of illness as a validator, it does not validate the diagnosis; the symptoms don’t validate it; there are no biological markers that differentiate it from other conditions. When you look at genetics in the huge GWAS studies, there’s a huge overlap of so-called MDD and bipolar. It’s not specific to ADD. So, nothing validates this when you look at the validators. I think psychiatrists like to diagnose it because they like to give people amphetamines. Amphetamines improve your attention right away. Everybody’s happy; everybody gets paid, and you know patients like it, and so they have a little of that rationale for doing that even though amphetamines – they don’t tell people, and they don’t know, usually, that amphetamines are harmful to the brain; they kill neurons; they are neurotoxic in animal studies repeatedly, and in humans, they haven’t been shown to be safe. The only reason we have them is because they were grandfathered into use before the FDA started regulating drugs for safety and efficacy in the 1960s. So for psychotherapists, what’s relevant then is that a lot of people will come to you with this claim that they have executive dysfunction or attention; the culture has set it up through DSM-5 for them to be able to say that, therefore, this leads to this diagnosis of adult ADD, and then they will want maybe referral or treatment for it, whereas the right thing to do is to look for the 80-90% that actually have mood illnesses or anxiety states and diagnosis and treat that.

MARK RUFFALO: Yeah, very, very helpful. And then my final question for you is a hierarchical question. I want to know, in your opinion, where personality disorder falls in the psychiatric diagnostic hierarchy. I’ve seen some people place it at the very bottom. Now, my problem with this personally is that you take a patient with DSM-5-defined borderline personality disorder, you can see problems with mood. You can basically see any Axis I symptom in borderline states, so why would we place that at the very bottom of the hierarchy when we ought to be considering something like a borderline personality in the patient who comes in with depressed mood, with anxiety, with transient psychosis, and the like? So, where do you place personality disorder in general in the hierarchy?

NASSIR GHAEMI: Well, just because something is at the bottom of the hierarchy doesn’t mean it’s less important. It just means you need to rule some other stuff out too. And maybe you need to rule them out for various reasons. Like I said, the biggest reason is that other conditions may have more symptoms; they capture more symptoms, but it also may be that they are treatable, for instance, in different ways. So, for instance, yeah, you say borderline personality captures all the symptoms; so, does bipolar illness. So does manic-depressive illness, defined [inaudible] way captures every symptom in psychiatry, so that ought to be ruled out for everything first before you diagnose something else. You will mistakenly make the diagnosis of borderline personality if you do not rule out manic-depressive illness, especially because we already know in the past that when you’re in a mood state, you can look borderline when you’re depressed, for instance. And there are studies that have shown in so-called borderline and MDD, you follow them for a year – half the borderline personality goes away, so it wasn’t borderline personality; it ... just the depression. But an important point is also these mood temperaments which we mentioned, like cyclothymia and hyperthymia, which most people don’t know about because it’s not DSM – being manic all the time as part of your personality. These are not episodic; they don’t come and go; they are there all the time, and so they produce anxiety and poor attention, and that gets misdiagnosed as adult ADD, as we talked about. So, when we talk about that ADD issue, you were just mentioning this again, it’s not about ruling out "bipolar” and saying, Oh, no, it’s not bipolar because they’re like this all the time. You haven’t ruled it out because with manic-depressive illness mood temperaments, they are like that all the time. So, a lot of these ADD patients actually have cyclothymia. The same thing with GAD; they can have hyperthymia as well. The same thing with borderline patients; your mood is up and down all the time, cyclothymic. You have unstable relationships, cyclothymic, etc. The things that are different are the course of illness features I mentioned, which is childhood sexual trauma and self-cutting, would be the most prominent. Also, dissociative states are certainly different between the two. So, you have to rule out the cyclothymia, the hyperthymia, the manic-depressive illness before you even start talking about borderline personality, but you can rule it out, and maybe they don’t have the genetics, and they have the self-cutting, and they have the other features that would be more classic for borderline personality. I will say this about personality disorders in general. I don't think the concept is valid. It’s been living with us for 40 years, so it’s easy to accept it, but we just have to remind ourselves nobody ever thought of the concept; the term didn’t exist before DSM-III in 1980. The term for personality disorders was invented to create a place in the DSM for psychoanalysts to continue to practice. That’s the reason the so-called AXIS-II was invented. When DSM-III was going through the process of getting voted at the APA, there was suddenly, in the relatively later stages, a lot of resistance from the psychoanalytic establishment, which was in 1980, very powerful in psychiatry, and they would not pass DSM-III unless they put in a section that would be a way to allow them to get reimbursement for psychoanalytic therapy, which at the time was reimbursed by the way by insurance very well, and they invented personality disorders as a way to do that. The concept of borderline personality did exist beforehand; the concept of antisocial personality existed, but none of the other “personality disorders” existed before. The idea of the terms was there; people were called narcissistic, they were called dependent, they were called avoidant, they were called schizoid, but those weren’t viewed as personalities or personality disorders. So I would kind of say not just the issue about the hierarchy; I would just say that the whole concept is not proven or valid, and in fact, DSM-5’s personality disorders task force was going to take out all the personality disorders because most of them were disproven except for borderline and antisocial, and it was kept in only because of Jon Gunderson who founded the borderline concept and others through a letter writing campaign that led the board of trustees to change their minds. So, there wasn’t really a scientific reason for it. So, I think the concept of personality disorders is not a good one necessarily from a scientific perspective, and that's another reason not to have it high on the hierarchy when you’re using an invalid concept.

MARK RUFFALO: Well, Dr. Ghaemi, this has been very enlightening; a great history lesson for us and wonderful clinical insights. So, I really appreciate your time with us on the podcast today: Nassir Ghaemi of Tufts Medical Center, Harvard University, a world expert in bipolar disease, lithium therapy, and the philosophy of psychiatry. Thank you so much for joining us, Dr. Ghaemi; we really appreciate it. 

NASSIR GHAEMI: Thanks, Mark.

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