Learn how an understanding of patient’s temperament and the meaning of their life story can unlock psychotherapeutic avenues of treatment on our interview with Margaret Chisolm.

Publication Date: 01/27/2025

Duration: 18 minutes, 12 seconds

KELLIE NEWSOME: DSM diagnoses have a way of pointing us toward medications, but understanding the patient’s temperament opens up other avenues. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.  

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of The Carlat Report.  

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. 

CHRIS AIKEN: Last week, we spoke with Margaret Chisolm about the Perspectives method of assessment in psychiatry. It’s a pragmatic approach that looks at the patient’s problem through four different lenses. 

KELLIE NEWSOME: 1. Diagnosis – this is the medical model, including categorical diagnoses in DSM. 

2. Dimensions – these are traits that occur on a spectrum, such as introversion-extroversion, risk-taking, perseverance, and IQ 

3. Behaviors – this is everything the patient does, but particularly the stuff that becomes a habit or an addiction. The behavioral lens helps us understand eating disorders, addictions, and many sleep and sexual disorders. 

4. Finally, there is the life story perspective. Here, we are interested not just in the narrative story, but in what it means to the patient. This lens is a natural fit for grief, trauma, and job burnout. 

CHRIS AIKEN: These perspectives overlap. Take bipolar disorder. At its core, it is clearly a psychiatric disorder, a diagnosis (level 1). But, 50% of people with bipolar disorder have affective temperaments – a dimensional lens that affects their life as they continue with dysthymic, hyperthymic, irritable, or cyclothymic traits outside of their episodes. From the behavioral lens, bipolar episodes can pull people into behaviors that may continue as habitual patterns after their episodes end. Like someone who starts using cocaine during mania and develops a secondary addiction, or someone who stays in bed all day during depression and then has to restore their circadian rhythms – as well as rebuild their social life – as the depressive symptoms improve.  

KELLIE NEWSOME: And for the life story, just getting diagnosed with bipolar disorder is life-altering. It changes your identity, you have to rethink your life, all the manic and depressive things you’ve done, and the explanations you used to make sense of them. You have a psychiatric disorder with all the stigma it entails, one that is heritable, and that requires ongoing mood stabilizer therapy. 

CHRIS AIKEN: Or take ADHD. If your patient has been watching tic-tok, they probably come to you with a disease model in mind when they complain of inattention. But, not all that is inattentive is ADHD, and the Perspectives model helps here as well (particularly, the dimensional side). Inattention and impulsivity are symptoms of ADHD (the categorical disorder), but they are also normal psychological traits, and like most traits, they follow the bell curve. Some are very focused and can delay reward while they stick with boring tasks. Others are easily drawn to the new, the novel, and the rewarding, and give up on anything that is tedious. 

KELLIE NEWSOME: The behavioral lens may also explain ADHD symptoms. Sleep deprivation, lack of exercise, and an unhealthy diet all cause cognitive symptoms that can be indistinguishable from ADHD, and a new study of a quarter of a million people from the UK Biobank adds screen time to that list. Using a "Mendelian randomization" design – which mimics a randomized controlled trial by adjusting for genetic links – the researchers found it’s not just ADHD that keeps people glued to their screens. Screentime itself – on TV and smartphones - raised the risk of ADHD. In these next two episodes, we’ll talk with Margaret Chisolm about how to work with the lenses that lend themselves to psychotherapeutic interventions – the dimensional, behavioral, and the life story. But first, a preview of the CME quiz for this episode. 

1. According to Dr. Gualtieri, which temperament is most likely to experience worsening of symptoms with stimulant treatment? 

A. Dysthymic types 

B. Narcissistic types 

C. Obsessive-compulsive types 

D. Impulsive types 

Pay attention up ahead for the answer, and earn CME for each episode through the link in the show notes. 

CHRIS AIKEN: Can you give our audience some of your favorite questions to open up the door on these different perspectives? 

MARGARET CHILSOLM: I’ll start with the dimensional; it’s the most challenging, I think. So, I'm really using the Five-Factor Model – personality and inventory I don’t give that to people unless they want to take that test. You can get a free version; it’s abbreviated online. But generally, I’ve been doing it long enough that I have some questions that I routinely ask that I kind of know the variability of how people answer these questions. So, for the neuroticism, which is about strongly felt emotions, I might say, “Have you ever punched a wall or thrown something” or “Are you a sensitive person who feels things really strongly?” I might for introversion/extroversion ask them if they are say at a party and they say the wrong thing is that something that dwells on them, or is it like water off a duck’s back and they are quickly able to rebound to get at the question of whether they are present-oriented or past or future-oriented. Do they worry about what they are gonna say? Do they worry about what they just said, or are they sort of happy-go-lucky at a party? So, there are standard questions I’ll ask for those two. The openness is a little more challenging, but if people have interests in abstract activities, art, if they are risk takers, there are some questions that can get at openness, and then for agreeableness, I sometimes ask about flexibility. If somebody changes plans at the last minute, or is that something that you kind of have problems adjusting to.  I might for conscientiousness ask, especially if they live with someone, if they feel like their partner is always nagging them about picking up their socks or keeping things orderly. Or how they feel about promises, like if somebody breaks a promise is that a big deal for them. So, I have a number of standard questions I ask to get at the dimensional perspective. That usually emerges more with time. I also always like to have a collateral informant like a family member or friend to be able to ask some of these questions of them because if somebody’s in a depressed state they might say they are never the life of the party, they’ve never been the life of the party, and it’s not a valid recollection of who they are.  

KELLIE NEWSOME: There are many ways to assess temperamental traits. Here, Dr. Chisolm has focused on the Big Five personality traits, which are measured in the NEO Personality Inventory (NEO-PI). For a short version of the test, go to chrisaikenmd.com/neo. The five traits it measures are: 

1. Neuroticism: A tendency to experience negative emotions like sadness, anxiety, fear, and anger 

2. Extraversion: assertive, energetic, sociable, and optimistic 

3. Openness: curious, imaginative, and open to new experiences 

4. Agreeableness: cooperative, altruistic, and trusting 

5. Conscientiousness: organized, reliable, and self-controlled 

People with borderline personality disorder tend to be high on neuroticism, low on conscientiousness, and hot and cold on openness – sometimes showing high openness and sometimes showing low. 

There are other ways to understand temperament, like the four affective temperaments that are often seen in depression and bipolar disorder: dysthymic (always a little depressive), hyperthymic (that is, always a little hypomanic), irritable (kind of like a chronic mixed state), and cyclothymic – unpredictable moods that go in all directions. 

CHRIS AIKEN: Another one I’ve found helpful is the New Personality Self Portrait by John Oldham. Dr. Oldham co-chaired DSM-5’s workgroup on personality disorders, and he wrote this self-help book to help the public understand those diagnoses. It is short, sweet, and practical. It breaks from DSM by taking a dimensional view of personality and divides each into its normal and problematic form, in other words, you can have healthy narcissistic traits and not have narcissistic personality disorder, and if you have those traits, Oldham’s book gives a brief list of practical steps to manage them, and another page for the spouses who live with them. For obsessive-compulsive personality types, here’s a sample for obsessive-compulsive:  

1. Make a list of 10 relaxing, non-work-related activities 

2. Practice making decisions and taking action, even if you don’t have all the information, you need 

3. Try for results that are good enough 

4. Take time out from thinking 

5. Notice every time that you begin a sentence with “I should.” Try rephrasing these statements with “I want” or “I don’twant” 

6. Every time you find you’ve made a mistake, say to yourself, “Ah, I’m human!” 

7. Practice expressing your feelings to others. 

KELLIE NEWSOME:  Sound advice that a lot of us who work in healthcare could benefit from. I love the words Dr. Oldham came up with to describe the personality disorders in positive ways. So, Narcissism is the “self-confident style,” obsessive-compulsive is “Conscientious”, paranoid is “Vigilant”, borderline is “mercurial”, and antisocial? Well, if you’renot a hardened criminal but have a few antisocial traits, there’s hope. You’re just Adventurous. 

CHRIS AIKEN: Circling back to ADHD, I recently spoke with Dr. Tom Galteri about his new book, ADHD World and the Adderall Explosion. Tom has treated ADHD since the early 1970s, and he's seen it evolve from a rare disorder in hyperactive, disruptive children to something that most Americans contemplate they might have. His book, which is free right now on Amazon Kindle, walks you through all the various ways that patients can present with ADHD symptoms, including personality traits, task overload from taking on too much, stimulant addiction, brain fog from menopause or medical illness, or COVID. Dr. Galtieri, he's open-minded about using stimulants in some of these cases, as long as we watch out for their risks. He knows that many of these patients are helped by them, even if they don't have the classic 1970s version of ADHD, called, back then, minimal brain dysfunction. But, he warns that most of these patients do not need stimulants for life. They might use a brief course while they are learning new tasks at work, and that might be all that they need. But there is one personality type where Dr. Galtieri warns against stimulants, and here's where that dimensional perspective can help, even with pharmacotherapy, and that is the compulsive conscientious style. These patients are anxiously perfectionistic, and they are increasingly presenting with symptoms of ADHD as they doubt their own abilities. They might come in and say, I think I have ADHD, and when you do the full review, it turns out they missed one work assignment in the past year, or they got a B on one of their classes. Their anxiety can distract them and slow them down, and they often do procrastinate. They avoid tasks because of self-doubt and fears about not doing a good enough job. What Dr. Colteri has found is that stimulants often make their compulsivity worse. And I agree. Stimulants can make people perseverative. Doubt themselves and overthink things like in this study of professional chess players where they actually did worse when they took a stimulant Because the chess players ended up second guessing all their moves and they ran out of time, but Galtieri had another observation some of these patients complain of higher anxiety on the stimulant but others will ask for a higher dose even as their compulsivity is getting worse on it. They become obsessed with their own inattention, watching for any drop in the effects of the stimulant. They'll say, "Well, the Adderall is working great in the morning, but I can feel my drive kind of start to slip a bit around 3:30 in the afternoon. I think I justneed a little bit more to keep on going and keep that energy and keep working into the night". 

KELLIE NEWSOME: The heart of the dimensional view is helping patients to understand what makes them unique and how those traits influence the way they react to life stress. As the Greeks wrote on the Temple of Apollo: “Know Thyself.” Everyone has traits that can be strengths or weaknesses depending on the demands they are under and how they manage them. This is true for compulsive types who think they have ADHD because they got a B-minus, creative iconoclasts who think they have Autism, and people who fall somewhere in the borderline personality spectrum. 

CHRIS AIKEN: Here’s how you can use a dimensional approach to explain the Borderline diagnosis to a patient:“People with borderline personality usually get better when they understand how their symptoms get triggered in relationships. One of those symptoms is interpersonal hypersensitivity, and it reminds me of what you’ve been going through. For example, when your emotions get very intense, I get the sense that you don’t know what to do with them. When you share them with others, they react in ways that make you feel rejected, so much so that you become furious with the person who rejected you.” You can modify that depending on the patient’s traits, but the idea here is to connect their personality traits to the problems that brought them in. After you come to an agreement on the problem, work with the patient to set goals for treatment, but make them life goals, not symptom goals, like “I want to live on my own and not depend on my parents” or “I want to have stable friendships” rather than “I want to feel less anxious.” This tends to go better if you prioritize goals at work over goals in romance. People with borderline do better with structured relationships like we find at work, and they can fall apart in the ambiguities of love. Then, meet with the patient at least once a monthto review progress. Help them break the goals down into smaller steps, problem-solve to setbacks, and stabilize their successes (too often, they let their success fall apart, taking them for granted as they move on to something else). If you want to learn more about that practical approach to borderline, check out Lois Choi-Kain's work called Good Psychiatric Management of Borderline Personality. We have an interview with her in the June 2020 edition of The Carlat Report.

KELLIE NEWSOME: We’ll be back next week with more from Dr. Chisolm as she explores how to use the behavioral and life story perspectives. Margaret Chisolm is a professor of psychiatry at Johns Hopkins University. She has authored over 150 scientific papers and two books that explore the perspectives of psychiatry, one for professionals, Systematic Psychiatric Evaluation, and one for patients, From Survive to Thrive: Living Your Best Life with Mental Illness. Have you caught the January edition of the Carlat Report? It’s online, with articles on non-stimulant meds in ADHD and How to Diagnose Borderline Personality Disorder. Get $30 off your first year’s subscription with the promo code PODCAST. The Carlat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay free of commercial support.