What personality disorders, neurodivergence, trauma, addiction, and executive dysfunction can teach us about human adaptation

By Doc Tomiko

October 2026

There is a peculiar moment in the modern psychiatric experience when someone hands you a diagnosis and everyone in the room seems to think the problem has been treated.

You might be borderline. Or narcissistic. Or obsessive-compulsive. Or avoidant. You might have ADHD, autism, a dissociative disorder, a substance-use disorder, or some exhausting combination that makes your medical chart look like the contents of a junk drawer. The terms may be accurate. Some may be useful. A few might be lifesaving. But they leave me with a question that is embarrassingly basic for how often it goes unasked:

Why does this person respond to the world this way, and what would help them respond differently when they need to?

I’m not proposing that we throw the DSM into a wood chipper. The Diagnostic and Statistical Manual of Mental Disorders and the World Health Organization’s International Classification of Diseases are attempts to help clinicians speak a common language. That matters. An emergency physician, a psychiatrist, an insurer, and a researcher need some agreement about what a word means. I spent decades in information technology; I appreciate a standardized interface even when its implementation is ugly.

And as I learned earlier this week, my definition of “hypomanic” does not align with my shrink’s.

But an interface isn’t the machine. A diagnostic code is not a developmental history, a theory of causation, or an individualized treatment plan. You can describe a broken process accurately without understanding why it breaks, and you can correctly classify a person’s distress – or an aspect of it – without knowing what they actually need.

There is a second problem, less dramatic and probably more widespread: millions of people who would benefit from psychological skills never qualify for the particular disorder that happens to have a well-tested treatment attached to it. You don’t need a borderline personality disorder diagnosis to learn emotional regulation. You don’t need OCD to work on intrusive thoughts and rumination. You don’t need ADHD to benefit from strategies for executive dysfunction. You don’t need dissociative identity disorder to make sense of feeling like different people in different circumstances. And you certainly don’t need pathological narcissism to examine a self-image held together with duct tape and bravado.

So, I’d like to suggest a shift in perspective. Keep the diagnoses. Keep the research. Keep the treatments that work. But start looking at development, triggers, responses, context, and the ability to learn another response. A diagnosis is a map of one part of the territory. Perhaps we could use a map that shows the roads between those parts as well.

The Filing Cabinet Is Starting to Fall Apart

Traditional psychiatric classification was built largely around recognizable clusters of signs and symptoms. If enough of the expected features appear, persist for the required duration, and cause sufficient difficulty, a person may meet the criteria for a diagnosis. That’s a tremendous simplification of actual clinical assessment, but it captures the basic architecture.

I spent half my career studying taxonomies. Hell, I even developed one as a kid for my Lego collection. I learned a lot about when they are broken — or when you need more than one.

Unfortunately, human minds aren’t particularly cooperative about keeping their troubles in separate drawers. Someone can struggle with rejection, compulsive rituals, social exhaustion, unstable self-esteem, substance use, and problems starting the laundry, all on the same Tuesday. Some symptoms overlap across several diagnoses; other diagnoses each describe individuals whose underlying difficulties differ dramatically.

This is hardly a revelation to psychiatrists. The DSM-5 includes an Alternative Model for Personality Disorders, emphasizing impairment in functioning of the self and in relationships, alongside pathological personality traits. It’s an alternative framework, not the replacement for the familiar categorical criteria. The World Health Organization went farther with ICD-11: personality disorder is assessed in terms of severity, with trait qualifiers such as negative affectivity, detachment, dissociality, disinhibition, and anankastia — the tendency toward rigid standards and overcontrol. A borderline-pattern specifier remains available. 1 2 3

A model called the Hierarchical Taxonomy of Psychopathology, or HiTOP, goes after the problem from another direction, clustering symptoms and traits according to the way they occur together in real populations instead of presuming sharp boundaries between categories. The U.S. National Institute of Mental Health’s Research Domain Criteria (RDoC) framework studies domains such as threat response, reward, cognition, and social processes across levels from behavior to brain circuits. Neither is a quick replacement for the diagnostic manual on your clinician’s desk. They’re evidence that the field itself recognizes that our current labels don’t tell the whole story. 4 5

What I find interesting is that these efforts resemble something familiar to a software engineer: rather than asking which application threw an error, start asking which underlying service failed. Ten applications can all crash because they’re calling the same broken library. Equally, ten applications may throw the same error message for entirely different reasons. The error message is important; the stack trace is more informative.

Mental health isn’t software, obviously. Humans have the very inconvenient habit of changing their own code while it’s running. Nevertheless, the distinction between an observed symptom and its underlying mechanism seems worth borrowing.

This is not an argument that diagnoses are useless, or that clinicians merely administer a two-week questionnaire and call it a day. Good clinical evaluations already examine childhood, medical history, context, duration, and alternative explanations. But a screening instrument that asks about the past two-or-four weeks cannot, by itself, explain forty years of development. And healthcare systems frequently reward efficient classification more reliably than they reward the slower work of understanding a person.

Nobody Arrives as a Blank Slate

Here’s a proposition I want to be careful with: many behaviors that become troublesome in adulthood began as reasonable attempts to function in an earlier environment.

That does not mean every psychological condition was learned, every difficult childhood produces a disorder, or every parent deserves the blame. Human beings arrive with different temperaments, sensory systems, levels of emotional reactivity, attentional capacities, and biological predispositions. A person doesn’t develop autism or ADHD simply because their parents handled discipline badly. Nor does everyone who develops borderline traits have a history of childhood trauma. Biology and experience interact; neither gets a monopoly.

Children also don’t select their adaptation strategies from a menu. They try things. They learn from what relieves distress, produces approval, prevents punishment, or makes the world more predictable. Some lessons are explicit. Others become so deeply habitual that the adult may not even recognize the original question the behavior was answering.

Imagine a child whose worth seems tied to being exceptional. The adults praise their intelligence, display their achievements, and tell everyone what a brilliant future awaits. Then the child struggles, as children eventually do, and discovers that admiration does not necessarily include patience, protection, or the right to fail.

I know something about that arrangement. I was the conspicuously bright kid who could succeed spectacularly at certain things and stumble over others. In my family, praise and opportunity were not always dependable companions. Sometimes I was a source of pride. Sometimes I was an inconvenience. There were experiences of abuse, upheaval, and decisions by adults that I could neither prevent nor repair – and many were never fully explained. For a young person, that is a hell of a curriculum.

I am not presenting my childhood as a laboratory experiment with a sample size of one. It cannot tell us what causes a personality disorder. It can tell us why the proposition feels worth investigating: a child can become practiced at proving themselves, anticipating danger, managing the adults, or refusing to need anybody. Those skills may keep the child afloat. The adult may continue using them long after they board a new ‘ship.

The popular term gifted-child syndrome doesn’t name a recognized clinical disorder. Gifted children aren’t inherently pathological, and perfectionism is not the inevitable price (or prize) of intelligence. But it’s perfectly reasonable to ask what happens when ability becomes the condition of acceptance. A brilliant child can learn that failure is unforgivable; a less conspicuous child can learn the very same thing. The mechanism interests me more than the prestige of the label.

A 2015 longitudinal study by Brummelman and colleagues made an especially important distinction. Parental overvaluation — teaching a child that they’re more special and entitled than others — predicted later narcissistic traits, while parental warmth predicted self-esteem. That complicates the appealing story in which every inflated ego is merely covering a secret conviction of worthlessness. Some self-protective grandiosity may be compensatory; some sense of superiority may be taught more directly. Different paths can reach similar destinations. 6

Now add the influences we cannot see so easily: inherited disposition, siblings, peers, teachers, romantic partners, economic circumstances, potential disabilities, discrimination, physical illness, and sheer dumb luck. What happens to a person isn’t a single event. It’s an ongoing negotiation between the person and their world.

A particularly useful 2024 meta-analysis by Cavicchioli and colleagues combined 106 studies involving 86,871 participants to examine factors preceding borderline personality features. Earlier psychological difficulties, invalidating relational experiences, and problems with emotional and behavioral regulation all showed meaningful associations with later features. The authors explicitly supported a transactional developmental model: vulnerability, relationships, and regulation affect one another over time. 7

I rather like that expression. It isn’t meant the way it gets tossed about when we talk about narcissists – though sometimes that can be a part of it. Transactional means the person is not merely a passive recipient of their environment, and the environment is not merely a passive backdrop. Each changes the other. The child who expects rejection may react defensively; the resulting conflict may invite more rejection. The child who earns approval by performing may become ever more terrified of failure; the adults may reward the performance even more vigorously. The behavior becomes part of the environment that reinforces it.

And thus a survival strategy becomes a personality pattern—perhaps an effective one, perhaps a disastrous one, often both depending on the circumstances.

The Trigger Matters as Much as the Reaction

In February 2024, Martin Blay and colleagues published a paper in Frontiers in Psychiatry with the gloriously academic title “Proposition of a transdiagnostic processual approach of emotion dysregulation based on core triggers and interpersonal styles.” It’s a hypothesis-and-theory paper, not an experiment that proves a master explanation of human suffering. Nevertheless, I think they are asking exactly the right kind of question. 8

Their starting point is that emotional dysregulation is not the exclusive property of borderline personality disorder. They examine it across borderline and narcissistic presentations, obsessive-compulsive personality disorder, antisocial personality disorder, bipolar disorder, autism, complex PTSD, and adult ADHD. Instead of stopping at this person became intensely upset, they ask what tends to trigger the upset and how the person characteristically responds to others.

A perceived abandonment might provoke frantic reassurance-seeking, anger, or withdrawal in someone with a borderline pattern. A threat to self-esteem might provoke shame, grandiosity, contempt, or a demand for admiration in someone with pathological narcissism. Perceived loss of control or deviation from rigid standards may provoke overcontrol in someone with an obsessive-compulsive personality pattern. Autistic overwhelm may follow sensory demands, unexpected change, or social overload. ADHD-related dysregulation may emerge in contexts of frustration, impatience, task demands, or poor inhibitory control.

And – perhaps most importantly overlooked – any of those of us who haven’t got these disorders may have exactly the same response under specific conditions. Skinner would be proud. The organism will do whatever the hell it wants.

These are simplifications of a much richer table, but the principle is straightforward.

Two people can look furious from across the room while having radically different problems. One thinks they’re about to be abandoned. Another thinks they’ve been humiliated. A third is trying to think through six competing conversations while somebody moves the furniture. If you respond to all three as though they have the same condition, you may miss the thing that needs attention.

This also helps explain why our informal vocabulary has become increasingly crowded. People discuss vulnerable narcissism, covert narcissism, quiet BPD, and other variations as if the old categories have spontaneously developed DLC packs. Some of these terms refer to important patterns in the research; others are loose community shorthand. They are not all distinct diagnoses in the DSM.

Take pathological narcissism. There is real literature on grandiose and vulnerable expressions, and the same person may experience both kinds of states. A 2024 systematic review found substantial evidence associating vulnerable narcissism with difficulties in emotional regulation, but much less consistent evidence for a comparable relationship with grandiose narcissism. That is a warning against the attractive assumption that every outwardly superior person is merely hiding the identical injury underneath. 9

Or consider so-called quiet BPD. A person may direct distress inward, conceal anger, withdraw, or blame themselves rather than display the explosive interpersonal behavior that makes for popular caricatures. The absence of a public spectacle does not prove the absence of suffering, nor does it establish a separate disorder. We need to examine the actual pattern and trigger instead of deciding who qualifies based on who is making the most noise.

Attachment theory is useful here, but I would resist using it as a master key. Anxious, avoidant, and disorganized attachment patterns concern expectations and behavior in relationships; a diagnosed personality disorder is a different kind of construct. They can be related without being interchangeable. Moreover, avoidant attachment, avoidant personality disorder (traditionally Cluster C), autistic overload followed by disengagement, and the ordinary human habit of avoiding unpleasant situations are four different things. A reluctance to answer a difficult phone call is not a clinical diagnosis, although I suspect telephones have been responsible for a great deal of unrecorded psychological suffering.

Complex PTSD provides another instructive overlap. It can involve emotional regulation difficulties, negative self-concept, and relational disturbance, all of which may resemble features associated with borderline pathology. But evidence also suggests differences in their interpersonal organization; a 2026 systematic review found partially distinct patterns of association for complex PTSD and BPD. The overlap is worth studying precisely because the distinctions may affect treatment. 10

For completeness, Cluster B also includes histrionic and antisocial personality disorders. Attention-seeking may sometimes function to obtain connection or validation. Aggression, manipulation, or disregard for others may sometimes be reinforced by an environment where those tactics work. But I would be very suspicious of a theory that assumes every callous or predatory act conceals an abandoned child desperate for a hug. Temperament, reward sensitivity, social learning, and individual choice can differ. A genuinely unified framework must be able to explain differences without compassionately erasing them.

This leaves us with a useful distinction: shared difficulties don’t prove a shared cause. Anxiety, withdrawal, irritability, and executive difficulties are common outputs. We still need to know what set them in motion, and what keeps them going.

There is new quantitative support for that broader view. In 2026, two substantial meta-analyses examined emotion regulation across psychiatric conditions. One, by Clamor and colleagues, brought together 619 studies and found broad transdiagnostic difficulties in emotion regulation, with meaningful disorder-specific differences. Another, by Sloan and colleagues, analyzed 188 studies across major diagnostic groups and likewise found widespread impairments — but not identical profiles. These are evidence that a problem can recur across diagnoses without becoming the same problem in every person. They are not studies proving my particular model. 11 12

A Spectrum of Control, Not a Contest in Being Normal

Now let’s talk about a different axis: rigidity, perfectionism, and the attempt to control uncertainty.

I can think of three people who insist on doing something in exactly the same order. To a casual observer, they appear equally inflexible. But one is experiencing intrusive, unwanted thoughts and feels driven to perform a ritual to relieve anxiety. Another believes the procedure is objectively correct and that everybody else should stop cutting corners. A third finds the predictable sequence comforting, accessible, and conducive to getting through the day without unnecessary sensory or cognitive strain.

Those people might be experiencing aspects of OCD, obsessive-compulsive personality disorder, or autism, respectively. They might also have none of those diagnoses, or more than one. The outward behavior is not enough to tell us which.

OCD often involves unwanted obsessions and compulsions that temporarily relieve distress. People commonly recognize something is excessive, though insight varies and can be poor. Obsessive-compulsive personality disorder, historically called anankastic personality disorder in some classifications (though my reading of it says, “management scientist from ‘Cheaper by the Dozen'”), centers more on pervasive perfectionism, orderliness, and control; the standards may seem reasonable or morally necessary to the person imposing them. Autistic routines can serve predictability, enjoyment, sensory regulation, and accessibility. A routine is not automatically a compulsion, and an autistic person’s desire for consistency isn’t evidence that they think everyone else is wrong. 13 14

The distinctions matter, because the right response can be very different. Someone trapped in a compulsive checking cycle may benefit from exposure and response prevention, a well-supported treatment for OCD. Someone whose perfectionism is destroying relationships may benefit from examining the beliefs, self-control, and fears underpinning that standard. Someone who relies on familiar routines to manage a disability may need accommodations — not a program designed to make them tolerate endless arbitrary disruptions. 13

A 2026 study comparing 51 autistic women and people assigned female at birth with 51 people diagnosed with BPD found differences in sensory processing and preference for sameness on the autism side, and more pronounced identity disruption and rejection sensitivity in the BPD group. The study selected participants with few traits of the comparison diagnosis and used self-report questionnaires, so don’t turn it into an all-purpose diagnostic sorting hat. What it illustrates is that two outwardly similar presentations may have different internal organizing problems. 15

And sometimes the similarity goes the other way. A person with executive dysfunction might become a fanatic for schedules because, without them, nothing gets done. Someone raised in chaotic conditions might keep a meticulously ordered home because unpredictability still feels dangerous. A perfectionist might avoid beginning a task because they cannot bear doing it badly. A seemingly disorganized person might respond to an overwhelming world by becoming controlling in their relationships. People are messy. This is why a framework based on visible behavior alone will always leave us with false equivalences.

Of course, some degree of consistency is essential to civilization. I would not want my surgeon to be spontaneously creative about sterile procedure, or the airline mechanic to decide that torque specifications are merely another expression of oppressive social norms. Rules and routines can be things of beauty. There is a reason we have procedures, checklists, and standards.

The question isn’t whether a person has a rule. It’s whether the rule is appropriate to the situation, proportionate to the stakes, and revisable when circumstances warrant.

People sometimes treat psychological flexibility as though it means becoming agreeable, cheerful, and entirely indifferent to what happens around you. That’s nonsense. Sometimes a person needs flexibility; sometimes they need tenacity. Sometimes the most adaptive thing a person can do is refuse to budge while everyone around them insists on doing something stupid or cruel.

The world is full of different weather. Dress appropriately.

A raincoat isn’t a moral failure. Neither is carrying an umbrella, moving indoors, or deciding that the weather is bad enough to cancel the picnic. But if you wear the same raincoat to bed, to the beach, and into a blast furnace, the original good idea has perhaps become a less useful habit. Tell that to my friend who wore polyester briefs while fighting a housefire.

There is a real therapeutic literature on this distinction. Radically Open Dialectical Behavior Therapy (RO DBT) targets maladaptive overcontrol — including excessive inhibition, rigidity, and difficulties with social connectedness—rather than simply treating every patient as insufficiently controlled. A 2024 systematic review found emerging evidence but also significant research limitations; we should not present RO DBT as a proven universal solution. I regard its existence as an encouraging sign that clinicians are beginning to ask whether some people need less control while others need more effective ways to regulate themselves. 16

DBT (typically used to treat BPD) and RO-DBT (used for eating disorders, OCD, autism, avoidant, dependent, and paranoid disorders) are opposite ends of the same spectrum of behavior – not from 0 to 10 but from -10 to 10.

I feel like I could waste entirely another essay on ABA and the tendency to say “Don’t do this. It’s bad.” without explaining why and when? That is kinda the crux of my whole argument. The circumstances matter more than the outward presentation.

And that, I think, is a better question than asking whether a rigid person has managed to look normal enough in public today.

Executive Dysfunction: The Invisible Load on the System

The trouble with the word functioning is that people tend to judge it from the outside.

A person can have a beautiful résumé and a disastrous kitchen. They can engineer a complex database and then spend four hours trying to make a dentist appointment. They can manage a crisis with poise, then become incapable of choosing what to have for dinner. They may be able to complete a complicated task on demand yet fail repeatedly at the simple task that comes just before it.

This isn’t necessarily laziness, although laziness is certainly a convenient thing for observers to diagnose. Executive functions include planning, prioritizing, working memory, task initiation, inhibition, and the capacity to shift attention or strategy. When those functions become unreliable, the person may construct compensations: alarms, lists, rigid procedures, avoidance, perfectionism, external deadlines, or dependence on another person to organize the day.

But linger a moment on every time that I spent 2 weeks on some crazy-ass moonshot process, while not filling in my timesheet or loading the dishwasher. That’s not laziness, is it?

Those compensations can work very well. They can also become problems. The adult who cannot begin unless every detail is perfect may actually be defending against an executive bottleneck: if the first step is uncertain, the entire task freezes. Someone who appears compulsively organized may have learned that one missed appointment can bring a week of cascading consequences. Someone who looks oppositional may simply have run out of cognitive capacity before the conversation even started.

And – someone with perfectly functional coping mechanisms to keep them from falling off the wagon might forget all about them the first time a family member has a medical emergency.

ADHD is one important developmental route to executive difficulties, and its diagnostic framework requires evidence of childhood onset, even though many adults are not identified until much later. But ADHD does not own executive dysfunction. Depression, anxiety, trauma, sleep deprivation, neurological illness, medication effects, addiction, and ordinary overload can interfere with similar capacities. Nor are all executive problems reducible to a single impairment in the same brain region. 17

This is personal territory. I can spend hours doing difficult technical work because the problem has enough structure and interest to hold my attention. The less glamorous work of keeping life organized has often demanded considerably more ingenuity. For years I could build systems that other people relied upon while struggling to maintain the smaller systems that were supposed to keep me going. It turns out competence isn’t uniformly distributed across all possible tasks, and no amount of telling somebody they’re intelligent will magically supply the missing scaffolding.

Here is the practical opportunity: you can teach task decomposition, environmental design, pacing, and alternative routines to someone who doesn’t have ADHD. You can examine perfectionism, avoidance, or shame without insisting the person first qualify for a personality disorder. And when the impairment is neurodevelopmental or medical, you can provide accommodations or appropriate treatment rather than endlessly demanding greater effort.

If your car is stuck in mud, it may need traction, not a motivational lecture.

Identity, Dissociation, and the Limits of a Single Story

I want to include dissociation without forcing it into a theory about personality disorders, and without assuming that every unusual experience of identity is an illness.

Dissociation encompasses disruptions or discontinuities in experience, memory, attention, perception, and the sense of self. Some experiences are ordinary and mild, such as becoming lost in a book or driving on autopilot. Others can be profoundly disruptive. Dissociative identity disorder has specific clinical features involving distinct identity states and recurrent gaps in memory, together with clinically significant consequences. It isn’t simply a diagnosis for anyone who experiences themselves as having multiple facets, or for anyone whose demeanor changes between work, home, and the bedroom. 18

People may also describe themselves as plural. Their experience and preferred language deserve to be heard, rather than automatically treated as something to be corrected. In clinical work, the important questions concern agency, safety, distress, involuntary disruption, amnesia, relationships, and what the individual actually wants help with. It would be perverse to claim that care must first erase a person’s account of their own experience before it can be considered successful.

Gee, I wouldn’t know anything about that.

Dissociation is also frequently discussed in relation to overwhelming experiences and trauma, and it can coexist with borderline features or complex PTSD. But the exact developmental mechanisms of DID remain contested. A 2024 review of research from 2011 to 2021 found a literature with methodological limitations that constrain strong generalizations, particularly about causes. We should neither dismiss the people living with dissociative disorders nor claim that the science has already explained everything. 19

My proposed framework treats dissociation as a potentially important response to investigate, not proof of a particular origin story. When someone compartmentalizes memories, emotions, or senses of self, we can ask what circumstances influence that process, whether it is voluntary, whether it creates difficulties, and what supports better day-to-day functioning. Those questions may be useful without deciding that every such experience is an expression of DID or BPD.

And for those who don’t have a dissociative disorder? Many of us still need to reconcile conflicting values, identities, roles, and ways of behaving. You can be the reliable professional, the exhausted caregiver, the terrified child still reacting to an old injury, and the stubborn adult who wants nothing to do with the whole damned mess. Learning to understand those differences doesn’t require a pathology code.

Addiction Is Not Merely the Coping Strategy

If we’re serious about building a framework around triggers, regulation, and reinforcement, we cannot leave addiction sitting outside the conversation as though someone spilled a drink on the research protocol.

Alcohol and other substances can provide immediate relief from distress, social anxiety, physical discomfort, or an unbearable amount of mental noise. That is one reason they can be appealing. A person discovers a remarkably effective short-term answer to a difficult feeling, and repetition teaches the brain to expect the answer again.

Or sometimes they just want to find the hammer so they can break-glass-in-case-of-emergency. Sometimes, self-harm is the feature, not the bug. Just sayin’.

But dependence is not simply a learned preference for a convenient coping skill. With repeated heavy alcohol exposure, reward, stress, habit, and executive systems can change. Drinking may shift from seeking pleasure to relieving the negative state produced or intensified by withdrawal. The behavior feeds the biological conditions that help sustain the behavior. The National Institute on Alcohol Abuse and Alcoholism describes this as a cycle involving intoxication, withdrawal and negative affect, and anticipation or craving. 20

And, I haven’t ruled out the notion that the gut-biome might be sending signals up the Vagus nerve to the brain to say “Hey, butler, can we get a little more booze down here? It ain’t a party without alcohol!”

That is a transactional model with teeth.

I’ve spent enough time looking at my own alcohol habits to know that the explanation I drink because I am stressed is not remotely sufficient. A useful account must also ask what happens at particular times of day, what the body expects, which routines cue the next drink, what other sources of relief are available, and what physiological risks accompany change. I have kept records, tried to identify patterns, and learned how much difference there is between deciding to change a behavior and successfully changing the system that supports it.

I don’t offer that as a triumphant recovery narrative. It is simply an example of the difference between describing a behavior and understanding its maintenance. If you ignore the biological feedback loop, you’re going to miss an enormous part of the problem. If you ignore the person’s reasons for reaching for alcohol in the first place, you may leave the original distress untouched.

A 2023 review by Stetsiv and colleagues examined the overlap of personality disorders and substance-use disorders, discussing shared vulnerabilities and reciprocal influences. We shouldn’t assume that every person with an addiction has a personality disorder or that treating emotional regulation alone will resolve a substance dependence. What the overlap demonstrates is that diagnostic categories are not independent compartments in the living person. 21

There is a practical boundary here. For someone who is physically dependent on alcohol, withdrawal can be medically dangerous. That is not an occasion for a heroic experiment in sheer willpower or an improvised exposure exercise. Appropriate medical assessment and treatment matter. Evidence-based AUD care can include medications such as naltrexone or acamprosate, gabapentin, topiramate, SSRIs (personally, I recommend Buspar, if you have a love-life), behavioral treatment, and other supports, individually or in combination. Teaching coping skills is a complement to addressing the addiction’s biology, not an alternative to it. 22

And, that’s just the booze. I haven’t even laid into prescription meds, cannabis, heroin, or other controlled substances — and I wouldn’t fuck that with *your* dick right now, because that is not the point of this article.

Addiction shows how incomplete the simple division between neurological and learned really is. A learned behavior changes the nervous system, and changes in the nervous system alter what a person learns and how they behave. The relationship runs in both directions.

The Family Resemblance That Refuses to Explain Itself

I have another reason to resist a neat story in which everything starts with bad parenting and ends with learned maladaptation. I’ve watched patterns recur across families in ways that don’t obey that simple explanation.

I once had an ex-wife whose behavior, in the 1990s, was understood by many of us through the language we had at the time. A practitioner at the time identified pathological lying as a problem, and likelihood of rapid-cycling bipolar disorder. I’m not retroactively promoting that description into its own DSM diagnosis — pathological lying is not a standalone personality-disorder category — and I’m not claiming access to every clinical conclusion that might have been reached. I’ll tell you what I understood then, from a very close vantage point. I want to be compassionate about it, assuming that’s even possible now.

However, I will add that we were tempted to re-enact a certain Sam Kinnisen joke, by filing a name-change application at the local courthouse, and I’m not the only one. There are independent witnesses.

Looking back from the present, parts of the pattern invite different questions. Were those shifts actually discrete mood episodes, or were they rapid reactions to interpersonal events? Was avoidance more central than we recognized? Could borderline features, or some mixture of problems, better account for the behavior? I cannot make a diagnosis from old memories, and I wouldn’t trust someone who pretended they could. But I can recognize that our explanation in the 1990s may have been – perhaps grossly – incomplete.

To be precise, rapid cycling in bipolar disorder means four or more distinct mood episodes in a year; it doesn’t simply mean that a person becomes furious at breakfast and cheerful by lunch — and every month, perhaps on the day, should be taken as something else entirely. (Maybe “lycanthropic disorder”, idek, jk/hk, anway…)

Bipolar disorder involves recognizable episodes of altered mood and energy or activity and often responds to appropriately selected medications (non-compliance as a confound, notwithstanding). Borderline personality disorder more characteristically involves enduring difficulties with emotional regulation, self-concept, and relationships, and psychotherapy is its primary treatment. The two can coexist, and neither diagnosis is reducible to a slogan. 23 24

What has troubled me more, in retrospect, is the apparent family resemblance in avoidance. I observed avoidant patterns in her father, in her, and later in her biological daughter, who was not raised by her. That last detail is particularly awkward for the simplest version of a parenting-based theory. If a child grows up apart from the person whose behavior they resemble, direct modeling by that person cannot explain the entire resemblance.

But neither does that observation prove a particular gene or neurobiological pathway. Other family members, temperament, limited-but-significant exposure, different-but-comparable experiences, shared cultural norms, selective memory, and my own interpretation all complicate the story. The child also had two other parents, another household, and a life full of influences that a short anecdote cannot capture. Three generations aren’t a genetic study, and the fact that I knew them personally doesn’t turn them into one.

Still, the observation should make us curious rather than defensive. A large 2026 genome-wide association study identified genetic signals associated with BPD and genetic overlap with conditions including PTSD, depression, and ADHD. The study’s discovery and replication samples were restricted to people of European ancestry, a limitation we ought to take seriously. Its results do not identify a deterministic personality gene or establish that any particular relative inherited a specific disorder. They do help demolish the idea that borderline pathology is merely learned, while bipolar disorder is somehow the only biologically respectable condition in the conversation. 25

Both biology and experience are real. Both can shape the way a person responds to the world. And because experience changes the brain, trying to divide psychiatric phenomena into neurological on one side and learned on the other is a rather poor way to draw the map.

All this, said from the PoV of someone who later had a relationship with a bipolar-type-schizophrenic person for over 13 years.

This is a useful kind of uncertainty. It isn’t an excuse to declare the whole subject unknowable. It’s a reason not to mistake a plausible explanation for an established mechanism, especially when you’re talking about people who are no longer present to tell their side of the story.

The Chaos God, the Control Freak, and a Shared Household

Suppose an autistic person who relies heavily on routine chooses to live with a family whose operating philosophy seems to be that every day should bring a new and preventable catastrophe. Suppose they even cheerfully adopt the mantle of the household’s chaos god. Is this adaptation, a terrible decision, or a little of both?

I suspect it depends on what happens next.

The predictable household may be comfortable but leave someone with very little practice handling change. The chaotic household may provide opportunities to learn, improvise, and discover that not every interruption is a calamity. It may also deliver so much sensory, emotional, and executive overload that the person spends their days barely keeping their head above water. We cannot know which from the label autistic, or from the label chaotic, or from the fact that everyone seems to be having a lovely time at dinner.

Here’s a possibility I find more interesting than demanding that one person change: reciprocal adaptation.

The person who needs predictability can experiment, at a tolerable pace and by choice, with changes that broaden their practical options. The household can learn that constant unpredictability is expensive, and that some changes are entirely unnecessary. Routines can be protected where they genuinely help. Surprises can be announced where possible. Emergencies can be distinguished from somebody’s sudden enthusiasm for rearranging the living room at 3 a.m.

In other words, the rigid person may gain flexibility while the chaotic environment gains structure. Neither side wins by forcing the other to live permanently in the conditions they find hardest.

This is where our theory has to distinguish impairment from social nonconformity. Being queer, trans, visibly different, socially unconventional, disabled, unusually introverted, or plural is not evidence that someone’s adaptation is defective. A person who refuses to conform to an unjust expectation might be the healthiest participant in the room. (I’m looking at you, Number Six.) Conversely, someone who has learned to cope by intimidating everyone around them doesn’t become immune to accountability merely because the behavior has an understandable history.

The test cannot be does this person make the majority comfortable? The test has to include distress, agency, actual harm, context, and the person’s chosen goals. Treatment should expand the individual’s capacity to live a life they want, not simply produce better compliance for whichever family, employer, or institution happens to have power over them.

Sometimes the appropriate intervention is helping someone tolerate a change. Sometimes it’s providing sensory accommodations, reducing workload, changing the household’s habits, repairing a relationship, or leaving an unsafe situation. Sometimes it means stubbornly holding a boundary that the rest of the world finds inconvenient.

Sometimes that breaks a family apart.

A flexible system need not surrender its principles. A resilient person need not enjoy chaos. And a well-regulated person is not one who quietly accepts mistreatment with a serene smile.

Diagnosis Is Useful; Formulation Should Do More

So what do we do with this collection of overlapping traits, learned strategies, biological predispositions, and interpersonal feedback loops?

We could invent a new grand unified disorder and give it a magnificent name. Then we could spend twenty years arguing over its diagnostic criteria, writing screening questionnaires, and splitting it into subtypes. Perhaps some future psychiatrist would collect them all like Pokémon. I suspect that would reproduce the problem we’re trying to solve in the moment.

I’d rather propose a developmental, process-oriented case formulation that sits beside the diagnosis instead of replacing it. In ordinary language, I want clinicians and patients to develop a working explanation of how the person got here, what keeps the difficulty going, and which changes might help.

The formulation should examine several things together. There is the person’s neurodevelopmental and temperamental starting point. There is their developmental history, including opportunities for safety, attachment, competence, and belonging. There are their current circumstances. There are specific triggers, the meanings they assign to those triggers, the body’s and mind’s reaction, the learned response, and the consequences that reinforce or weaken that response. Then there are the person’s own goals and their capacity to try something different.

To put that in the language of an engineer, don’t merely collect error logs. Build a model of the system, test what happens under load, identify the causes of failure, and find out which changes actually improve performance. Be prepared to revise the model when your first hypothesis turns out to be bullshit.

The formulation might sound like this: When my partner becomes quiet, I interpret that as rejection. My fear spikes, I demand reassurance, the conversation becomes hostile, and my partner withdraws. Their withdrawal makes my original fear appear correct. That’s an understandable feedback loop, and a potential target for treatment. Whether the person meets criteria for BPD is clinically relevant, but the loop is meaningful in its own right.

Or: When I don’t understand the first step of a task, I anticipate failure. I start gathering more information to avoid doing the task badly. The preparation becomes endless, the deadline approaches, and I feel even less capable. I may even delay starting until I truly believe I haven’t enough time to finish, then burn myself out to get it done on time. This could involve executive dysfunction, perfectionism, anxiety, ADHD, or several of them. Naming the loop creates possibilities that the vague accusation you’re procrastinating does not.

Or: A sudden schedule change overwhelms me because I cannot reorganize the day’s demands quickly enough. Other people interpret my distress as anger at them. Their reaction adds interpersonal pressure to the original cognitive overload. Then, I respond, because now I have reason to be angry. Again, the point is not to choose the diagnosis by intuition. It’s to find an account accurate enough to guide a response.

Importantly, the model must include what is working. Some habits should be protected. Some boundaries should be strengthened. Some routines are accessibility tools. Some forms of persistence have kept people alive.

A therapist who sees every protective strategy as something to extinguish may do as much harm as the person who refuses to examine any of them.

Likewise, a therapist who fails to accurately account for the interactions between multiple people is committing malpractice.

Teach the Skill, Treat the Mechanism, Change the Environment

This isn’t merely a theoretical exercise. It has implications for what happens after the diagnostic appointment.

Dialectical behavior therapy (DBT) was developed for people with BPD, but its tools — mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation — aren’t valuable solely to people who qualify for that label. Someone with narcissistic vulnerability may need help tolerating shame and threats to self-worth. Someone with an avoidant pattern may need safer ways to enter relationships without immediately retreating. Someone without any disorder at all may need help making a difficult conversation less of a demolition derby.

That does not establish that DBT has equal evidence for every one of those conditions. Nor does it imply that the entire treatment program should be transplanted indiscriminately into a different disorder. The more careful proposition is that a clinician should identify the mechanism being targeted, select interventions with appropriate evidence, and measure whether they work for this person.

For OCD, that may specifically mean exposure and response prevention, not merely general advice to relax. For a bipolar disorder, accurate identification and medical treatment of mood episodes are essential, while psychotherapy may help with coping, adherence, and daily life. For ADHD, medication, executive-function supports, and environmental accommodations may be appropriate. For AUD, medical and behavioral interventions must address dependence and reinforcement. For overcontrolled personality patterns, RO DBT may be relevant, although its research base is less mature than those of some established treatments. The common framework is intended to improve selection, not flatten clinical distinctions. 13 16 17 22 23

Acceptance and commitment therapy (ACT) offers a related language: psychological flexibility, values, and committed action. A 2024 meta-analytic review found that ACT could improve dimensions of flexibility and that these changes were associated with reductions in distress, though the strength of the evidence varied across study designs and settings. To me, the idea of committed action is particularly important. Flexibility does not mean yielding to every passing breeze. It means being able to respond to circumstances while pursuing what actually matters to you. 26

A real treatment plan might therefore involve several kinds of change at once. First identify the troubling pattern accurately, including its triggers and history. Then address conditions that require specific treatment — medication where supported, withdrawal management where necessary, trauma care, sensory accommodations, or supports for executive limitations. Learn alternative responses in circumstances that are safe enough to practice them. Finally, change the reinforcing environment where possible, so that doing the healthier thing doesn’t require fighting the same unwinnable battle every day.

And yes, sometimes treatment needs to address the other people. If someone’s response is being reinforced by abuse, manipulation, an impossible workload, or repeated violations of their boundaries, teaching them to tolerate it more gracefully is not an adequate solution. We must be willing to ask whether the person should change, the environment should change, or both.

I also want to distinguish the ability to change from the willingness to change. Some patterns are so deeply engrained, and some executive, emotional, or biological limitations so consequential, that changing them is genuinely difficult. That calls for support, practice, treatment, and perhaps accommodation. Other people are capable of changing particular harmful behaviors but unwilling to examine them. Their history may explain the response without excusing what it does to everyone else. Understanding isn’t absolution.

Nor should we pretend that longstanding personality problems are automatically permanent. A major ten-year longitudinal study found that many people diagnosed with BPD achieved symptom remission, although social functioning often improved more slowly. Remission and full recovery are not identical outcomes, and progress can be uneven, but this is a far cry from the fatalistic image of an untreatable character defect. 27

Perhaps the most consequential part of this argument, however, is what happens before someone qualifies for a diagnosis. Psychological skills shouldn’t be withheld until a person becomes sufficiently impaired to satisfy a billing code. Teaching people to recognize emotional triggers, develop executive supports, challenge destructive perfectionism, handle conflict, tolerate intrusive thoughts without obeying them, and identify when they need accommodation could prevent avoidable suffering. It could also help people who simply want a more capable relationship with themselves and their neighbors.

So, TL;DR, let us stop talking about the “worried well” and actually start helping everyone.

That is not a promise that a self-help workbook can replace psychiatry. It is a refusal to concede that useful knowledge belongs exclusively to the already-ill.

A Better Question Than “What’s Wrong With You?”

This is the point where I’m supposed to announce a grand unified theory, ideally with an acronym and a diagram impressive enough to hang over a university department’s coffee machine. Sorry. I don’t think we’ve earned that.

Not that you’d accept my credentials from the School of Hard Knocks anyway.

The evidence supports substantial overlap among emotional regulation problems, developmental vulnerabilities, personality traits, and learned coping patterns. It supports the usefulness of examining triggers, functioning, and context. It also makes clear that autism, bipolar disorder, dissociation, OCD, personality disorders, and addiction retain important differences in their mechanisms and treatment. An observational association isn’t a causal demonstration; a persuasive personal history isn’t a controlled study; and a tidy model isn’t necessarily a true one.

What I am proposing is less grandiose and, I hope, more useful: a working habit of asking what a behavior does, where it came from, what keeps it going, and whether there is a better response available now.

Sometimes the answer is to learn a new skill. Sometimes it’s to use medication or specialist treatment. Sometimes it’s to install a checklist, leave a damaging relationship, set a boundary, or stop demanding that a neurodivergent person perform normality for the comfort of observers. Sometimes the strategy that got us through childhood deserves a respectful retirement — sometimes it deserves a promotion.

We are not required to become infinitely flexible creatures with no convictions, limits, or familiar comforts. We need to recognize the problems we’re actually facing, distinguish them from yesterday’s problems, and expand the range of choices we can make about tomorrow.

If you cannot recognize a problem, you cannot begin to fix it. If you cannot understand your old solution, you may keep applying it long after it stops working. And if you can’t imagine another response, a diagnosis alone won’t give you one.

The world is full of different weather. Dress appropriately.

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Sources and further reading

The following sources support specific factual statements and help frame the argument. They do not collectively establish the essay’s proposed unifying formulation; the synthesis and its limitations are my own. Research and diagnostic standards continue to evolve.

1. American Psychiatric Association. Alternative DSM-5 Model for Personality Disorders. Focus (2013). The DSM-5 alternative framework for self/interpersonal functioning and traits.
2. World Health Organization. Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (2024).
3. Bach, B., and First, M. B. Application of the ICD-11 Classification of Personality Disorders (2018). Overview of severity and trait qualifiers.
4. HiTOP Consortium. The Hierarchical Taxonomy of Psychopathology: The Framework.
5. National Institute of Mental Health. RDoC Domains and Constructs.
6. Brummelman, E., and colleagues. Origins of Narcissism in Children. PNAS (2015).
7. Cavicchioli, M., and colleagues. Antecedents and Risk Factors for Borderline Personality Disorder: Etiopathogenic Models Based on a Multi-Level Meta-Analysis. Journal of Affective Disorders (2024).
8. Blay, M., and colleagues. Proposition of a Transdiagnostic Processual Approach of Emotion Dysregulation Based on Core Triggers and Interpersonal Styles. Frontiers in Psychiatry (2024). Hypothesis/theory paper.
9. Blay, M., Cham, M.-A., Duarte, M., and Ronningstam, E. Association between Pathological Narcissism and Emotion Dysregulation: A Systematic Review. Psychopathology (2024).
10. Interpersonal Outcomes of Complex Post-Traumatic Stress Disorder and Borderline Personality Disorder: A Systematic Review and Meta-Analysis (2026).
11. Clamor, A., Lincoln, T. M., and Schulze, L. Emotion Regulation in Mental Disorders: A Systematic Review and Multilevel Meta-Analysis of Transdiagnostic and Disorder-Specific Impairments. Psychological Bulletin (2026).
12. Sloan, M. E., and colleagues. Emotion Regulation Impairment Across Psychiatric Disorders: A Systematic Review and Meta-Analysis. Translational Psychiatry (2026).
13. National Institute of Mental Health. Obsessive-Compulsive Disorder: When Unwanted Thoughts or Repetitive Behaviors Take Over.
14. Centers for Disease Control and Prevention. Clinical Testing and Diagnosis for Autism Spectrum Disorder.
15. Barnicot, K., and colleagues. Overlapping and Differentiating Clinical Features of Autism and Borderline Personality Disorder in Women and People Assigned Female at Birth. Autism (2026).
16. Hatoum, A. H., and Burton, A. L. Applications and Efficacy of Radically Open Dialectical Behavior Therapy: A Systematic Review. Journal of Clinical Psychology (2024).
17. National Institute of Mental Health. Attention-Deficit/Hyperactivity Disorder: What You Need to Know.
18. American Psychiatric Association. What Are Dissociative Disorders? (reviewed 2024).
19. Boysen, G. A. Dissociative Identity Disorder: A Review of Research from 2011 to 2021. Journal of Nervous and Mental Disease (2024).
20. National Institute on Alcohol Abuse and Alcoholism. The Cycle of Alcohol Addiction.
21. Stetsiv, K., McNamara, I. A., Nance, M., and Carpenter, R. W. The Co-occurrence of Personality Disorders and Substance Use Disorders. Current Psychiatry Reports (2023).
22. National Institute on Alcohol Abuse and Alcoholism. Recommend Evidence-Based Treatment: Know the Options.
23. National Institute of Mental Health. Bipolar Disorder.
24. National Institute of Mental Health. Borderline Personality Disorder.
25. Genome-Wide Association Analyses of Borderline Personality Disorder Identify 11 Loci and Highlight Shared Risk with Mental and Somatic Disorders. Nature Genetics (2026).
26. Macri, J. A., and Rogge, R. D. Examining Domains of Psychological Flexibility and Inflexibility as Treatment Mechanisms in Acceptance and Commitment Therapy: A Comprehensive Systematic and Meta-Analytic Review. Clinical Psychology Review (2024).
27. Ten-Year Course of Borderline Personality Disorder: Psychopathology and Function from the Collaborative Longitudinal Personality Disorders Study. Archives of General Psychiatry (2011).

Author’s note: Personal accounts are necessarily selective and interpretive. People mentioned in generalized or anonymized examples are not presented as clinical case studies, and no retrospective diagnosis is implied. This essay is an argument for thoughtful, individualized care, not a substitute for clinical assessment.

Editor’s Note: I helped my sister to write this, not because I didn’t think she knew the words, or lacked the clinical knowledge or discipline to write it, but because I felt that she needed an objective view of the “facts” as she understood them at the time. Neither my intention to erase, nor to verify every detail of what she said. Duly reviewed, we both stand by it.

And I love the notion of a Unified Personality Theory – someday maybe.