David Puder M.D.

🧵 Different personality styles struggle under different triggers: Borderline: attachment loss Narcissistic: image loss Depressive: loss of love or moral/meaning failure Obsessive: collapse of inner rules or chaos Schizoid: invasion or engulfment

Retweeting @DavidPuder’s amazing interview with Otto Kernberg, which I’ve listened to twice. I hadn’t realized how affectively focused he could be, talking about tenderness and love. Clinical gold from a pioneer. podcasts.apple.com/us/podcast/psy…

@daviddorg @superpower @ouraring Love the idea. Thank you 🙏

Hi, my name is literally David And I’m going a year without screens in 22 days (down from 10h+ per day) While tracking: - Neuroimaging (fMRI + MRI) - Cognitive + motor tests (very comprehensive) - 131 blood-based biomarkers (@superpower) - Sleep and activity data (@ouraring) - Vision exam - Hearing exam - And more I’m excited to see what the data show We all deserve to know more about how our devices in their current form are affecting us

@robkhenderson @rorysutherland lol. 😂 that would work

"men may be hardwired to use displays of technical aptitude as a status signal...If you want your husband to do all the cooking, do not under any circumstances buy him a recipe book: instead, get him into Japanese knives." spectator.co.uk/article/how-to… @rorysutherland

Episode 261: Understanding Delusions Leading to Violence: Types, Assessment, AI Risks & Treatment in Forensic Psychiatry 10:31 Introduction to Delusions 13:12 How to Assess and Rate Delusions — Key Scales for Clinicians (SDSS, BABS) 20:43 Delusions in OCD, Mania, Body Dysmorphic Disorder & Beyond Schizophrenia 28:54 Most Dangerous Delusion Types — Persecutory Delusions and Violence Risk 43:10 AI Chatbots Reinforcing Delusions — The Rise of AI Psychosis 01:05:35 Cultural Influences on Delusion Content Over Time 01:11:54 Risk Assessment — When Delusions Become Dangerous for Clinicians & Patients 01:19:57 Treatment of Delusions: Antipsychotics, Long-Acting Injectables & CBT

What Is Reflective Functioning? Mentalization, Attachment Theory & RF Scoring with Dr. Miriam Steele 09:37 Reflective Functioning History 13:32 MBT, TFP 20:35 BPD, Eating Disorders 26:17 How to Increase RF 28:15 Abraham Lincoln 54:32 Theodore Roosevelt 01:06:07 Pseudo-High RF in Manipulation, Psychopathy, Sadism & Cases Like Jeffrey Epstein

Post your highest “reflective functioning” comment regarding this episode…

@ContrapunctusC You might find this article interesting, links dark personalities to worse sleep. pmc.ncbi.nlm.nih.gov/articles/PMC70…

@DavidPuder Do you think that psychopaths have bad sleep because their conscience weighs on them? I think not at all. Putin has already murdered nearly 2 million people, and it doesn't weigh on him. If he sleeps poorly, it's only because he worries about himself.

There is no evidence I can find that Epstein used GHB (Xyrem aka the date rape drug), but I found an email where he recommended it for sleep. Odd recommendation. In my experience sleep is tough for the morally bankrupt.

@KATrustyFriend @WesleyLHuff @grok translate this

Never before photographed back side of a summarian tablet. This particular tablet hasn't been translated since 1930s, needless to say we should probably take a second look given the modern advancement in understanding cunaiform. @WesleyLHuff 👀 maby you know somebody...

Interview with @robkhenderson where we discuss his book "Troubled" detailing his early childhood trauma, foster care, neglect and abuse and his journey through the Air Force, Yale & Cambridge. Only posting this one on X... ⚠️ WARNING: Detailed childhood trauma

@imbrettcooper Tough. Really tough. I really feel young people are increasingly naive to how it could negatively impact them. psychiatrypodcast.com/psychiatry-psy…

I personally know people who have had great experiences with cannabis, especially when dealing with chronic illnesses. I also know many people, including my brother, who have had awful experiences. Both sides have been studied. Many of us are simply asking for people to be honest about the risks, the vulnerable populations, and to stop gaslighting young people who think it’s a harmless drug just because it’s legal.

@atx_therapist Yes sir! Totally random lol

@DavidPuder You're matching!

I interviewed Dr. Reid on guilt... 02:19 Guilt vs Shame: What’s the Difference? 03:45 Healthy Guilt 05:19 Do Narcissists Feel Guilt? 06:40 Guilt as a Symptom of Depression and Anxiety 9:25 Childhood Roots of Adult Guilt 12:14 Therapist & Doctor Guilt 17:21 How to Stop Feeling Guilty About Referring Unsafe Patients 26:39 Setting Boundaries to Reduce Guilt and Prevent Burnout 31:47 CBT for Guilt: How to Challenge Guilt Thoughts 35:30 Role-Play 57:12 Practical Ways to Reduce Guilt Every Day 01:03:19 Guilt in Mental Health & Healthcare Systems

Tragic Irony: despite decades of Epstein filming the rich and powerful of the world, creating allegedly extensive blackmail material to leverage influence, the material has failed to convict anyone new… This hits different to me after helping so many trauma victims for so many years. Justice where are you?

We just published the largest review of creatine for mental disorders. Creatine + therapy or antidepressant leads to greater response.

@MAHA_Action Article by 2 psychiatrists about keto: psychiatrypodcast.com/psychiatry-psy…

@karenmitchell__ Thank you for your further clarification. I agree that the big 5 is not helpful in diagnosis. I am sorry if I poorly communicated that.

Thank you for responding, David. I appreciate it. It is an interesting response though. Having provided several substantial reasons for my belief that the FFM is not helpful to society in identifying human predators, you provide me with a table based on the FFM. 🤔 You can’t play it both ways David. You either support the predators/dark personalities by continuing to push concepts that are unhelpful to humanity based on flawed research designs, skewed research populations and powerful researcher agendas, or you explore a new paradigm which may potentially make those who harm without remorse far more visible to the rest of humanity, saving lives. The table you provide here is based on an entire body of knowledge which is misleading. Data can be statistically significant but meaningless unless if it measures the wrong thing! Not all human predators/malignant narcissists/dark personalities have low modesty. Some of the higher functioning human predators adopt façades which are self effacing, understated, shy, humble. As a human race, we need to focus only on the shared attributes and the commonly used tactics of the human predator. This makes them easier to see. Human predators have differences just like other people. They are irrelevant though in identifying them. Focusing on these differences is exactly what human predators want us to do.

Jeffery Epstein on the psychopathy checklist hypothetically scored high on factor 1 which is the interpersonal/affective domain based on public records. Factor 1 is often seen high in white collar offenders, calculated predator thriving in high society, aka “the successful psychopath” till exposure of them. For educational purposes, consider each of the 20 domains of the psychopathy checklist and potential score: 1. Glibness/superficial charm: Exceptional impression management; rapid career ascent despite lacking credentials; charismatic grooming of victims and elites. Score: 2 2. Grandiose sense of self-worth: Pervasive narcissism; exaggerated achievements and superiority; expected deference from others. Score: 2 3. Need for stimulation/proneness to boredom: Compulsive high-risk activities; escalating criminal enterprises; thrill-seeking in exploits. Score: 2 4. Pathological lying: Habitual deceit about education, finances, and activities; sophisticated contradictions in statements. Score: 2 5. Cunning/manipulative: Systematic grooming and exploitation; instrumental relationships; Machiavellian tactics for gain. Score: 2 6. Lack of remorse or guilt: No acknowledgment of harm; viewed victims as complicit; continued offending without change. Score: 2 7. Shallow affect: Performative emotions; emotionally detached in abuse; lack of genuine depth or reciprocity. Score: 2 8. Callous/lack of empathy: Treated others as objects; disregard for suffering; incapable of recognizing others’ needs. Score: 2 9. Parasitic lifestyle: Reliance on others’ resources like funding and power; extravagant living on unearned wealth. Score: 2 10. Poor behavioral controls: Compulsivity in offending; violations and outbursts, though with some strategic restraint. Score: 1 11. Promiscuous sexual behavior: Extreme promiscuity; abuse of hundreds; compulsive predatory patterns without bonds. Score: 2 12. Early behavioral problems: unknown 13. Lack of realistic long-term goals: Demonstrated long-term planning in schemes, though exploitative and non-prosocial. Score: 0 14. Impulsivity: Evident in escalation and rule-breaking; risky decisions, but mitigated by calculation. Score: 1 15. Irresponsibility: Failure to honor obligations like registrations and transparency; abandonment of duties. Score: 1 16. Failure to accept responsibility for own actions: Externalization and denial; minimized harm and claimed ignorance. Score: 2 17. Many short-term marital relationships: Never married; no multiple short-term marital-like ties, though unstable bonds. Score: 0 (although his SO seemed like a means to his ends) 18. Juvenile delinquency: No “caught or recorded” documented antisocial behavior ages 13-17; academic success without legal issues. Score: unknown 19. Revocation of conditional release: Violated 2008 work-release and registration; disregard for supervision. Score: 2 20. Criminal versatility: Diverse offenses like trafficking, fraud, and manipulation across jurisdictions and methods. Score: 2

Thank you for your response. I think we agree to get a good image of a person, you really have to see them from multiple contexts, multiple interviews, and not self-report. I have found it interesting that Narcissistic personality scores are linked to the subdomains of low straightforwardness and low modesty. But I agree that I would not use this in a way to discover or diagnose.

Thank you for interacting with my comment. First, and having thought about this a lot based on substantial data, I don’t like using the Five Factor Model or its language for several reasons. 1. The FFM is based on a selection of ‘normal’ human behaviours. The darkness and depth of depravity and cruelty of the human predator is not captured by it. 2. I don’t believe predators are on a spectrum. You either are one or you are not. Placing a person somewhere on a spectrum of 30 different behaviours and 5 groupings does not allow us to ‘see’ human predators. All predators have the same set of attributes and use the same tactics to destroy and avoid accountability. Attributes might manifest differently according to intelligence, impulse control capability, socio economic status, context and other factors but they are all the same intrinsically. The spectrum theory plays into the hands of predators because you can never actually be one. You can just have some traits of one. 3. Prior to the 1980s researchers discussed actual behaviours that we could all see and understand. The use of ‘jargon’ has moved us, as a global community, further away from having common, easy to understand, language that we can use to see and call out the patterns of behaviours of predators. 4. For those of us who have worked extensively with human predators and been targeted by them personally, there are many other sometimes more subtle behaviours and mannerisms common only to human predators which can never be captured in something like the FFM and yet many of these are defining features that set predators apart from the rest of the population. There are other reasons, but these are a few key ones. While people like Costa and McCrae likely had innocent motives, researchers and academics working in the field who are themselves dark personalities/human predators have taken the FFM and run with it, knowing exactly what they are doing. The FFM gives them a get out of jail free card. To answer your question, yes, human predators/dark personalities have higher levels of intelligence, impulse control capability, and are generally of higher socio economic status. They are able to mimic the mannerisms of non-predators more convincingly. They are able to pay or bribe others to engage in nefarious behaviours on their behalf, so they are less at risk. They more effectively use fronts such as charities and religion to create convincing facades of goodness. Their intelligence and strategic abilities allow them to secure solid roles in society such as surgeon, CEO, lawyer, psychologist, priest etc. all higher functioning human predators have a double life. The facade and then the life of harm to others, lawbreaking, and exploitation. It’s important to understand that the brains of human predators are profoundly different so they are not motivated by love or affinity or normal accomplishment. They are motivated by control and dominance. They also get great satisfaction from sadistic behaviour, exploitation, and manipulation. They lie even when they don’t need to because it is what motivates them, deception. Yet most of the research on human predators has been done by self assessment. The amount of anomalies in research approaches and populations is staggering. We have been so led astray in truly understanding the human predator, and in many cases purposely.

I appreciate your thoughts and agree that sadism, lack of impulsivity are common in the higher functioning psychopaths. My post is not meant to be comprehensive by any means. I have thought this is likely because the higher functioning psychopaths are also likely high conscientiousness (big 5). Curious what you think about that.

Isn’t it evident to you David that the PCL-R is not an effective tool for classifying higher functioning psychopaths like Epstein? PCL-R scoring must include all items from factors 1 and 2 to be able to assess someone as a psychopath. You can’t just focus on factor 1 items as you are doing here. Depending on the country, a person must score at least 30 out of 40 to classify as a psychopath and that’s not possible by using only the factor 1 items. It’s actually impossible to classify Epstein as a psychopath using the PCL-R. What does that tell you? If you examine it deeper, you will see concerning issues including that the key driver of psychopaths is control, control of a body during a rape, of a family, of people etc yet control is not contained in the PCL-R. In my research sadism came out as a huge driver of their behaviours too, the enjoyment of harming, disadvantaging, demeaning, humiliating others. Sadism is not in the PCL-R either. Impulsivity is a core attribute in the PCL-R which Hare has argued for years is a core feature. Of course, Epstein and other higher functioning psychopaths are not impulsive. The PCL-R is merely a tool to assess physically violent criminal offenders with low impulse control and who are not so smart. It is not an assessment tool which is nuanced or comprehensive enough to assess higher functioning psychopaths. You might want to have a glance at my PhD thesis based on the largest study ever undertaken of all the fields of research examining people who actively violate social norms and harm and disadvantage others by conscious choice. It is also based on the first research ever undertaken with experts like yourself working long-term with higher functioning dark personalities/human predators outside of jail and their victims (note that Hare only studied incarcerated populations so all of his data is based on a forensic context). Applying a model developed from incarcerated populations is never going to be sophisticated enough to identify higher functioning psychopaths which puts us as a human race at risk. We need to be able to see these people more rapidly.