Psychodynamic Observations

Here you go! Initial Psychodynamic of George Costanza, an adult male referred for evaluation due to chronic self-sabotage, pervasive insecurity, interpersonal volatility, and recurrent self-defeating patterns, often masked by elaborate rationalizations, petty deceptions, and explosive outbursts amid professional stagnation and familial enmeshment. Reality Testing and Level of Organization George Costanza demonstrates generally intact reality testing in routine contexts, with accurate appraisal of immediate social cues, though significant distortions arise under stress, including paranoid attributions, grandiose fantasies of success, and impulsive fabrications to preserve a fragile self-image. His sense of identity is cohesive yet chronically undermined by feelings of inadequacy, with minimal dissociation but frequent externalization of distress through blame-shifting and scheming. His personality organization aligns with the neurotic spectrum, featuring mid-level defenses and intermittent capacity for insight, supporting the establishment of a stable therapeutic alliance prior to interpretive interventions. DSM Diagnosis George presents with features of Persistent Depressive Disorder, characterized by longstanding low mood, self-criticism, and pervasive pessimism, alongside Generalized Anxiety Disorder manifested in anticipatory worry and somatic tension. Traits of Narcissistic Personality Disorder are evident in fragile grandiosity and entitlement to recognition, compounded by Dependent Personality Disorder elements in his reliance on parental support and avoidance of autonomy. It is prudent to rule out Adjustment Disorder with Mixed Anxiety and Depressed Mood, particularly in response to repeated occupational and relational failures. Psychological Pattern George exhibits a pattern of 'moral masochism,' where intense guilt drives him to self-sabotage as a way of seeking atonement. His emotional stability is fragile, characterized by shifts between grandiosity and depressive episodes. He manages these fluctuations through a range of defenses, including projection, denial, and symbolic undoing of his actions Their coping strategies range from intellectualizing failures to regressing into avoidant or impulsive behaviors during stress. This stems from an unstable identity that swings between defensive grandiosity and total self-collapse. Relationally, object relations instability predominates, with a desperate need for parental recognition paired with rage toward authoritative or disappointing figures, resulting in bonds characterized by resentment, envy, and repetitive relational rupture. A core organizing theme for George is the conviction that “I am inherently flawed and unworthy, and any attempt at success or closeness will inevitably expose my inadequacies, inviting humiliation and rejection.” This operates as an emotional truth, driving cycles of ambition, deception, and inevitable downfall while sustaining chronic interpersonal discord. Developmental Formulation George’s history is defined by a critical maternal figure and an ineffectual paternal one, creating a household where emotions were suppressed and achievement was used as a weapon. This lack of early validation resulted in an unstable identity. His current state is dominated by depressive position dynamics intense guilt over perceived harm to others and failed attempts at psychological repair. Each subsequent failure serves only to validate and deepen his existing self-loathing. Transference and Countertransference In transference, George may cast the therapist as a critical parental surrogate or authority figure, eliciting defensiveness, elaborate storytelling, or testing through complaints to evoke judgment or rescue. Countertransferentially, the clinician might experience frustration, amusement, or helplessness at his convolutions, requiring careful self-reflection to resist collusion with avoidance and instead promote authentic engagement.

this is another observational cohort studies that gets headlines but can’t actually prove anything. They used a food frequency questionnaire from the baseline of the ELSA-Brasil cohort, meaning people reported what they ate once at the start, then researchers estimated sweetener intake and followed cognitive scores for about eight years. Self-reported diet data is noisy as hell people forget, underreport, or change habits over nearly a decade and they only measured intake once. Even after adjusting for some covariates like age, sex, blood pressure, and cardiovascular disease, residual confounding is almost guaranteed. People who already have poorer metabolic health, higher body weight, or diabetes are more likely to use these products in the first place (classic reverse causality), and the association showed up mainly under age 60 and was stronger in those with diabetes. While the numbers sound dramatic 62% faster decline in the highest tertile this design can only show an association. It doesn’t establish that the sweeteners caused the cognitive changes, and the randomized controlled trials we actually have on these ingredients for weight and glycemia point in the opposite direction.

My musing today… I was listening to this song and it started making me think about when clients lie to Therapist. Why would someone lie to the very person they’re paying to help them understand themselves? It happens in psychotherapy more often than people might realize, and I don’t think it’s always about deliberately deceiving the therapist. Sometimes patients minimize problems in their relationships, exaggerate how well they’re doing, or avoid discussing feelings they’re uncomfortable acknowledging. From a psychodynamic perspective, these omissions can serve a protective function. Telling the truth might bring up feelings of shame, fears of being judged, or the possibility of having to confront something they’re not quite ready to face. This is what makes the singers Sabrina Carpenter’s line, “I lied to my therapist about you again,” from Tornado Warningsworth examining. The person may not simply be protecting a romantic partner but also preserving an idealized version of the relationship and the hope of what it might eventually become. There’s another dimension to this as well. Someone who grew up learning that honesty could lead to criticism or rejection may bring those same expectations into therapy. I think this is why understanding what a patient chooses not to disclose can be just as important as understanding what they share. Sometimes the question isn’t whether someone is being honest, but what they fear might happen if they were. This will be one of my articles in the future weeks, so stay tuned You can find my Substack link in the bio

ICYMI

“young adults having strokes increasingly have the bodies of 60-year-olds” is classic framing that jumps way past what the paper actually measured. Most people in that age band still don’t have multiple major risk factors even among those who stroked, absolute stroke rates in the young remain low relative to older adults, and the study is describing the risk profile of people who already had an event, not declaring that average 25-year-olds now biologically resemble their grandparents. The boring takeaway is the useful one which is don’t smoke, keep blood pressure and lipids in check, don’t carry excess body fat, and move more.

The 250,000 number is a decade-old hot take that never really held up under scrutiny. It came from a 2016 commentary in the BMJ not an actual study. In the commentary they took a handful of older papers, did some rough math, and landed on a figure that would mean roughly a third of all hospital deaths were preventable medical errors. That never really made sense when you look at the data, and the CDC has never tracked medical error as a cause of death that way for a reason. A tighter 2020 review of higher-quality studies put preventable hospital deaths closer to around 22,000 a year, and most of those were in people who were already expected to live less than three months. More recent work has shifted focus to diagnostic errors specifically. A 2024 analysis estimated about 795,000 people in the U.S. suffer serious harm (death or permanent disability) from misdiagnosis every year across all care settings, with roughly 371,000 of those being deaths. Still a big problem, but it’s a different, more specific number based on disease rates rather than that old broad extrapolation.

This NLSY study shows that the association is there, OR around 0.60 after basic adjustments. But let’s not pretend it’s cleaner than it is. First, every behavior outcome is pure self-report. Smoking is one of those things people systematically under-report, especially once the social costs go up, and the higher-scoring group may just be better at giving the “right” answer or more aware of the stigma. There’s also a decent amount of missing data, particularly on adult income, so the analytic sample is smaller than the original cohort and not necessarily representative in the ways we want. It’s observational and longitudinal, which is better than a cross-sectional snapshot, but you still can’t claim causation and these are plenty of residual confounding from personality, impulsivity, genetics, and family environment that they didn’t fully capture. Adult SES attenuates a lot of the effect, which tells you the pathway is at least partly mediated or confounded by later-life factors rather than some pure early-intelligence effect. And among the people who do smoke, the relationship with cigarettes per day is inverted-U, not a nice linear story. So the “higher IQ, less likely to smoke” finding holds as an association in that dataset, but the limitations mean you shouldn’t treat it as a simple, causal rule. Context matters.

Free bonus article for Halloween! Some of the people who haunt our relationships are still very much alive. A forgotten phone call can feel like abandonment. An ordinary disagreement can awaken the feeling of being a child who was never quite understood. And sometimes we find ourselves having the same emotional argument with different people, years apart. For Halloween, I’ve written a special essay for Psychodynamic Observations called “The Ghosts We Bring Into Every Relationship.” It explores how our earliest relationships continue shaping the way we experience love, rejection, disappointment, and intimacy. I’m making this one completely free, including for readers who haven’t subscribed. I hope you’ll take a few minutes to read it.

New article is now out! Link in bio A couple sits in my office, angled away from each other on the sofa, exhausted. They have spent forty-five minutes walking me through an argument that began on Tuesday evening over an unemptied dishwasher. On the surface, the dispute is mundane, almost trivial. Who ran the cycle, who walked past it twice without opening the door, who had a harder day at work, and whose turn it was to pull the clean plates out. If you listen, you notice that their energy is entirely detached from the kitchen and their volume is controlled, yet the air in the room feels suffocating.

I see this a lot with newer therapists, and it almost always starts from a decent place. They come out of training programs that emphasize being warm, validating, and careful not to retraumatize anyone. The patient walks in describing a long history of being hurt, misunderstood, or let down, and the natural response is to step in as the steady, caring person who finally gets it. That impulse is reinforced in a lot of current training. For instance, they focus on the alliance, help the client feel safe, avoid anything that might feel critical. What doesn’t get enough attention is how quickly that can harden into the exact relational pattern the patient has been living out elsewhere the wounded, aggrieved patient and the idealized rescuer. Good post by Jonathan

Another thought is that procrastination isn’t always about poor time management or a lack of motivation. Sometimes delaying a task serves a psychological purpose, especially when someone’s sense of self-worth depends heavily on how well they perform. If they wait until the last minute and things don’t go well, they can attribute the outcome to a lack of time rather than having to question their abilities. In some ways, procrastination allows them to preserve the belief that they could have done better if they’d simply given themselves more time. This can be understood as a form of a psychological defense. Someone may hold on to an idealized image of themselves while avoiding situations that might challenge it. The difficulty is that the same defense protecting their self-esteem can also prevent them from developing a more realistic and stable sense of competence. I think this is why addressing procrastination sometimes requires more than improving time management or developing better habits. It may also involve learning to tolerate disappointment and recognizing that falling short of our expectations doesn’t necessarily mean we’re inadequate. Just something I’ve noticed over the years

Hyperbole at its best interesting how the y left this part out of it- 118 fewer students compared to last year they have a total of approximately 46,000 students in the school

New article is out! Link in bio

The moment a therapist can only hold the injured, vulnerable, wronged part of the patient and has to look away from the part that wants to punish, control, or destroy, something essential gets lost. Patients don’t arrive with just pain but arrive with the full package of being human such as the longing mixed with rage or vulnerability coexisting with a capacity for coldness or retaliation. If we can only see the first half, we end up colluding with a split. The patient often senses that certain feelings aren’t welcome here, so they go underground or get acted out elsewhere. Skilled work means staying present when the aggression shows up not as something to soothe away or reframe but as a real force that has to be known and metabolized in the relationship and that is usually where the deeper change happens. Not because we approve of the hate, but because we can bear it long enough for the patient to stop having to manage it alone.

Besides it being correlation, it may be wonder what are the top 10 things Grok- longitudinal studies and meta-analyses keep pointing to a fairly consistent set of factors with the strongest links to longer life. These aren’t fringe ideas—they come from large cohorts (often tens or hundreds of thousands of people followed for decades), and combining several of them can add years of both total and disease-free lifespan. Here’s a natural rundown of the top ones with really solid evidence: 1Not smoking stands out as one of the biggest. Never-smokers consistently show dramatically lower mortality risk, sometimes with odds ratios around 3x better than current smokers in mid-to-late life analyses. 2Regular physical activity and cardiorespiratory fitness is right up there. Higher fitness levels (even just daily movement or walking) are among the strongest predictors of survival we have, with clear dose-response benefits and no obvious ceiling in many studies. 3A healthy, mostly plant-forward diet (think Mediterranean-style: plenty of vegetables, fruits, whole grains, legumes, nuts, and limited ultra-processed food) repeatedly associates with lower all-cause mortality and longer disease-free years. 4Maintaining a healthy body weight (roughly BMI in the normal range, avoiding both obesity and underweight) shows up as a key independent factor across multiple analyses of longevity and healthy aging. 5Getting about 7–8 hours of sleep a night is linked to lower mortality risk; both short and long sleep durations tend to track with worse outcomes. 6Strong social connections and relationships have surprisingly large effects. Meta-analyses have found that better social ties are associated with roughly 50% higher survival odds—comparable in magnitude to quitting smoking in some reviews. 7Cognitive engagement and mental stimulation (reading, learning, problem-solving, etc.) is tied to longer life, partly through better cognitive reserve and slower decline. This is the same line of evidence as that book-reading survival curve from the Yale study. 8A sense of purpose and lower psychological stress (including traits like lower neuroticism and a feeling of meaning) show protective associations in long-term cohorts, beyond just the lifestyle habits. 9Moderate or no alcohol (avoiding heavy drinking) is consistently better than excess; light drinking sometimes appears neutral or mildly protective in older data, but the strongest signal is simply not overdoing it. 10Overall clustering of healthy behaviors compounds the benefits. Studies combining never-smoking, activity, diet quality, healthy weight, and sleep routinely show 7–10+ extra disease-free years compared with people who hit few or none of them. Genetics matter too (and some people just have better luck there), but these lifestyle factors are the ones that repeatedly show up as modifiable and strongly predictive across large datasets. The more of them you stack, the bigger the apparent advantage.

when someone jumps to “Don’t worry, you’ll be fine,” they’re usually managing their own anxiety more than helping the other person. Sitting with someone else’s distress can stir up helplessness, guilt, or old feelings of not knowing how to comfort someone who mattered to them, so the quick reassurance functions as a way to shut the feeling down before it gets too close. It’s a mild form of avoidance or intellectualization and it’s turning an emotional moment into a problem that can be solved with a few words so they don’t have to stay in the discomfort with the other person. For the person on the receiving end, that response often lands as a subtle rejection of their experience. It can activate a sense that their affect is too much or not welcome, which may reflect earlier relational patterns where feelings were minimized or met with discomfort. Instead of feeling accompanied, they can feel pressed to regulate or suppress what they’re feeling so the conversation stays comfortable for the other person. That mismatch tends to create more distance rather than safety, even when the intention was kind. What’s often missing is the capacity to tolerate affect together. Reflecting the feeling keeps both people in the emotional moment instead of rushing past it. I would point out that the difference isn’t about better technique so much as whether someone can stay present with another person’s state without immediately needing to neutralize it for their own sake.

Fear mongering post the $500 is for going 100+ over the limit. Tickets start at $50, and each camera sends 60 days of warnings first.

So true

Saying EMDR has no active component for attaching a new narrative isn't just an innocent omission it’s gross negligence

Looking at that European map of people who drink at least once a week, it doesn’t really line up with alcoholism rates the way you might expect. Places like Italy and Spain have high regular drinking but pretty low alcohol use disorder rates, while Poland sits at the bottom of the weekly drinkers list yet ranks near the top for alcoholism because of the binge-and-spirits pattern. The US falls somewhere in the middle. For instance fewer people drink weekly than in a lot of Western Europe, the overall per-capita consumption is a bit lower than Poland’s, and the alcoholism rate sits higher than the Mediterranean countries but lower than Poland’s. Americans do a fair amount of binge drinking too, so it’s more episodic than the everyday wine-with-dinner style you see in Southern Europe. The chart doesn’t really predict or show a correlation well with alcoholism not that it was supposed to

That’s a huge success