 My name is Sam Vaknin, I am a professor of psychology and the author of Malignan self-love, Narcissism Revisited and several other books about personality disorders. I'm cheerful and there's nothing you can do about it. So me, knowing myself, I am probably cheerful because I'm about to discuss trauma and traumatized people. Always cheers me up. And today's topic is, are you the listener, the viewer, the self-styled victim, the real victim, the so-called empath, a covert narcissist probably? Are you a victim of post-trauma? Are you a victim of complex post-traumatic stress disorder? Are you a garden variety, run-of-the-mill, borderline personality disorder patient? Are you a borderline or are you a CPTSD? In today's online cyber environment where everyone and his dog is a life coach, everyone is an expert on narcissistic abuse, everyone knows everything about everything. Then of course to have suffered from complex post-traumatic stress disorder, lends you an air of self-importance, aggrandizes you, makes your experience special. But complex post-traumatic stress disorder is much more rare than we are led to believe. Generally, trauma is an extremely rare reaction to stressors, to stressful life events. PTSD is so rare that we have been able to observe it only in veterans of war. For example, Vietnam vets. And most of the writings on trauma have been offered and published by psychiatrists who have spent most of their professional lives working with war veterans. So you need to endure a war. Exploding shells, flying body parts, you need to endure this in order to be truly traumatized. Now no one is disputing that in very extreme situations of domestic violence, sexual abuse, mental abuse, psychological abuse, that is well constructed, repetitive over decades, there's no question that some people might experience complex post-traumatic stress disorder. But there is good reason to believe that the majority of people who style themselves, empaths, sufferers or victims of CPTSD, majority of people who aggrandize their abusers in order to aggrandize themselves actually. You know, if your abuser is special, you're special. If there's no one as demonic as your abuser, then poor you. Poor you is, you know, a badge of pride. I can envision the parades of poor you victims in the future. And it pays many of them right books, many of them sell all kinds of products and so on. It's a cottage industry being a victim, victim would pays. Crime used to pay, now victim would pays. I am not invalidating or minimizing what abusers do to their victims or pray. I just am challenging and trying to undermine the proliferation, the explosion of misapplied clinical and diagnostic labels. It's tend to reason that the majority of people who claim to have suffered complex post-traumatic stress disorder are actually nothing more than borderlines, collapse narcissists, covert narcissists or suffer from some other form of dysregulation. We'll come to it in a minute. But perhaps before we go there, let us start with a bit of history. I teach the topic of post-trauma, borderline personality disorder. Other PTSD related and CPTZ related conditions. I teach this a whole semester. It's a whole semester dedicated to this in the universities where I'm a professor. And so I'm very hard pressed to encompass all this information in a single video or even perhaps in a series of videos if you express, if there is demand, if you express a wish. So please bear with me and forgive me for neglecting some aspects and some dimensions in the doomed attempt for brevity. I will also state my view of the issue to get it out of the way so that we can discuss other experts and what they think. Some of these experts know a lot more than me about trauma. Very few, if any, know more than me about narcissistic personality disorder. And some of them know a lot more than me about borderline personality disorder. So I defer to them and I respect their views and I'm going to mention some of them. But I would like all the same to present my view. I've spent the last six or seven years trying to reconceive of borderline personality disorder and narcissistic personality disorder as post-traumatic conditions. I've been saying that these personality disorders are actually not personality disorders. They are post-traumatic disorders. They are reactions to CPTSD, reactions to complex post-traumatic stress in childhood. So in this sense, of course, narcissists and borderlines, they are as much victims of abuse as the people they victimize. And this affinity between abuser and abused is what generates the trauma bonding. Your narcissistic abuser is every bit as much and as like you, is like you. The narcissist is also the outcome of narcissistic abuse. He is a link in a chain, in the chain of narcissistic abuse. His parents abused him, he's abusing you. You will both abuse your children who will go on to abuse your grandkids and so on and so forth. Abuse is transmissible exactly like a virus. It's contagious exactly like a virus. It's a pandemic exactly like a virus. So borderline and narcissistic personality disorders are reactions to complex post-traumatic stress disorder in childhood. But the reaction has very special features. It involves dysfunctional attachment, dissociative self states, arrested development, infantilism, regression to infantile states, cognitive deficits, and emotional and affective dysregulation, being overwhelmed by emotions or suppressing them altogether in order to not be overwhelmed by them. I have dealt with all these issues at length in previous videos. And before you post comments wasting my time, please don't be lazy, don't be indolent, don't be spoiled. These are narcissistic traits. Search the channel for answers. I promise I give you my word to respond to any question, the answer to which does not exist in one of my videos. Now let's go to complex post-traumatic stress disorder. Judith Herman was the first to suggest this diagnosis in 1992. But it has since taken wings and evolved and its most important iteration was in 2006 by Roth. Immediately after Herman proposed complex post-traumatic stress disorder. And by the way, she proposed this diagnosis in conjunction with war wounds, the effects of war. She studied war veterans. She had inklings that CPTSD could be applied in other settings of repeated trauma, repeated stressful trauma. And so she, in some of her writings, she hinted that CPTSD may be one day applied to domestic violence situations. And others saw the merit in this new diagnostic category. And the reason there was a need for this category is that the classic PTSD, classic post-traumatic stress disorder, as it had been defined in the Diagnostic and Statistical Manual Edition 4 text revision. PTSD there in this Bible of the profession was a reaction to a single stressful event, a natural disaster, an accident, a pandemic, a death in the family, a divorce. But I mean like an event. So PTSD was a pinpointed reaction to a single catastrophic traumatizing event. And Herman said, justly so, what if a person is exposed repeatedly to numerous smaller events, but all of them catastrophic, all of them traumatizing, all of them disorienting and dislocating, all of them enough to induce repression and dissociation? What then? She said, we need something that leads ultimately to post-traumatic stress disorder, but it is much more complex in the way it leads there. Hence complex PTSD. As early as 1994, two years after Herman came up with her suggested diagnosis, van der Kolk, who is probably by far the leading trauma expert, expert on trauma and traumatic disorders, van der Kolk and Fischler wrote an article in 1994 in psychiatric clinics on North America. It's an academic journal, December 1994. And this is what they had to say, linking trauma to borderline personality disorder. This is what they had to say. I'm quoting, prolonged and severe trauma, particularly trauma that occurs early in the life cycle, tends to result in a chronic inability to modulate emotions. When this occurs, people can mobilize a range of behaviors that are best understood as attempts at self-soothing. The task of therapists and researchers alike is to understand which memories are related to which effects, to know when to explore feelings to allow conscious remembrance of past horrors, and to decide when to focus on mastery in the here and now. That's 1994, van der Kolk and Fischler. But, contra to misinformation online. And I'm so tired of saying this because I think I'm going to shorten it. Because if it's online, it's misinformation. I discovered to my horror and sadness, most of the so-called information online is utter rubbish. So contra to a lot of information online. The diagnostic and statistical manual does contain reference to CPTSD. It's not true that the text revision published in the year 2008 years after Herman proposed CPTSD. It's not true that the DSM committee ignored Herman's work. They actually incorporated it in the DSM. So if you go to the DSM, Diagnostic and Statistical Manual, Edition 4, Text Revision, Year 2000. On page 425, it says the following. An associated constellation of symptoms that may occur and are more commonly seen in association with an interpersonal stressor, such as childhood sexual or physical abuse, domestic violence, torture, or being hostage or a prisoner of war. So it seems that the committee, even at that early stage, because eight years in terms of science or nothing, even at that early stage, they saw merit in the possible diagnosis of CPTSD. Indeed, there's a new edition about to be published of the global equivalent of the DSM. The DSM is mostly used in North America and within North America, mostly in the United States of America. There's another book, another diagnostic manual, it's called the International Classification of Disorders. It's in its 10th edition, and the 11th edition is about to be published. Segments have already been published, but the total edition is about to be published. And within the ICD, International Classification of Disorders, ICD 11, the 11th edition, there is a diagnosis. A clear-cut diagnostic entity, clinical entity, complex post-traumatic stress disorder. CPTSD has arrived. It has made it. ICD, the ICD is used by many more countries than the DSM. It is the global bug of psychiatry. The Chinese have their own DSM bug. And so, we have all converged within the profession on the realization that there are traumatic processes which are gradual, incremental, pernicious, surreptitious, invisible, subterranean, and yet, at some point, volcanically erupt and generate the equivalent of PTSD, post-traumatic stress disorder. At some point, all the defenses crumble, there's massive decompensation, and there is acting out, as we will discuss a bit later. My only beef with these diagnostic manuals is the narrow definition of abuse, because they stick to the 1950s and 1940s definition of abuse, where abuse is only incest, sexual abuse of children, or beating up your wife, or shouting at someone. I mean, these are all abusive behaviors, of course, and they entail the leveraging and misuse of aggression. And so, they're all abusive, but today we know that abuse is any situation where boundaries are breached. Simple. It's a simple definition, and it encompasses all the known forms of abuse. If I have sex with you against your will, I'm breaching your physical, corporeal, body boundaries. If I humiliate you in public, I'm breaching your boundaries. If I force you to do something, I'm breaching your boundaries, of course, if I beat you up, I'm breaching your boundaries. All these are boundary, boundary breaching, boundary violation conditions. When it happens in childhood, there are many ways to breach the boundaries of the child. Sexual abuse, physical abuse, verbal and psychological abuse, all these are, of course, boundary violating or boundary victimization conditions. But there are many others. For example, if you idolize the child, you convert him into an idol, you convert him into an object. If you instrumentalize the child, if you use the child, for example, to realize your unfulfilled dreams, to see your wishes come true, by instrumentalizing the child, you have converted him into an instrument, again an object. These are forms of objectification. If you parentify the child, if you force the child to behave as your parent and you act as your child's child, parentification. If you provide conditional love, love that depends crucially on performance and on fulfillment of expectations. You see, all these spoiling, pampering, all these don't allow the child to separate from you and to become an individual, a process that is known as separation individuation. And any breach and violation of boundaries during the separation individuation phase is abuse. Regrettably, all these official texts don't recognize these behaviors as abusive. And of course, they don't recognize these behaviors as abusive, precisely because of the reason they don't accept sadism as a mental health disorder. I'm kidding you not. Sadism is not included in the DSM file. And why is that? Politics, political correctness, or trying not to infringe on law enforcement, trying not to mix boundaries, not to try to keep boundaries between the profession and law enforcement. So like, if you spoil your child and I'm telling you that you're abusing your child, you will say what? Get out of here. If you idolize your child, isn't it normal? And if you're sadistic, shouldn't you be put in jail rather than treated? So there's a lot of politics that go into the determination of what is mental illness and what is socially unacceptable behavior. Many conditions are culture bound. They reflect values and mores, not clinical entities. And many clinical entities actually should be included and are not. Many behaviors should be pathologized and are not. So we said, wine break, we said that the ICD-11, the world equivalent of the DSM, published by the way, among others by the WHO, I'll propose this pandemic. We say that the ICD-11 recognizes CPTSD and it describes CPTSD in the new text as combination PTSD plus emotional dysregulation, plus negative self cognition, plus interpersonal hardship. Let's focus on each of these briefly. Emotional dysregulation is when your emotions overwhelm you. You feel that you're about to drown. You feel that a faucet has been turned on and you're drowning. You can't help it. There's nothing you can do. You must escape. You must run away. You must do something crazy. You must drink. You must do drugs. This is emotional dysregulation. Negative self cognitions are known in cognitive behavior therapy as automatic negative thoughts. These are beliefs that you hold about yourself which are negative and also untrue, counterfactual, unreal. It's a failure of reality testing with regards to yourself. An interpersonal hardship asks any spouse of a borderline and he will explain this part in details, I'm sure. But if you put all of these together, the PTSD, the emotional dysregulation, the negative self cognitions and the interpersonal hardship, what do you get? Yes, you get borderline personality disorder. If you take the ICD-11's definition of CPTSD, it is suspiciously identical to the DSM's definition of borderline personality disorder. Of course, borderline plus an active trauma, a condition called complex trauma. A complex trauma usually involves a feeling of threat, imminent, ambient threat or direct threat, a feeling that you are trapped, that there's no way out, that you're at a dead end, there's no outlet and no solution and a feeling of interpersonal friction and hardship. So CPTSD and the ICD-11 is borderline plus, borderline plus and the plus is active complex trauma. But aren't all borderlines, aren't all of them involved in active complex trauma? Isn't the borderline condition reflective over an active underlying trauma? I would go even further. Isn't borderline personality disorder, all its manifestations, lack of impulse control, objecting constancy, splitting, acting out, self-harm and self-mutilation up to suicide, all these don't they reflect what Van Kalk called attempts at self soothing? Aren't all these mere reactions to very active trauma? I suggest that yes, they are. In other words, I say that all BPDs, all people with borderline are in a permanent state, a permanent post-traumatic state. Never ending, never seizing, not for a second. They are embedded in their trauma, entangled with their trauma, inseparable from their trauma. They are their trauma. I refer you to a March 2018 article in the World Journal of Psychiatry by Gio Skoku and Gela Stopulu. I must tell you, as an aside, with these names I would also end up in psychiatry. So, this article deals exactly with these issues. So, what's the differential? How do we differentiate CPDs D from BPD? If someone comes to us and we see emotional dysregulation, D is dead, acting out, negative self-cognitions, all this mess, we see an active trauma. Should we, just because it's an active trauma, rule out borderline personality disorder? Or should we say the hell with it? It's a borderline person with an active trauma. In other words, what's the primary diagnosis? Is the primary diagnosis borderline and the CPDs D is a kind of symptom, like temperature in COVID-19, fever in COVID-19. Is the CPDs D the fever aspect, the symptomatic aspect of borderline personality disorder and when the trauma is not active, the borderline is asymptomatic to use pandemic vocabulary. Or should we make a clear distinction between these two? And that's exactly the big debate today in psychiatry. A debate to which I will induct you, I will introduce you the rudiments of this debate. Some, there's a group of scholars who say there is a clear demarcation, a clear distinction between CPDs D and borderline personality disorder and that's the way it should be. Because borderlines, these scholars say, borderlines are frantically trying to avoid abandonment. The efforts to avoid abandonment, these distinguish borderline from someone with PTSD, CPDs D. Borderlines have identity disturbance, identity diffusion, we discussed it in many of the videos. They have an unstable sense of self. They don't know who they are to use a colloquial sentence. That's not typical of CPDs D. Borderlines have unstable and intense interpersonal relationships. Borderlines are impulsive and so say these experts. These elements alone are enough to distinguish borderline from CPDs D. If someone comes to you with CPDs D, he is not likely to be afraid of abandonment, terrified of abandonment. He's not likely to engage for example in preemptive abandonment, which I described in several of my videos. He is likely to have a very stable kernel or core, what Jung called Constellate itself. What Freud called the trilateral model. He's likely, someone comes to you with CPDs D, he's not likely to have problematic interpersonal relationships. And if he is, these are the results of his CPDs D, not the cause. In other words, because he had acquired CPDs D, that affected relationships which otherwise used to be stable and not intense. And finally, people with CPDs D are not impulsive. They don't have a problem to delay gratification. They foresee the consequences of their actions and they allow these consequences to affect the decision making process. They are also much more empathic, consequently. So, in the European Journal of Psycho-Traumatology 2014, you can read an article by Kloater, Garvert and Bryant, which presents this point of view. Other scholars disagree. Julian Ford and Courtois, for example, disagree. They say that complex post-traumatic stress disorder includes dysregulation in emotions processing. People with CPDs D, the first thing you see is that they cannot regulate their emotions. They come to the session, to the therapy session, they start to cry. Or they fall apart in front of your very eyes. And sometimes a falling apart is so abrupt that we might as well call it switching between self-states, very similar to multiple personality disorder. So, emotional dysregulation is critical part of CPDs D, say Courtois and Ford. Self-organization, relational security are also affected by dysregulation. The level of organization of the personality under perpetuated stress and repeated trauma. The level of organization goes down. The personality becomes much less organized, much more chaotic. The self-organization is dysregulated. Relational security is affected. In other words, these people gradually come to distrust their partners. They come to expect their partners to harm them and hurt them. There's paranoid per-secretary ideation. They create per-secretary object. They expect abandonment and rejection. And they act in advance to forestall or to regain control of perceived abandonment or projected or anticipated abandonment. Very similar to BPD. And so they said, the only difference between CPTSD and borderline is that we don't know what is borderline. That's the reason for the arguments, they say. Borderline is a kind of basket clinical entity diagnosis category, whatever. It's like we throw there. Everything doesn't fit anywhere else. We throw into borderline. This heterogeneity of the diagnosis is so gigantic, so enormous, that the diagnosis is actually polythetic. In other words, it's not monovilant. It's not clear-cut. Give me any 10 patients. And if I tweak a little, tweak a little their parameters, I can claim that all of them have borderline personalities. Because what is not included in borderline? Narcissism in borderline. Psychopathy borderline. Impulse control borderline. Defiance borderline. Abandonment borderline. Disregulation. Negative automatic thoughts. You name it. It's in borderline. There's never been a diagnosis. So open-ended that everyone and his therapist fit into it. Heterogeneity is a problem. And the heterogeneity has to do with the fact that each and every one of us reacts very differently to psychological trauma. So if we have comorbidity, if we have a mental health condition that goes together with trauma, with post-traumatic stress disorder, if we dissociated big parts of our childhood and childhood abuse, if our affect is dysregulated. So if we have all this, of course, we will present differently. Each one of us will present totally differently. But still, as you see, it all has to do. All of this has to do with trauma and how we react to trauma. So in other words, the authors are asking, and I'm asking as well, how on earth can you dissociate? Can you disconnect? Can you detach borderline from trauma? Borderline personality disorder is meaningless if we take away the traumatic etiology. Meaningless. At least that's what I teach my students. Borderline personality disorder is actually an elaborate form of complex PTSD. A form of complex PTSD with emphasis on some behavioural and trait dimensions. There are those who go as far, like Kulkauni, they go as far as suggesting to strap, to delete borderline personality disorder altogether. And to replace it with a much wider category called emotional dysregulation or emotional regulation disorder. Within which there will be CPTSD. I refer you to Kulkauni's article, March 2017, in Australasian psychiatry. It's an academic journal. Another discovery over the years was that our reaction to trauma or the very fact that we experience trauma is crucially dependent. Not only on internal factors, but on social support and on our attachment style and attachment figures. If we have very high level of social support, if we are loved, if we are surrounded by our loved ones, nearest and dearest. If we have relatively healthy attachment style, we are very unlikely to experience trauma. And that's what I told you, that the incidence of trauma is much less than people make it out to be online. People self-diagnose or rely on anecdotes or my neighbours aunt told me that I'm traumatised. Trauma is rare. Because most people have some form of social support. And the vast majority of people believe it or not have a healthy attachment style. Frustrated by others, mainly abusers. But still, vast majority are healthily attached. I can prove it by the way. The vast majority of people have children. And the vast majority of people have very good relations with their children. So attachment, healthy attachment is much more common. The dysfunctional attachment, like for example, avoidant attachment. And so when we have social support and healthy attachment, we don't have trauma. And there's been a study in the academic journal Advances in Psychiatric Treatment, Volume 15, Issue 3. Where this has been conclusively demonstrated. In the same article, they made a comparison between complex PTSD and borderline personality disorder. And here are the differences they found. In my view, differences in degree, quantitative differences, not qualitative. But you be the judges. In complex PTSD, there's impaired affect modulation. Affect is how we express our emotions. So when we have an impaired affect modulation, we express our emotions wrongly. It could be wrong affect, flat affect, bed affect, whatever. We kind of, there's a disconnect between how we feel and what other people see from the outside that we are feeling. It's easy to misunderstand how we are feeling. Because we don't express our emotions properly. So in complex PTSD, there's impaired affect modulation. In borderline, there's impulsivity in at least two potentially self-damaging areas. Recurrent suicidal thoughts, instability, inappropriate intense anger or difficulty in controlling anger. So they're comparing impaired affect modulation with impulsivity. And of course, impulsivity is usually the outcome of a disconnect with your emotions. It's compensatory, it serves soothing. But it also reflects the fact that you're not in touch with yourself. In complex PTSD, according to the authors, there's dissociative symptoms. In borderline personality disorder, transient, stress-related, paranoid ideation or severe dissociation. That's what I said before. This is a matter of quantity, not of quality. While in complex PTSD, there would be dissociative symptoms, you will lose minutes. In borderline, you could lose hours or days for severe dissociation or you could have derealization or depersonalization. Identity is persistently unstable. There's unstable self-image or even sense of self and there's a chronic feeling of emptiness in borderline. But of course, again, it's a question of quantity. Because if dissociation is all pervasive, if it's strong enough, how will you form an identity? If you keep forgetting things, if you don't have continuous memory, how can you have a continuous identity? I have a lecture that I gave in a university in Russia. It's available online. It's called identity and memory. You can have a deeper look there. And finally, the authors suggested in complex PTSD there's impaired, insecure relationships with others, while in borderline there are frantic efforts to avoid real or imagined abandonment and a pattern of unstable relationships. I want to quote something written by one of the foremost European experts. Bryant is by the way Australian, but he works with Europeans mostly, not with Americans. Clever chap. Bryant wrote in American Journal of Psychiatry, August 2010, an article. And I found one of the paragraphs very pertinent to our discourse. I will quote him now. CPTSD shares certain properties with borderline personality disorder. Imagine that it's an Australian accent. I know very good at imitating. Borderline CPTSD shares certain properties with borderline personality disorder. But the latter borderline is distinguished by its emphasis on severe behavioral and emotional dysregulation and fear of abandonment, rather than PTSD symptoms. What are you saying in effect? The two diagnoses are coterminous. They are the same. But the emphasis is different. The emphasis is different. In borderline, the emphasis is on behavioral problems, emotional dysregulation, fear of abandonment, chaotic personality structure. In CPTSD, there's obvious, but the emphasis is on the trauma, on PTSD. He continues, Bryant, 2010. Whereas some studies of borderline personality reporting increased reactivity to stimuli as would be expected in patients with PTSD. Other studies have found that patients with borderline personality disorder are characterized by elevated tonic levels of emotional intensity, but not increased reactivity. And this is the famous distinction between shy or quiet borderlines and real borderlines. A totally spurious, unsubstantiated, non-clinical, nonsensical distinction. Very, very similar to empaths and other trash online. There is no such thing as shy or quiet borderline. All borderlines are sometimes shy and quiet, and then they are emotionally intense, but they don't show it. They don't have increased reactivity. And at other times, the very same borderlines suddenly erupt, lose impulse control, become defiant, psychopathic, and egregiously misbehave. They externalize their aggression in the form of secondary psychopathy. All borderlines are both. It's not true that a shy borderline would never ever aggress against someone. Again, it's a self-aggrandizing, self-slapped label. I am a borderline, but I'm not a bad person because I never hurt other people. I am an empath. I'm 100% victim. I didn't do anything wrong to deserve this. Don't you see what's going on? These are narcissistic, grandiose defenses. These people are probably covert narcissists. I'm continuing with Brian. Complex PTSD is also conceptually similar to disorder of extreme stress, not otherwise specified. Which, in addition to PTSD symptoms, is often described as having alterations in self-identity, self-directed harm, and chaotic relationships. In other words, disorder of extreme stress, not otherwise specified, is a very long phrase to describe essentially borderline. And PTSD, as Brian admits, is very similar to this. And so groups of scholars decided enough is enough, including Brian, by the way, enough is enough. Let's test. Let's see who is who, what is what, and who is right. So between 2010, 2014, I'm sorry, and 2020, there were a series of studies, very, very big studies, with interesting results. Before I go into these studies, I would like to introduce you to a methodology, a research methodology called LCA. LCA is a methodology that allows us to reveal differences between the two. And so LCA is short for latent, latent class analysis. It's a measurement model in which individuals can be classified into mutually exclusive and exhaustive types. So we have a number of different classes of people. And so LCA is short for latent, latent class analysis. It's a measurement model in which individuals can be classified into mutually exclusive and exhaustive types. So we have groups that have nothing to do with each other. These are called the latent classes. Based on their pattern of answers on a set of categorical indicator variables. In other words, they are interviewed as a series of structured interviews and questionnaires, very long. They answer these and then they're divided into groups that have nothing with each other, nothing in common with each other. These are called latent classes. And it's a bit similar to factor analysis. It's also a measurement model, but factor analysis has discrete indicators. So factor analysis analyzes factors, factor 1, 2, 3. There's factor analysis, for example, for personality. It has five factors, but five, no continuity. Just 1, 2, 3, 4, 5. As though we were all fragmented into five portions, which of course is not true. So today most scholars, most researchers prefer LCA, latent class analysis. LCA gives you continuity, gives you a spectrum of responses. And so in 2004, the aforementioned Australian from Down Under, Bryant, Garvert and Cloitre, which we have mentioned before, they set out to determine who is who, who is doing what to whom and why. And allow me to quote their research rationale, their research goals. They said, we set out to determine whether the patterns of symptoms endorsed by women seeking treatment for childhood abuse. These patterns of symptoms, whether they form classes, classes that are consistent with diagnostic criteria for PTSD, complex PTSD and borderline personality disorder. In other words, they went from the tail to the head. It's okay. Women come to us, they complain of childhood abuse, usually sexual abuse, by the way. Women come to us, they complain of childhood abuse and they display symptoms. And these symptoms coalesce into clusters, into patterns. Let us see if these symptoms form latent classes. In other words, let's see if these symptoms congregate or coalesce around the core that is different for each disorder. To put it much more simply, let's see if PTSD, CPTSD and borderline have different classes of symptoms. The latent class analysis revealed, I'm continuing to quote from the study. The latent class analysis revealed four distinct classes of individuals. A low symptom class characterized by low endorsements on all symptoms, kind of simmering for traumatic condition. A PTSD class characterized by elevated symptoms of PTSD, but low endorsement of symptoms that define complex PTSD and borderline diagnosis. In other words, people with PTSD had symptoms that were in a class of their own and had very little to do with the symptoms of CPTSD and BPD. The third group was a complex PTSD class characterized by elevated symptoms of PTSD and self-organization symptoms that defined the complex PTSD diagnosis, but were low on the symptoms of BPD, borderline. Now that's an interesting part. The class of symptoms of CPTSD had a lot to do with the class of symptoms of PTSD, but very little to do with the class of symptoms of borderline. And there was a fourth, the borderline class, borderline personality disorder class characterized by symptoms of borderline personality disorder, and that's all. There continue. Four borderline personality disorder symptoms were found to greatly increase the odds of being in the borderline class compared to the complex PTSD class. So there were four symptoms that were much more likely to be found in the borderline class than in the CPTSD class. Four symptoms is a lot. So if we really have a situation where BPD has four symptoms that CPTSD doesn't have, they're not the same. And these are the symptoms they found. One, frantic efforts to avoid abandonment. Two, unstable sense of self. Three, unstable and intense interpersonal relationships for impulsiveness. These were typical of borderline, but not typical of CPTSD, according to the authors. Six years have passed. Our techniques improved. Our understanding of borderline has changed dramatically. Today's knowledge of borderline is absolutely, I would even say nothing to do with our knowledge of borderline 20 years ago. For example, today we conceive of female borderline personality disorder as a manifestator expression of secondary psychopathy in females, secondary reactive psychopathy in females. It's totally new. Today we understand that BPD has such pronounced dissociative features that possibly it's in the class of dissociative disorders rather than personality disorders and so on. So today we're beginning to see a different picture of borderline. And consequently, this year, Karacias and Shevlin, two scholars, published a new study in academic journal called Personality Disorders, Theory, Research and Treatment, Volume 11, Issue 1, 2020. And what they have done, they have essentially replicated the 2014 experiment of a study of Bryant and others. They replicated it and they came to dramatically different conclusions. So you can say before I proceed, you can say, so whom should we believe? Of course, it's easy for me to say I believe the latest. I tend to believe that CPTSD, borderline personality, psychopathy, narcissism, they're all indistinguishable. They're a single clinical entity with different emphasis. So I like this. I love the result in 2020 and I dislike the result in 2014. But science is not about liking or disliking. Even psychology, which is not a science, is not about liking and disliking. You must look at the facts. But I still vouch for the 2020 study for several methodological reasons, which I don't want to go into right now. One of which is our developing understanding of borderline personality. But I think another is that I believe that in the original study of 2014, the definitions, the parameters, diagnostic parameters for each of these categories, in my view, could have been improved. And I'm trying to be charitably understated. While in the Karatsios and Shevelin study, I found some good work as far as differential diagnosis. So let's see what they have to say. I'm quoting, complex post-traumatic stress disorder, CPTSD, has been included as a diagnostic category in the International Classification of Diseases 11th Edition, consisting of six symptom clusters, the three PTSD criteria for re-experiencing, avoidance, and hypervigilance, in addition to three disturbances of self-organization symptoms, defined as emotional dysregulation, interpersonal difficulties, and negative self-concept. This borderline personality disorder shares similar features to disturbances of self-organization presentations. And this borderline personality disorder is commonly associated with PTSD. There is a debate as to whether and how CPTSD is distinct from PTSD or morbid with BPD. In other words, what they are saying is, if we have someone with borderline who has PTSD, maybe this is CPTSD, maybe the patients who come to us with CPTSD are borderlines who have just been traumatized. This article, the authors continue, this article aimed to identify groups with distinct profiles of self-reported CPTSD and BPD symptoms and associated trauma history characteristics. A latent class analysis using CPTSD and BPD symptom variables was conducted on a sample of 195 treatment-seeking adults at a specialist trauma service. The classes were then compared on demographic and clinical characteristics, using a series of analysis of variants and kind of statistical tests. The latent class analysis determined three distinct classes. Before I proceed, you remember that a 2014 study found four classes, and they had nothing to do with each other, with one exception. The CPTSD class had some elements of the PTSD class. But according to the 2014 study, there was no overlap between the diagnosis. They were clearly demarcated, and the differential diagnosis was very strict and boundary. This study came up with three, not four, three classes. A CPTSD high BPD class, characterized by high symptom endorsement across both conditions. So the first class of people had CPTSD and very high borderline personality disorder, extreme borderline personality disorder. And they had high symptoms, very egregious symptoms of both conditions, comorbid. Second group of people, second class, a CPTSD moderate BPD class, characterized by high CPTSD and high disturbance of self-organization, symptom endorsement, and moderate borderline, moderate BPD. And so this was the second group. The second group is like the PTSD was high, the post trauma symptoms were very high. There was a disturbance in self-perception, self-organization, the personality was chaoticized, like some explosive device imploded or exploded or like the personality imploded. So that was very high, but the BPD itself was moderate. Still, pay attention, in this second group, we still have comorbidity. We still have PTSD going hand in hand with borderline. And the third group similarly involves both PTSD and borderline. They did not find a single class, single group, which had only PTSD or only borderline. All 195 participants had both. So the third group was PTSD, low borderline personality disorder class, characterized by post traumatic stress disorder symptoms and low disturbance of self-organization and low borderline personality disorder symptom endorsement. So here the trauma was the most expressed. I suspect that had they interviewed narcissists immediately after modification, they would have found this very high PTSD and very low narcissism or grandiosity and very low disturbance of self-organization. On the contrary, I think modification enhances self-organization, which is a very new experience for the narcissist, very shocking, very traumatic in its way. The two, the authors continue. The two CPTSD classes were associated with a greater exposure to multiple interpersonal traumas earlier in life. Both of them exhibited higher functional impairments, findings they summarized, the authors summarized, findings support the construct, findings support the construct. Of a CPTSD diagnosis as a separate entity, although borderline personality disorder features seem to overlap greatly with CPTSD symptoms in this highly traumatized clinical sample, which of course begs the question, if there's such a giant overlap, why do we need two diagnosis? There was precisely the problem with the DSM-4. There was such a huge overlap between cluster B personality disorder that every patient ended up with three diagnosis or four diagnosis. It's very common to find someone who has been diagnosed with narcissistic, antisocial, borderline and histrionic personality disorder, plus mood disorder, plus I don't know what. It's ridiculous. It's ridiculous because clinical entities should be clearly demarcated. The next leap that these authors should have done is to say with great courage, let's eliminate borderline. It's wrong. There's no such thing. There's only a post-traumatic, single post-traumatic state. It may lead to expressed grandiosity and hypervigilance related to that grandiosity. Then we have a narcissist. It may lead to severe abandonment anxiety, hypervigilance related to abandonment and rejection, anticipation of hostile, hostile world and its reactions and so on. And then we have borderline. And then we also have secondary psychopathy as a reactive behavior. Or it may lead to desperate attempts to control the world impulsively, aggressively, violently, at all costs, disempathically. Then we have an antisocial. Cluster B personality disorder are like the famous story of the elephant and the three scholars. One scholar hugged the legs of the elephant, another touched the trunk of the elephant, yet another touched his ears. And of course they had three totally different descriptions of the same animal. We're dealing with the same animal. And the name of this animal is trauma. My name is Sam Vaknin and I'm the author of Malignance & Club Narcissism Revisited. Psychosis is chaotic thinking that is a result of severely impaired reality tests. Patient cannot tell inner fantasy from outside reality. Some psychotic states are short lived and transient. We call them micro episodes. These lost from a few hours to a few days and are sometimes reactions to stress. Psychotic micro episodes are common in certain personality disorders, most notably in borderline and schizotypopersonality disorders, but also in narcissistic personality disorder. Persistent psychosis are a fixture of the patient's mental life and manifest for months or years. These are not micro episodes. These are full-fledged diseases. Psychotics are fully aware of events and people out there. They cannot however separate data and experiences originating in the outside world from information generated by internal mental processes. The inside and the outside blur into one. They confuse the external universe with their inner emotions, cognitions, preconceptions, fears, expectations and representations. Similarly, patients suffering from narcissistic personality disorder and to a lesser extent antisocial and histrionic personality disorders fail to grasp other people as full-fledged entities. They regard even their nearest and dearest as kind of cardboard cutouts, two-dimensional representations, introverts or symbols. They treat people as instruments of gratification, as functional automata or extensions of themselves. To them, people are functions, near functions, nothing else. Consequently, both psychotics and people with personality disorders have a distorted view of reality and they are not rational. No amount of objective evidence can cause these people to doubt or reject their hypothesis and convictions. We call it confirmation bias. Full-fledged psychosis involves complex and even bizarre delusions and the unwillingness to confront and consider contrary data or information. Psychotics are preoccupied with a subjective rather than with the objective. Thought becomes utterly disorganized and fantastic. There is a thin line separating non-psychotic from psychotic perception and ideation. On this spectrum, we also find the schizotypal and the paranoid personality disorder. The diagnostic and statistical manual defines psychosis as restricted to delusions or prominent hallucinations with the hallucinations occurring in the absence of insight into the pathological major. So what are delusions? What are hallucinations? And in which way are they distinct? A delusion is a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. So delusions are entrenched and very hard to eradicate. A hallucination is merely a sensory perception that has a compelling sense of reality or a true perception, but that occurs without external stimulation of the relevant sensory organs. A delusion is therefore a belief, an idea or a conviction firmly held despite abundant information to the contrary. The partial or complete loss of reality test is the first indication of a psychotic state or episode. Beliefs, ideas or convictions shared by other people, members of the same collective are not strictly speaking delusions, although they may be or marks of what we call a shared psychosis, a massed psychosis. There are many types of delusions. There are paranoid delusions. Paranoid delusion is the belief that one is being controlled or persecuted by stealth powers and conspiracies. And this is common in the paranoid, antisocial, narcissistic, borderline, avoidant and dependent personality disorders. Then we have the grandiose magical delusions, the conviction that one is important, omnipotent, omniscient, possessed of occult powers or is her historical figure. This kind of megalomania, as it used to be called in the 19th century, is typical of narcissists. Narcissists invariably harbor such delusions. Then we have referential delusions, formerly known as ideas or reference. That is the belief that external objective events carry hidden or coded messages or that one is the subject of discussion, dissection, derision or equilibrium, even by total strangers. This is common in the avoidant, schizoid, schizotypal, narcissistic and borderline personality disorders. Again, hallucinations are not delusions, but hallucinations are fast perceptions based on false sensor, sensory input, not triggered by any external event or entity. The patient is usually not psychotic. The patient with hallucinations is not psychotic. He is aware that what he sees, smells, feels or hears, is not there. Still, some psychotic states are accompanied by hallucinations, in the famous case of formication, feeling that bugs are crawling over or under one's skin. That's an example of a hallucination which accompanies psychotic states. Similarly, there are a few classes of hallucinations. We have auditory hallucinations, the false perception of voices and sounds, such as buzzing, humming, radio transmissions, whispering, motor noises and so on. We have gastatory hallucinations, the false perception of taste. We have olfactory hallucinations, the false perception of smells and scents, burning flesh, candles, somatic hallucinations, the false perception of processes and events that are happening inside the body or to the body, for instance, piercing objects, electricity running through one's extremities. Somatic hallucinations are usually supported by inappropriate and relevant delusional content. We have tactile hallucinations, the false sensation of being touched or crawled upon, or that events and processes are taking place under one's skin. This is usually supported by inappropriate and relevant delusional content as well. Let me have visual hallucinations. They are most common. The false perception of objects, people or events in broad daylight, or in an illuminated environment with eyes wide open. Hypnagogic and hypnopopic hallucinations are imagerous, trains of events, experience, while falling asleep or when waking up. These are not hallucinations in the strict sense of the word, but they are closed. Hallucinations are common in schizophrenia, effective disorders and mental health disorders with organic origins. Hallucinations are also common in drug and alcohol withdrawal and among substance abusers, but they are not common among people with personality disorders. Why do narcissists feel that they are victims all the time, victimized by everyone in every possible circumstance, in every setting? The family, workplace, church, neighborhood pub, a club, you name it. Why this constant, all permeating, ubiquitous feeling of being disrespected, being slighted, ignored, discriminated against, treated unjustly abused? Well, today I'm going to give you an innovative or novel answer. I'm going to ground the narcissist's sense of victimhood in his own inner turmoil. It's a disruption in his inner dialogue, a confusion between internal objects and external objects, you. And the desperate attempt that he makes to avoid total meltdown, psychosis, by deploying an infantile primitive defense mechanism called splitting. A narcissist uses splitting in a very, very special way, which has not been described in the literature very well or at all. There's been a lot of attention given to splitting in borderline personality disorder, but scant attention and almost no studies with regards to narcissistic splitting. This is the topic of today's video. You're going to discover amazing things about the narcissist's internal world and how he sees you. But before we go there, I would like to draw your attention to a new study published actually a few weeks ago, less than two or three weeks ago. The study is titled The Tendency for Interpersonal Victimhood, the Personality Construct and Its Consequences, and it was co-authored by a group of Israelis, Rafab Gabbay, Boaz Hameiri, Tami Rubel Lipschitz, and Alien Adler. What they say is that there is a personality construct. Now, for you to understand what is a personality construct. Personality construct is a set of traits and behaviors that are correlated. They go together and they appear in a variety of settings, in the family setting, in the workplace, outside the workplace, etc. So you have the same traits and behaviors manifesting, expressed in a variety of unrelated settings and across the lifespan. So it's not unique to a specific period in one's life. It's not reactive. It's not a reaction to something bad that had happened or to a real state of victimhood. It seems to be detached from reality. There's poor or impaired reality testing, etc. So these guys, they propose and girls, they propose a new personality construct. They describe people who persistently see themselves as victim within interpersonal conflicts. Well, you see, narcissists, for example, they're hyper-vigilant. They go around. They scan the environment all the time. Is someone disrespecting me? Is someone talking about me, gossiping about me behind my back? This is known as referential ideation or ideas of reference. Are people skimming and conspiring and colluding to deprive me of what's mine, to undermine me, to sabotage my work, to keep me from getting promoted, to treat me unjustly, etc. And this whole attitude to life and to other people is known as hyper-vigilance. We all are subjected to disrespect, to insults, to mistreatment, to abuse and to injustice. This is an integral part of life as people experience friction with each other. You know, we move in the same spaces and there are many of us, billions of us. It's inevitable that we are going to clash like so many billiard balls. But most people shrug it off. Yeah, it's been unpleasant, even unwarranted. I shouldn't have been treated this way, but I'll let it go. So some people shrug it off, moments of hurt, but other people get stuck. They get stuck, they keep rehashing the incidents, they hold grudges, they ruminate and they persistently paint themselves as victims. The authors say that this persistent sentiment, this persistent conviction that one is a victim is not just yet another thing, another eccentricity, if you wish. But it's a personality construct. It influences how these people make sense of the world around them. In other words, it imbues their life with meaning. I've been saying the same thing since 1995 when I wrote the article, When Victims Become Narcissists. The researchers coined a new phrase, a new word, and they call it Tendency for Interpersonal Victim TIV. And they define it as an ongoing feeling that the self is a victim which is generalized across many kinds of relationships. So there's an ongoing feeling. Through the time, you feel as a victim, and you generalize this feeling across many types of relationships. In all relationships, you tend to find yourself victimized, or so you believe. You seem to attract abusers, you remember, and magnet, and puffs, and all these other nonsense. This is actually an eternal victim stance. This is what these authors call Tendency for Interpersonal Victim. The authors have conducted three studies, and all three studies have shown that Tendency for Interpersonal Victim is consistent. It's stable. It's a trait that involves four dimensions. One, moral superiority or moral elitism. These perpetual professional victims, they believe that they are morally superior, not only to their abusers, but to everyone. Number two, a lack of empathy. Yes, you heard me correctly. These perpetual eternal victims, the empaths and so on, they lack empathy. Exactly like narcissists, which leads me, or led me, long ago to believe that self-styled victims are actually covert narcissists. Number three, the authors say, number three is the need for recognition. Narcissistic supply. Number four, rumination. They describe an obsessive-compassive narcissist without calling it by name because it's politically incorrect to say that victims are narcissists. I refer you to yet another study published almost a year ago in British Columbia, which had demonstrated conclusively that many social justice activists, you know, Black Lives Matter, Greta and the ecological movement, all these saints or self-styled saints, social justice activists, this study had discovered, actually have pronounced psychopathic traits, including defiance and grandiosity. Psychopaths seem to drive me too. Black Lives Matter and so on, they seem to be the driving force in social justice movements. Similarly, victims, not all, not all, of course not all, but victims who make victimhood their identity, they're actually narcissists. And there was a follow-up study to this Israeli study and it found that the tendency for victimhood is linked to anxious attachment. To remind you, I refer you to my video on attachment styles. Anxious attachment is an attachment style characterised by feeling insecure in one's relationship, suggesting that the personality trait of victimhood is rooted in early relationships with caregivers. Sounds very much again like close to being. The two studies, the two of the three studies, they discovered the people who scored higher on interpersonal victimhood, people who were victims by definition and as an identity, they were more likely to desire revenge against the person who wronged them. You don't have to trust these studies. Just go to any forum of self-styled empaths. These are cesspools and cesspeeds of viciousness and malice and aggression, the likes of which I have never come across in 26 years of studying the film. This desire for revenge translates into behaviour according to these studies. People high in TIV, in interpersonal victimhood, they are more likely to, for example, remove money from an op-op, still, cut a long story short, they are more likely to still when given the chance. Despite being told that stealing will not increase their own welfare, so they are still to hurt the other person, to spite their spiteful. Participants who are very high on the victimhood trait, they reported experiencing more intense negative emotions and a higher entitlement to immoral behaviour. They conducted something called mediation analysis and it offered insight how the revenge process unfolds. I'm quoting from the study. The higher participants' TIV victimhood trait, the more they experienced negative emotions and felt entitled to behave immorally. However, only the experience of negative emotions predicted behavioural revenge. Gabai and her colleagues, they express the belief that their studies indicate the tendency for interpersonal victimhood is a stable personality trait that is linked to particular behavioural, cognitive and emotional characteristics. They say in the study, deeply rooted in the relations with primary caregivers. This tendency affects how individuals feel, think and behave in what they perceive as hurtful situations throughout their lives. The authors of the study suggested that TIV, this tendency to feel like a victim, the construct offers a framework for understanding how a person's interpretation of social transgressions, real or imagined, can inform feelings of victimhood and lead to revenge behaviours. And these insights probably can underline a therapeutic approach, etc. The authors conclude by suggesting that it would be particularly interesting to study in the future what happens when people high in victimhood trait are in positions of power. They wonder whether leaders like Donald Trump with this persistent tendency to see themselves as victim, these leaders might feel more inclined to behave in a vindictive way. Brilliant. Just confirms what many of us have been saying for a while and what I have been saying for well over two and a half decades. Many, many victims are actually narcissists and psychopaths. Many victims adopt victimhood as their engine of grandiose narcissistic supply. It's a power play, revenge, vindictiveness. These are not saints and the motives are not only. Be very careful who you associate with online and avoid these toxic movements of self-styled empaths and so on and so forth. These are very sick people. Very sick people. Okay. I said in one of my previous videos that narcissists constantly feel that they are victims. They are eternal victims. They actually have TIV. They have this victimhood trait, this victimhood kind of tendency for interpersonal victimhood. They would score very high on these tests. Why is that? It's because all narcissists actually collapsed. All narcissists, you heard me well, even high-functioning narcissists, even productive narcissists, even successful narcissists, even accomplished narcissists, pillars of the community, celebrities, presidents of countries, they all collapse narcissists in their own minds and they are collapsed because they are faced with unattainable unrealistic goals. They have an inner voice which is perfectionist. We will come to it a bit later, but suffice it to say at this stage that when you have a constantly receding target, when your aim is perfection and nothing less, when you strive and aspire to be God-like in the fullest sense of the world with all of God's attributes, you're bound to fail. You're setting yourself up for failure. Never mind how much you accomplish. Never mind how much you possess. Never mind who you possess. You would still feel that you fell short of your goals and aims and purpose in life. You would still feel, in other words, like a failure. And this leads us to the imposter syndrome. The imposter syndrome was first described in relations to women in position of power. Women felt that they were faking it, that they were imitating men in the 1970s when they started to attain a higher representation in the workforce and accumulate more societal and political power. Many women describe the sensation that they're faking it, that they're fake, that they're frauds and that men around them might expose them. So this is called the imposter syndrome. The narcissist has the imposter syndrome. Narcissists avoid intimacy, push you away, destroy relationships. Don't let you get too close because they're afraid that you will see them for who they are. The narcissist knows that he is an emptiness. Nothing but avoid howling deep space. The narcissist knows that at the core of himself, there is no self. There is nothing there. The narcissist is terrified to let you come too close, to let you observe him in a variety of ways because he is afraid that you will discover who he truly is or more precisely who he truly is not. He is afraid that you will discover his absence and then you will dump him. Once he is exposed as a fraudster, the narcissist anticipates inevitable punishment. So the narcissist keeps you at arm's length. Approach avoidance, intermittent reinforcement. It's a tool of control, of course. There are other reasons to behave in these ways which I've described in other videos. But one of the crucial, critical reasons is that the narcissist really, really believes that he is faking it and not making it. And he doesn't want you to realize that he is fake, that he is a concoction, that he is a piece of fiction, that he is self, is false, that his grandiosity is founded on fallacies and confabulations. He doesn't want you to find out the con. He is a con artist, he is a scammer and he doesn't want you to expose the plot too early or to his detriment. So there is an imposter syndrome. But there is a much deeper layer, there is a much deeper, more profound explanation as to why the narcissist feels constantly like a victim. Now, you're in for a bumpy ride. Focus, stay with me. Rewind, re-listen, rewind, re-listen. It's not going to be easy, but it's going to be very rewarding if you invest the effort. Understanding the narcissist will lead you to understand yourself. In many ways you were attracted to the narcissist because your shadow is resonating. There's something in you that complements the narcissist. If you listen carefully to my description of the narcissist in a world, to the mechanisms that he uses to try to reconcile his internal irreconcilable differences, you might yourself embark on a path to healing and you may avoid similar bed choices, the wrong made selection in the future. So let's dive right in. The narcissist has a problem of attribution. Remember my previous video about the inner dialogue? Your mind is populated by objects. Many of these objects, internal objects, they represent other people. They represent the voices of your parents, teachers, role models and influential peers. These are known as introjects. They represent constructs, ways, interpretative frameworks and organizing principles, how you make sense of the world, what is called the internal working model. The internal working model includes a theory of mind, what it means to be human and how other people teach, how they function. This empathy is part of this and includes a theory of the world, how the world function, how you should function within the world, self-efficiously as an agent in order to secure favorable outcomes and all this gigantic egosphere, like ecosphere, but egosphere, all this gigantic egosphere, inside it there's a lot of tension, numerous debates and arguments, disagreements, conflicts and dissonances, voices clash, voices fight, voices disagree, voices argue and many times these are unsettled arguments. No party wins. There's a stalemate. Actually the state of stalemate is homeostatic. This equilibrium is a good state in effect. But the tension, the dissonance, the conflict is fake, you feel it. It's a problem of attribution is the fact that many internal objects used to be external. Your mother's voice used to belong to your mother and your mother was an external object, yet now her voice is inside you, she is inside you. There is an avatar, a representation of your mother in your mind. So now she is an internal object, but wait a minute, she is also an external object. Here's an external object who is also an internal object, mother. This is very confusing. When you hear mother's voice in your mind, are you listening to the external object or are you listening to the internal object? And what is the difference between the external and the internal object in this case? How faithfully does the internal object, the introject, the voice of your mother, how faithfully does it represent your actual mother who is an external object assuming she is alive? So many internal objects used to be started off as external objects, and this creates a normal confusion. Now this confusion between internal objects and external objects, if it is taken too far, if it is not reconciled and mediated, if it is not resolved psychodynamically, it leads to two very, very, very bad and self-destructive outcomes. If you confuse external object, if you think, if you confuse, you're confused, you're bewildered, you're befuddled, and you consider external objects, internal objects to be external, you are psychotic. That's one solution, psychosis. It's when you say, okay, I can't tell the difference between external and internal anymore. This work is too onerous. I can't do it. So I'm going to assume that everything is external, that even the objects that I think maybe are inside my head are actually not inside my head. They are out there. I can see them. I can hear them. These are called audio and visual hallucinations. So the psychotic gives up, raises his hands and says, I surrender. I've been trying for years to tell the difference between external objects and internal objects I give up. From now on, everything is external. The voices that used to be inside my head are now external. And this is called hyperreflection. Hyperreflection is actually a narcissistic defense. The psychotic person inflates, like in the Big Bang, those of you who know astrophysics, there's an inflationary theory in the Big Bang. So the psychotic inflates. There's a Big Bang, psychotic Big Bang, and the psychotic person becomes the universe. From that moment, he has no boundaries in any sense of the world. He is the world. Like the famous song, we are the world. That's a psychotic song. Okay. The second solution, if you can't tell the difference between internal and external objects that you're about to give up, the second solution is exactly the opposite, is to say everything is internal. Remember, the psychotic says all objects are external. The narcissist says all objects are internal. There are no external objects. I am God-like. The universe is within me. I include everything. I am everywhere, omnipresent. I am the world, but in a different sense. The world is me. It's like Louis XIV in France, the king, the emperor, who used to say, let's say what? The state is me. Or like Nixon and Donald Trump, who said that the United States is the president. The narcissist says that there are no external objects, what seems to be external, like you, his spouse, his intimate partner, his children, his coworkers. They are not external. They are actually internal. What he does, the narcissist, he takes a snapshot of you. He internalizes this. He converts you into an internal object via the snapshotting process. And then he continues to interact only exclusively with the internal object. Okay, these are two dysfunctional solutions to the attribution problem. When we can't tell the difference between internal and external objects, when we fail, when we are very, very uncertain, insecure, which of the voices, which of the entities, which of the elements is inside our mind and which are outside, at that point, we choose either narcissism or psychosis. Psychosis, they are only external objects. Narcissism, they are only internal objects. Now, most mental health conditions belong to the psychotic group or the narcissistic group. So for example, borderline and psychopathy, they belong to the narcissistic group. And borderline, sorry, borderline belongs to the psychotic group, my apologies. Borderline belongs to the psychotic group. Psychopathy belongs to the narcissistic group. So you can take all mental health disorders and divide them into these two solutions. Okay. Mindactic break before we proceed. What are these introjects? I keep talking about internal objects. Okay, some of them are easy to understand. Your mother's voice, your teacher's voice, someone who is very influential in your life, your own personality, elements of your own personality, constructs of a kind. Similarly, you perceive other people, the way you perceive what it is to be human and how other people's minds work, theory of mind. The way you perceive the world and how you should operate in the world, that's the theory of the world and together the internal working model. Attachment has its own internal set of internal objects. You actually get attached to internal objects. Attachment by definition is narcissistic. There's no non-narcissistic attachment, but we'll leave it to another video. So all these are objects. But what are these objects? Can we categorize them? Can we classify them? Can we make a cast, like in a film, like in a movie? Can we make a list of characters in the cast? Who plays what? Well, here we get a lot of help from Carl Jung. Now, I am not a proponent or an admirer of the late Jung. I think he went off the rails. Technically, diagnostically, clinically, the man was psychotic. He had, for five years, he suffered from psychotic disorder. And you can see it very clearly in his late work. His late work is utterly insane and nonsensical in the extreme. But his early work is amazing. And the bridge between his early work and his late work are the archetypes. Jung suggested that there are all inner objects. First of all, he suggested that we are born with a set of inner objects. And that these inner objects dictate to us how we acquire language and how we use language to form consciousness. In other words, how we interact with the world. So Jung's internal objects are what he called the archetypes. Of course, the archetypes are the inner objects according to Jung that we are born with. Later on, we acquire many other inner objects. The most famous of which is the self or what Freud called the ego. So we'll come to it in a minute. Okay, so Jung gives us a list of archetypes. These are inner objects. And this list is very helpful because Jungian archetypes help us crucially to distinguish between external objects and internal objects. So there is the self. The problem of attribution in the inner dialogue is that there's a constant inner dialogue in your mind. But you don't know, you can't tell which of these voices is actually you. Which of these voices is authentic, genuine, echt in German? Which of these voices is you? And which of these voices is not you? Is a snapshot? Is an introject? Is a construct? Is the outcome of empathic resonance? Which of these voices is not you? This is the problem of attribution in a nutshell. And Jung says there's only one voice that is the authentic voice that is you. And he calls it the constellated self. Now ironically in Jungian theory, self constellates via processes of introversion and narcissistic introversion. I have two videos dedicated to this and I recommend to you to watch them. They're fascinating. Jung's thinking is fascinating. But coming back to our core issue, Jung says, yes, there's a whole family of archetypes, which I call inner objects. There's a whole family of archetypes, but only the self is you, the constellated self. All the others, they were given to you when you were born, which is where I disagree with him. But that's besides the point. He makes this distinction between voices that are you, the only voice that is you, the self, and all the other voices which were given to you. Much later in his work, he said that these other voices, which he calls the archetype, these other internal objects, which he calls the archetypes, they actually represent collective conscious, the collective conscience consciousness. So it's like the collective unconscious. So the collective unconscious is like the legacy of the entire history of mankind, compressed and represented symbolically, like in dreams, via the archetypes. So Jung's approach is, yes, in our mind, there are many, many internal objects. One of them is you, that's the self, that's the authentic, genuine voice that is you, and only this voice is you. The others are given to you, and they are given to you by the collective history of mankind. They form the collective unconscious. They are part of the collective unconscious. And as part of the collective unconscious, they dictate to you how to comprehend reality, how to make sense of reality, how to make, how to meaningfully decipher reality by dividing it, classifying it, categorizing it into highly specific forms of principles of operation. So Jung once was asked, what are the important? Because there are like 360 archetypes. And Jung was asked, which of the archetypes are the real ones? Which are the original ones? Which archetypes do you stand by? And he answered, I'm quoting him, the shadow, the wise old man, the child, the mother, and her count about the maiden. And lastly, the anima in men and the animus in women. These are the Jungian, the classic Jungian archetypes. He did not accept other archetypes, proposed by other post-Jungians, followers, fans, and so on. Okay, so this is the Jungian ecosystem, or ecosystem. That's the habitat. Jung didn't call it internal objects, he called it archetypes. And he too made the distinction between one privileged observer to borrow from physics, and that is you, which is the consulated self and all the others, which represent, according to him, the collective unconscious. So I suggest that all the internal objects are divided to six types. The per-secretary object, that's the object that abuses you, victimizes you, punishes you, trashes you, destroys you, hates you, criticizes you, etc. That's the per-secretary object. The sage. The sage is an inner guru. This is the repository of life, experience, and wisdom, yours and others. So it's a kind of a hive mind. It's a composite. It's a kaleidoscope of everything you've ever heard, which resonated with you as a pearl of wisdom. That's the sage. When you're in trouble, when you're in crisis, you consult the sage. There's the infant, especially with narcissists. The infant is the immature parts of you. You see, when you grow up, when you mature, when you become an adult, the infantile parts of you, they don't die, they don't disappear, and they're not replaced. They're sliced off. They're firewalled. They're isolated. They're in an enclave, in an island, like Lord of the Flies, you know? There's this group of kiddos and children interacting in this totally isolated island as outcasts, and they have no effect on the rest of your psychology, on the rest of your mind, but the infant part of you exists, and when all other voices are silenced, when you crumble, for example, in the case of narcissistic mortification, there is regression to the infantile, to the infant inside you. There is regressive phase where you become childlike. You have infantile defenses, infantile behaviors, and infantile traits come out. Lack of impulse control, for example, immaturity. So there's the infant. Three voices until now. The persecutor, the sage, the infant. The next voice is the mother. We all have a mother voice, mother in a voice. Now, it doesn't have to be your real mother. It's a mother, the mothering, the maternal voice. It's a voice that parents you and reparents you. It's the voice that allows you to explore the world from a safe base or is a bed and dead mother. To borrow from Andre Green is a bed and dead mother and creates a new insecure, avoidant attachment style. So the mother voice inside you can be either a good enough mother, a winnicotian mother, or Andre Green mother, dead mother, but you always have a mother. If your mother voice is dead, dysfunctional, absent, cold, detached, rejecting, you will never be able to reparent yourself. And when you do try to reparent yourself, for example, you're exposed to a crisis, you're mortified, you are destroyed, you went through divorce or bankruptcy or illness or whatever, you regress to the infantile phase and you call the mother introject or the mother voice or the mother internal logic. As a child, when you regress, when you become childlike, you ask the mother inside you to come and raise the child, reparent the child so that the child can emerge from a safe base and become again an adult. But if the internal mother is bed and dead, she will not provide a safe base. On the contrary, she will increase the anxiety. She will, in other words, generate internal modification in addition to the external modification. She will enhance and amplify the life crisis. She will make it much worse, which explains many dynamics in narcissism and in borderline. The next voice is the gender voice. What the Jung called the anima and the animus. The gender voice has two parts. There is the dominant gender voice. So if you're a man, it's a man. If you're a woman, it's a woman. And there is the recessive gender voice. It's dominant and recessive. Some would say dominant and submissive because studies in psychosexuality have shown conclusively that in all of us, especially in women, there's a submissive part. So the gender submissive part, I mean psychosexual. So the gender voice has a dominant, recessive or submissive part. Dominant side corresponds with your gender identity, which doesn't have to be same as your sex identity. You could be a man and feel like a woman. So your dominant gender side would be a woman. You would be transgender. Anyhow, you have a dominant gender. So the gender voice is critical. People who failed to differentiate as far as gender, they have severe difficulties in functioning according to their assigned gender, self-imputed gender, adopted gender. Whichever way they try to act gender-wise, they fail. And we feel something or I, something wrong in their gender function. And finally, the last voice is sex. But when I say sex, I don't just mean the act of copulation. I mean denuding yourself, being naked, being vulnerable, being susceptible, being open to the world, not only to other people. Sex, exactly as Freud said, is the libido. It's eros. It's the life force. So I would say that the last voice is not sex necessarily. It's what Bergson called Elan Vitan, the force of life, libido. Now, where is death? Where is Thanatos? Thanatos can be in any of these. Thanatos, while the force of life is usually confined to a specific introject or internal object, the force of death is diffuse. The secretary object, for example, the secretary internal object can push you to commit suicide. I'll talk about it in a minute. The mother could be a dead mother. And because she cannot reparent, she can push you into infancy so much that she actually pushes you back to the womb, pushes you to unlive your life, to not live anymore. So the dead mother can push you to become a dead baby in her womb because she does not allow you to reparent yourself and experience regrowth, experience becoming again an adult. So you can see that death is everywhere. The Thanatic, Destrudo, Mortido, as it was called. The opposite of libido is Destrudo or Mortido. So these powers are diffuse. We are actually, if I had to describe it, we are driven not by the force of life, as Freud said. We are driven by the force of death. It also makes sense. We are dying all the time. We are born and from the first second that we are born, we are on the way to dying. Death is the vector of our existence. It's the aim of our being. It's the end all and be all. Death defines us. Of course, we deny it. We ignore it. We pretend there's no death. We act as though we were immortal. These are classic defense mechanisms against the truth, against reality, against fact, in this sense at least. We are all, when we are confronted with death, we are all to a very large extent psychotic. See the reactions to the pandemic, for example. So these are the voices. Back to the narcissist. The narcissist's constant collapse state is the outcome of a disruption in the inner dialogue between his internal objects and the resulting confusion between internal and external objects. Because his inner dialogue is disruptive and disrupted, because it leads nowhere except to inner turmoil, chaos, mayhem, dissonance, anxiety. The inner dialogue in the narcissist is an engine of anxiety and depression and emotional negativity. It's a horrible state to be in. It's like having an internal insurgency, a civil war, a constant civil war. So the narcissist has a problem with his inner dialogue and when he tries to somehow solve this, he confuses external objects with internal objects. His collapse state is the outcome of these dysfunctional strategies as we are going to show in a little while. It's important to understand that within the narcissist there's a sadistic perfectionist inner critic, inner critic, erstwhile called super ego. This sadistic perfectionist, judge. There's a constant, constant trial, like in Kafka's der Pozess, the trial. There's a constant trial, but the narcissist doesn't know what are the challenges against him. The tribunal sits in sessions after sessions, after sessions, after sessions and never informs the narcissist. What is the rap? What's the charge? What are the charges against him? What's the evidence for the charges? The narcissist keeps attending this court, this sadistic court, and never ever with no prospects of absolution and redemption. So there's this perfectionist. Vile, harsh, abrasive, brutal, hateful, perfectionist super ego inner critic, and it sets him up for failure, of course. Why? Because it keeps posing unattainable and unrealistic goals. Because it keeps chastising and criticising and mocking and deriding and decrying the narcissist without telling him why. It's energy depleting in the extreme, and the narcissist does his best to avoid this group of introjet, or introjet, or internal object. He tries to avoid the persecutor, the persecutory object. And so when the narcissist is pushed in adversity, in times of adversity, in times of extreme, deep life crisis, narcissistic modification, he becomes psychotic. That's not some Wagner, that's Otto Kernberg. Narcissists and borderline. Narcissists becomes psychotic. When the inner critic of the sadistic super ego becomes overwhelming, becomes life-threatening, the narcissist becomes psychotic. He misperceives this persecutory object. He misperceives this judge as external. He projects this judge. There is a voice in him, and the voice tells him, you're bad, you're unworthy, you're a failure, you're a defeat, you're weak, you deserve to die. You should die, die, die, die. And Narcissist can't stand it anymore. It overwhelms him, and he feels very threatened because he realises, should this continue? He'll end up committing suicide. So what he does, he takes this persecutory object inside himself. He takes this tribunal. He takes this prosecutor. He takes this voice of voices which hate him, which drive him to self-annihilation, which amplify his innate emptiness. He takes these voices, and he projects them. He throws them out onto other people. These voices continue to victimise and criticise and attack and deride and decry and humiliate. Humiliate, and they continue to do their thing. But now, they don't belong to him. They belong to other people. So he feels victimised. Ironically, the narcissist is victimised by his own internal objects, which he mistakenly attributes to other people via the process of projection. Now, we all project this in inner dialogue, even in healthy people, becomes overwhelming and sometimes life-threatening in everyone. Healthy, narcissists, neurotypical, you name it. High empathy, low empathy, no empathy. Irrelevant. The inner dialogue is not optimised, is suboptimal and leads to suboptimal results. And the reason it is suboptimal and not optimised is because voices keep being introduced into the inner dialogue. So the inner dialogue is open. The environment keeps affecting the inner dialogue. So we can't really close it off in an enclosure and say, OK, now we isolate the inner dialogue and we can optimise it. We can't do this because it's open to the world. So it always leads to dissonance. Always increases anxiety. There's always a feeling of something wrong. There's always a feeling of inner conflict and disagreement and so on. And everyone, healthy or not, uses projection to resolve the inner dialogue or voices within this dialogue that are so uncomfortable, ego-dystonic, so uncomfortable that they cannot no longer be countenanced. So we project the inner dialogue whenever we are overwhelmed. In the case of borderline, this happens every two minutes. In the case of the narcissist, during modification or extreme narcissistic injury. In the case of the psychopath, when there's a goal, there's no orientation in the psychopath. In the psychopath tends to provoke this projection of the inner dialogue. We'll discuss it some other time. But we project the inner dialogue. Now we project the inner dialogue when we are triggered to a condition called revividness. Revividness is the clinical term for flashbacks. What's behind you is reliving an experience in its totality, including smells and tastes, mistaking the relived experience for reality, disconnecting from reality, and believing yourself to be back in the forest of Vietnam or being life-threatened by your mother. So flashbacks are dissociative islands in the river of life, where for a minute or for 10 minutes or sometimes for days that's called a fugue, you disconnect from reality, you have no access to reality, zero access to reality, and you are in another reality, which is inside your mind. So, and this is called revividness. We project the inner dialogue when we are triggered to revividness. In other words, post-traumatic stress disorder is a form of psychosis. No, follow me. It's a bit of a complex argument. What happens when we project the inner dialogue? When we project the inner dialogue, we mistake internal objects as external objects. If I'm a narcissist and there's a voice inside me that keeps criticizing me, disparaging me, mocking me, calling me a failure and a defeat and a weakling, I can't stand it anymore. So I take this voice, I project it onto my wife. From that moment, it's my wife's voice, not mine, and I feel that I'm being victimized by my wife. So, on that occasion, I'm acting as a psychotic person. It's a psychotic reaction because I mistake my internal object, which is the internal voice, for an external object, which is my wife. So when we are triggered, when we experience flashback, what we do, we take an internal object and we experience it as real, as external. Flashbacks are therefore psychotic. They're forms of psychosis. And people who've been traumatized went through traumas and then developed PTSD or other post-traumatic conditions. They were actually driven to adopt psychotic solutions through the overwhelming inner dialogue. Okay, so this is one form of projection. We're overwhelmed, we're projecting internal objects onto an external reality via flashbacks or via classical projection, and so we become psychotic. The other process is when we interject in inner dialogue. When we are traumatized, we tend to interject the inner dialogue. Now, in the first case, when we are triggered, an external object, because we are triggered from the outside, something or someone triggers us in the first case, yes, in the previous case. Something or someone triggers our trauma that creates PTSD. PTSD is founded on triggering in flashbacks. So something triggers us. Someone triggers us. It's external. It comes from the outside. So an external object initiates direct communication within internal objects in PTSD. So PTSD is the following. An external object communicates with an internal object inside us, triggers us. The triggering is overwhelming. We take the internal object that is communicating with the external object and we attribute it to the external object. We say it's on by voice. It's really out there. It's really there. It's a flashback. So we react psychotically. We no longer can tolerate our internal object. So we pretend that it is external or we attribute it to an external object. And this creates, of course, confusion about reality. And this confusion is known as flashbacks. Okay. In the second case, an internal object. So in the first case, external object, initiated communication with internal object. In the second case, an internal object initiates communication with an external object. And this is the process of trauma. When we are traumatized, trauma is not an objective external event. You can take 10 people, expose them to the same natural disaster or car accident or war or domestic violence. Seven of them would not be traumatized in the list. Three of them would be traumatized. One of them would be seriously traumatized. Why? If trauma is an objective external reality, all 10 should have been traumatized because trauma is not. Trauma is an internal reaction. Trauma is the reaction to circumstances, the reaction to an event. In other words, trauma is 100% an inner dialogue. So when we're traumatized, an internal object or group of internal objects initiate communication with reality, initiate communication with the external traumatizing object. The external object just does what it does. The external object acts. How we react to the external object is the trauma. When we allow internal objects inside us to interact with the external objects, to react to the external object, to be in cahoots with the external object, to be influenced by the external object, it is then that trauma is generated. And that's why trauma, all trauma, is a narcissistic reaction. Again, what is narcissism? The narcissist considers external object as internal. Same happens in trauma. In trauma, the trauma is an internal experience, 100% internal and contained. It has no external element, none. And yet, we experience it as external. We confuse internal and external, external, internal. Our reaction is narcissistic. We take an external event, external event. Our internal objects communicate with this event and appropriate it. We kind of digest the event, merge with the event, fuse with the event, which explains why codependents are very often traumatized. They are much more prone to being traumatized because they tend to fuse and to merge. So when we are faced with a situation, any situation, we can take it, internalize it and then continue to interact with internal objects, which creates the trauma. That's narcissism. That's the reason why it's very difficult to tell apart borderline personality disorder and complex post-traumatic stress disorder. CPT, SD and BPD are indistinguishable. Traumatized people tend to become more narcissistic. For example, we have numerous studies that show that traumatized people lose empathy. They become disempathic, they lose their empathy, which is a narcissistic trait, psychopathic trait also. So, let's summarize this very difficult section. There's an inner dialogue, okay? There's an inner dialogue. Sometimes an external object, someone, something, some place, some circumstance, some event, an external object initiates direct communication with an object inside us, with an internal object. And this triggers us. As we are triggered, we relive, we re-experience a traumatic event from the past. This is called reviviveness or in colloquial term flashback. So, when an external object initiates communication with an internal object, it may create PTSD flashback, reviviveness. But this is a psychotic reaction because we experience the inner object as an external thing. We lose touch with reality. We are really inside the flashback. We hallucinate. We think the flashback is real. That's why it's called flashback. You're there again. So, it's a psychotic reaction. And PTSD, in this sense, is a form of psychosis. We project our inner dialogue. There's an external object communicating with an internal object. This creates an inner dialogue. And we take this inner dialogue, and we throw it out. And we experience it as though it's happening outside in the form of flashback. So, PTSD is psychosis because this is what psychotics do. They take internal objects, and they throw them out. They project them. And then they experience these objects that they had projected as real in the form of hallucinations. So, in psychosis, it's hallucinations. In PTSD, it's flashbacks, which are, according to many scholars, a form of hallucination. And so, PTSD equals psychosis. It's a psychotic reaction. Remember, there are two reactions to disruptions in inner dialogue. Psychotic and narcissistic. Now we come to the narcissistic. The opposite. An internal object inside us initiates communication with an external object. You remember, in the previous case, external communicated with internal. In this case, internal communicates with external. As we communicate with the external object via the internal object, we get traumatized. Trauma is an internal experience. 100,000 million percent internal experience. So, when our internal objects communicate with an external object, it can create trauma. Trauma is one voice of our internal objects. It's a way of relating to the world. It's an organizing principle. It imbues everything with meaning, direction, purpose. Trauma is an organizing scheme. So, when internal objects communicate with an external object, they can react with trauma. And when they react with trauma, this leads to narcissism. Because at that point, they merge with the external object. They fuse with it. They internalize it. And they continue to interact with the external object inside themselves, which is a great definition of narcissism. So, what they do is, they project the dialogue. In the first case, they project the dialogue. In the second case, they project the dialogue. How do people, narcissists, psychotics, traumatized people, victims, cluster B, borderline, I mean, out of all these people. All these people that I just mentioned, they have problems with regulation of internal dialogue, which leads us to understand that the inner landscape, the inner ego sphere includes, for example, emotions. And that's why borderlines cannot regulate emotions. They have dysregulated emotions. These emotions are inner voices. They are their inner objects. Cognitions are inner objects as well. So, how do these kind of people, people with disrupted inner dialogue, people were in their internal and external are confused. People where the internal objects are in conflict and dissonance. People who resolve and solve this situation by becoming psychotic, by believing that the internal is external, or by becoming narcissistic, by believing that the external is internal. How do they try to solve it? They try to solve it via a very primitive, perhaps the first, defense mechanism, known as splitting. But to remind you what is splitting, and I advise you to read the work, worked by Melanie Klein and others. Melanie Klein, Winnicourt, Vermala, object relations in general, I mean, all great names of object relations theory have dealt with splitting. Splitting is simply when information, splitting is a very infantile defense mechanism. It happens in the first few months of life. It's when there is contradictory information that is hard to reconcile, hard to put together, hard to attribute the two types of information to the same object. So, for example, mother. Mother could be good and loving and caring and compassionate and warm and accepting, but she can also be withholding and absent and angry. So, here are two streams of information. Information about the good mother, or what Melanie Klein called pornographically the good breast, and information about the bad mother. So, we have good information about mother and bad information about mother. Consequently, we have a good mother and a bad mother. How to put them together? The baby is not capable of integration. He is not sufficiently developed, to integrate these conflicting streams of data. Mother can be nice and then she can leave the room. That's not nice. That's frustrating. So, how to put the two together? He doesn't. He doesn't put the two together. He creates two objects. One object is all bad, one object is all good. Problem solved. Now, all the information that is good, loving, caring, compassionate, safe base, accepting, all the information that is good goes to the good object. And all the information that is bad, withholding, absent, cold, narcissistic, all this information goes to the bad object. But because mother can never be bad, it's life-threatening to think that mother is a bad object. Because if she is a bad object, she may not give me food as a baby and I will die. So, I can't think about this. No way. No way I can think of mother as bad. Instead, I think of myself as bad. So, we have in splitting, in classical infancy, splitting, the baby becomes the bad object and mother becomes the good object. And mother is 100% good and the baby is 100% bad. Of course, splitting is black and white thinking. What we call dichotomous thinking. All bad, all good, all white, all black. Enemy or frame. Idealization, devaluation is a process of splitting. Prolonged, mature and adult process of splitting. But it's still splitting. Now, to resolve the disruptions and the contradictions in the inner dialogue, the narcissist, I mean people and the narcissist, use splitting because splitting leads to dissociation. And when you have a civil war inside you, the first thing you want to do is disengage the forces, remove them apart. When you remove them apart, they can't fight. But how to remove them apart? You need to dissociate. You need to forget certain things. You need to not have access to certain things. Now, splitting is, as I said, a primitive defense mechanism. And it operates in two ways. You remember that the baby divides, the baby's world includes only the baby and mother. And by the way, until age six months more or less, the baby doesn't make distinction between himself and mother. It's me mother, my mother, mother me. It's one entity. So, the splitting defense mechanism operates to heal, to resolve the conflicts in the inner dialogue, in one of two ways. Method number one. We are all bad. We are all bad. The environment is okay. External objects are okay. We and our internal objects are at fault. We are guilty. We are to blame. We are responsible. The corruption, the decadence, the fighting, the dissonance, the anxiety, the depression, the emotional negativity. All this resides here and only here. We are the bad object. Mother and the world are the good objects. External good, internal bad. That's one solution. We are all bad. External, all good. We call this internal modification. So, splitting leads to internal modification. We are all bad. Mother and the world are all good. And then we need to remove ourselves, to kill. Literally to commit mental suicide. Because we are the source of everything that's evil and vile and wicked and bad. So, we need to put a stop to it. By eliminating ourselves. And how do we eliminate ourselves? Depersonalization. De-realization. We remove ourselves from reality. Psychosis. We remove ourselves from reality. All the solutions that remove you from reality are solutions where the inner objects are all bad and the external objects are all good. It's a splitting solution. Now, depersonalization is when you feel that you don't exist. De-realization is when you feel that you exist but not in reality. So, you're a devotion reality. You're not affecting reality. You're not contaminating reality. You're not contagious. You're like a virus, you know? So, all these solutions, these psychotic solutions are splitting solutions that render the subject all bad and the mother world all good. The other solution is amnesia. In this solution, the subject is all good. We are all good. Our inner voices are all good. The environment is all bad. The environment is sick to destroy us. Hates us. The environment is sick and decadent and violent, corrupt and wicked and spiteful. Environment is all bad. Mother world is all bad. I am all good. Subject all good. That's the opposite. Splitting solution. So, the first splitting solution, I'm all bad. The world is all good. The second splitting solution, I'm all good. The world is all bad. And in this solution, we need to kill, we need to eliminate, we need to destroy the all bad environment, the all bad mother world. We are good. There's no problem with us. There's nothing we can do, nothing we should do with us. We need to drive away, eliminate, disengage, firewall, destroy the environment. How? By forgetting. Forgetting is when we remove ourselves. All good subjects that we are from the environment. Amnesia. Now, depersonalization, derealization, amnesia, these are known as dissociative phenomena. They are forms of dissociation. The ultimate solution to an inner dialogue that is disrupted to the point that it becomes overwhelming and creates disregulation is actually splitting. And splitting leads to dissociation and internal modification in the first case. I'm all bad. The world is all good. An external modification in the second case. I'm all good. The world is all bad. Now, of course, cluster B personality disorders all use this on a pretty regular basis. But even people without cluster B use this. For example, alcoholics, drug addicts. Why do people use substances, abuse substances? Why do they drink? Why do they do drugs? Why do they develop other addictions? Like sex addiction, shop capitalism, work capitalism to forget. Addictions main role is to allow dissociative processes to operate. It fosters amnesia. It fosters depersonalization and derealization. Anyone who ever got drunk knows what I'm talking about. So addiction is the splitting solution of people who are not psychotic or narcissistic or borderline or psychopaths or people who are not mentally people who are essentially neurotypical. They use addictions to induce the very same state. And that's why I consider depression, anxiety, disruption in inner dialogue. Depression and anxiety are signals, symptoms of disrupted inner dialogue. Addiction and dissociation, narcissism, psychosis. Other cluster Bs, especially borderline, I consider all these manifestations, different facets of the same hypercube. It's the same thing. Absolutely the same thing. The inner dialogue is disrupted. We choose psychotic solution, narcissistic solution. We choose psychotic, narcissistic solution. We need to split. We split with dissociate. Dissociate this way. We dissociate that way. And we use substances to dissociate. And all this to reduce depression, anxiety, dysregulation, which are simply the way we experience disrupted inner dialogue. All chickens come home to roast. Yes, Suri. So hello everyone in another video with Professor Sam Vaknyin. And he's the visiting professor of psychology in the Souther Federal University, Rostov-Ondon in Russia. And the author, of course, of the Malignan Self-Love Narcissism Revisited. And the professor of finance and psychology in CS, in Center for International Advanced and Professional Studies. Hello again. And I did all this by the tender age of 61, can you imagine? Hello. Hello. Thank you for having me. Thank you for agreeing. So today I would love to speak with you about some differences and connections in general. So my first question will be about connections, I would say between secondary psychopathy, covert narcissist, dark personality versus overt narcissist and primary psychopathy. If you could elaborate about this. When the study of narcissism started in earnest, which was more or less in the 60s and 70s, there was a big debate whether pathological narcissism is a compensatory defense mechanism or whether it is a primary feature of the personality. In other words, to put it simply, is the narcissist covering up for a sense of inferiority and inadequacy and failure? Is narcissism based on shame? Or is narcissism a feature of the personality? Narcissism is supremely self-confident, has a very stable self-esteem, is egocintonic, he likes the way he is, is comfortable with the way he is, and actually proud of his disorder. And the problem was that we found narcissists who were like the first type, ashamed or feeling guilty or feeling inferior and inadequate and they felt like failures and losers and so on. So we found this type of narcissists. And we also found narcissists who were very proud of their narcissism and thought, considered their narcissism to be an evolutionary advantage. So we didn't know what to do because we had a clinical entity, a single clinical entity, with two radically different descriptions. And the debate went on for many, many, many decades and all the big names in the field, Theodore Millen, Kernberg, Sperry and all the big names in the field, couldn't reach an agreement. So we have two descriptions of narcissism, compensatory and overt. Gradually in the late 80s, we begin to realize that there are two types of narcissists, one is the overt, that is the type of narcissists everyone is used to. That's the type of narcissists described in mass media, in show business, in movies, and that's the kind of narcissists you would come across. In the street, as your boss, as your neighbor, as your spouse, that's the kind of narcissists you're most likely to come across. And then there is the covert narcissist. He's shy, he's fragile, he's vulnerable, and he's hiding. He's stealth narcissist. He's not in full view. It's very difficult to identify such a person as a narcissist. But the big revolution that is happening in the past two years is that we are beginning to realize that what we used to call overt narcissists are actually a subspecies of psychopaths. They are actually primary psychopaths. And their pride and arrogance and hotness, they are forms of reactance, forms of defiance, which is a typical characteristic of a psychopath. So we're beginning to think that we made a big mistake. The overt narcissist is actually a form of primary psychopathy. And the only true form of pathological narcissism is the covert narcissist. To complicate the issue even further, scholars like Robert Hare and others had suggested that there are two types of psychopaths, not only one. So we have facto one psychopath and facto two psychopath. And the difference between them is that facto two psychopath experiences empathy and emotions. It's a psychopath with empathy and emotions. And then we discovered that when the borderline, someone with borderline personality disorder is subjected to stress, rejection, anticipatory anxiety, imagined or real abandonment, she briefly becomes a secondary psychopath. She acts out. She becomes reckless, aggressive, violent, deceitful, defiant and so on. So she becomes a secondary psychopath. She maintains her empathy. She maintains her emotions. So the morning after, she feels guilty and ashamed. And throughout the episode, she still can empathize. But by the way, she can empathize more with strangers than with loved ones. It's another interesting feature which appears only in alcoholism. So we are beginning to think in terms of addiction. The whole field is undergoing a revolution. So to summarize this first part of the answer, today we think the following. Overt narcissists are psychopaths, primary psychopaths. Borderlines are secondary psychopaths and covert narcissists are the only real narcissists. This ties in to another emerging field in psychology known as dark personalities study. It is a study of people who are almost psychopaths, almost narcissists, almost sadists. This is known as subclinical psychopathy, subclinical narcissism, subclinical sadism and Machiavellianism, which is manipulativeness, the tendency to act in the environment and on the environment by manipulating people. That's Machiavellianism. Dark personalities have these four components and maybe shortly we will be adding a fifth, which is what used to be called borderline, subclinical borderline. People with borderline traits who are not fully borderline. So dark personalities are people who are almost narcissists, almost psychopaths, almost sadists, almost borderlines and Machiavellian manipulative. Now these people resemble very much overt narcissists and they resemble very much primary psychopaths who are essentially pro-social. And yes, there are pro-social narcissists and psychopaths. So as you clearly see by now, there is an enormous confusion right now. It's a period of transition in our understanding of personality disorders. And of course there are only two solutions. One solution is to say, okay, since all these disorders interlap and intertwine and intersect, they are one disorder. They are simply one disorder. And we are seeing different aspects and different angles and different facets of a single disorder. That's one solution that is a solution adopted in the 11th edition of the International Classification of Diseases. But not the solution adopted, unfortunately, in the DSM-5. And it is a solution I had been advocating since 1995 in many, many articles and so on. The second solution which I have been advocating only in the last 10 years. The second solution is to say, well, these disorders have so many things in common. Because they have a common etiology. They have a common reason, cause, causation. What made all these disorders happen is the same thing. And this same thing is abuse in early childhood. Traumatic abuse. So we could say that all these conditions are post-traumatic conditions. And we can discuss it a bit later. But when we discuss the affinity between borderline personality disorder and CPTSD, we can discuss it then. But generally speaking, if we reconceive of all these disorders, not as personality disorders, but as post-traumatic conditions, then we have a unifying theory and then everything falls into place. Sooner or later, we're going to decide one of these two things, or maybe both. We're going to reduce all personality disorders, or at least cluster B, to one personality disorder. And this one personality disorder must be linked vigorously, somehow, to trauma. Must be somehow trauma related. That's the current picture. That's the latest in the research. Okay. So speaking about BPD and CPTSD, you mentioned already that can be post-traumatic conditions. So what is the difference then between CPTSD and BPD? Not much, honestly. There are very, very serious scholars such as Judy Thurman and others, many others. Myself included, if it's of any value. So there are many serious scholars who consider borderline personality disorder to be a form of CPTSD. Complex trauma, form of complex trauma. We don't see any distinction. And all of us advocate to eliminate the disorder, to eliminate borderline personality disorder from the next edition of the Diagnostic and Statistical Manual, and to replace it with a much bigger diagnostic category, complex trauma. Now, I will describe briefly the things, the features that are common to CPTSD and to borderline personality disorders. And when I finish, you will see that nothing is left. All the features of borderline personality disorders are also features of CPTSD. And so there is a big debate now, maybe to rename borderline personality disorder and to call it emotional dysregulation disorder. We'll come to it later and we have another point to discuss this. But right now, gradually, there is an increasing acceptance that borderline personality disorder is a post-traumatic condition. I am pushing now to accept narcissistic personality disorder as complex trauma, as another type of reaction to complex trauma. All these are reactions to complex trauma. They are not the complex trauma, they are reactions to complex trauma. That's a very important distinction, by the way, because many self-styled experts on YouTube and so on, they tell you that they are identical. It's borderline personality disorder is how someone reacts to complex trauma. It's a reactive pattern. So what is common to people who react to complex trauma and they remain without a personality disorder and people who are borderline? That's what are the differences? Not much. A lot is common. First of all, the borderline would tend to have repetition compulsion. She would tend to be approach avoidant. She would approach an intimate partner, for example, and then she would fear abandonment by the intimate partner. And then she would try to preempt the abandonment by abandoning the intimate partner first. She would abandon before she is abandoned. She would also be very afraid of engulfment of being subsumed, simulated by the intimate partner. So this gives her a big incentive to approach and then avoid. Approach and then avoid. It's like the famous saying, I hate you, don't leave me. So it's a repetition compulsion. This is common to people with CPTSD and to borderlines. Self soothing is the same. Behaviors which are forms of self-medication. You can self-medicate with food, you can self-medicate with men, you can self-medicate. So the only difference between CPTSD and borderline is that borderlines tend to be reckless while people with CPTSD don't have this. So recklessness is a differential diagnosis. Next thing is dysfunctional attachment style. The borderline usually will have some form of insecure attachment style. While people with CPTSD have an underlying secure, well, could, can have, can have an underlying secure attachment style with temporary insecure attachment style. A post-traumatic artifact. But the temporary insecure attachment style gradually fades away and the foundational attachment style comes back up. In people with CPTSD, there is no need, no diagnostic need for insecure attachment style. But borderlines all have insecure attachment style. There is no borderline with secure attachment style. It's a contradiction in terms. So that's another difference between CPTSD and BPD. Next thing is dissociation. People with CPTSD tend to dissociate in the immediate aftermath of the trauma. So they would dissociate for a week or a month or two months or three months or six months. But the dissociation is closely linked to the trauma, the content of the dissociation, the things that are dissociated, the things that are forgotten are closely linked to the trauma and the dissociation definitely disappears after some time, stops. With borderline dissociation is a feature. Dissociation in borderline is permanent all the time. It's a critical feature of the disorder and also one of the diagnostic criteria is dissociation, not so with CPTSD. Dissociation is there but disappears. So I'm describing now what are the differences. Although I think that borderline is an extreme form of reaction to CPTSD. I agree with Judith Herman, but I still think it's an extreme form and so I'm describing the structural differences between these two. The next thing is arrested development. What used to be called arrested development, we don't say it anymore, it's politically incorrect. It simply means that when the borderline is exposed to stress or rejection or abandonment or anxiety or depression, she regresses, she becomes infantile. Her defenses are very infantile, primitive defenses, like for example, splitting. Now this does not happen in CPTSD. In CPTSD we have a different phenomenon known as somatization. People with CPTSD would react through their bodies. They would have headaches, they would have pains, they would have gastrointestinal problems, so they would react with the body. The borderline reacts by becoming a child, by totally going back to age two, by splitting, by infantilizing, by becoming hyperdependent, so she infantilizes. That's a serious difference in the form of arrested development. Next difference is cognitive distortions. And again I'm emphasizing, right now I'm describing the differences, what we call the differential diagnosis. But I think what's common is much more than what is different. And what is common you can find online, there are many videos, including many of my videos. So I'm now talking about what is different, because there are almost no videos about this. So it's important. Next thing is cognitive distortions. Borderlines misperceive reality, they misperceive external reality and they misperceive internal reality. So when it comes to external reality, for example, the borderline would tend to be paranoid. She has persecutory delusions and persecutory objects. She would tend to be very paranoid. That's a way of misperceiving reality. On the contrary, she would tend to idealize the intimate partner. That's also a way of misperceiving reality. It's also a cognitive distortion. She is grandiose. The borderline is grandiose, which is a cognitive distortion. It distorts the way you perceive yourself in reality. So these are all cognitive distortions. CPTSD, in CPTSD, cognitive distortions happen but are not necessary for the diagnosis. So there are many people with CPTSD who do not have cognitive distortions. There is not one borderline without cognitive distortion. Next thing is emotional affective dysregulation. Now both people with CPTSD and people with borderline display, present with dysregulation of emotions and dysregulation of affect. So they are both unable to cope with very powerful overwhelming emotions that they have after the trauma. The difference is that people with CPTSD revert to internal regulation after a certain period of time. It looks like CPTSD is temporary borderline. So they revert to internal regulation. Borderline never has internal regulation. She is always dysregulated. It's a fixture of borderline. There is no borderline who is not dysregulated. Another thing, two last things. Another thing is that borderlines go through a process called decompensation. When they are exposed to stress, anxiety, rejection, abandonment, depression, etc., extreme, the borderlines tend to lose all their defenses. And that includes the splitting defense. They are completely defenseless. They are unable to filter painful, hurtful reality anymore. They get in direct touch with reality. We say that the borderline becomes skinless. She has no skin. So they get indirect. At that point, the decompensation causes the borderline to become essentially psychopathic or secondary psychopath. And leads to a series of behaviors known as acting out. So when borderlines decompensate, they end up acting out. Now acting out involves recklessness, defiance, aggression, violence, a lack of perception of reality, delusionality, etc., etc. And this rarely, rarely happens, extremely rarely happens with typical victims of CPTSD. Typical victims of CPTSD do not act out and they do not decompensate. This is unique to borderline. And finally, borderlines in many, many states, many, many stages of their disorder, they have empathy deficits. They are unable to empathize and they resemble very much narcissists in these stages. They have empathy deficits. But this, I will describe more when we discuss the motion of this regulation. Okay. I'm so happy and I'm so glad that we are speaking about this topic because even in my clinical experience, I've got many clients that they come into my office and was telling me that, what's wrong with me? Am I BPD or what is going on? Because, yeah, and they've got, for example, CPTSD. They've been, yeah, dysregulated, but it was CPTSD and not BPD. And they've been confused even. So, yeah, I think it's really important to talk about that. More generally, I think, psychology, clinical psychology needs to recognize and it's not recognized right now. It needs to recognize that all mental health disorders can happen in a transient form, that we can become borderlines for six months, that we can become narcissists for one year, that we can even develop bipolar for half a year or depression for three months. So, in clinical psychology, there is the intuitive mistake that if you have a mental illness, it's always lifelong and it's always result of childhood and so it must start very early and so it's like a lifelong, a lifespan thing. But I strongly dispute this. I don't agree at all. I think people are capable of developing full-fledged mental illness and that includes even psychotic disorders. They can develop this situationally. They can develop it in circumstances, environments and situations that present with extreme stress and so on. So, I think CPTSD is best defined as a form of CPTSD and people with CPTSD can develop transient borderline personality disorder and get rid of it after six months. Yeah, exactly because during the therapy you can see that they regulate it and most of the symptoms are gone. So, this is also the difference you can see. You will not see this with BPD and with people with CPTSD even if they look like BPD, the symptoms will be gone. Yes, very true. Same with narcissism. I mean, if you are exposed to specific stressors and so on, it will provoke narcissistic defenses and these narcissistic defenses, if they are powerful enough, they resemble narcissistic personality disorder. We know, for example, that people after trauma have reduced empathy, severely reduced empathy. We know that people who drink, people who consume alcohol, they develop something called alcohol myopia. Alcohol myopia is a form of grandiosity and at the same time, they develop acute empathy deficit. So, we know that alcoholism creates temporary narcissistic personalities disorder for a night, for one night, you know, when you're drunk. So, it's completely nonsensical to say that if you cannot diagnose someone for life with borderline personality disorder, that it can never happen. That I think is a very big mistake of clinical psychology. Yeah, I do agree. I can even see when I'm, you know, going back to my own therapy, that after a relationship with NPD, I've got like narcissistic defensive mechanism. I saw it clearly that I have it and I was working with it. So, yeah, I do agree. Okay, so be careful even after the interview it can happen. Am I not the most honest guy you ever met? Okay. Okay, so let me know if you will see some symptoms then, please. Okay, so another question then. You suggest many years ago, like you already mentioned 1995, I would say, that we have like, we supposed to have like why one diagnosis for all personalities because we've got like self states. What do you mean by that? Can you? No, there's a two separate issues, but I will answer both. The first one is, as I mentioned, I suggested that there should be only one diagnosis personality disorder with emphasis or overlays. So you would say this person is diagnosed with personality disorder with narcissistic emphasis or borderline emphasis. And this is exactly the attitude that had been adopted in the new edition, 11th edition of the International Classification of Diseases. The ICD is the DSM of the world. The DSM is used only in North America and sometimes sometimes. So ICD is actually the DSM of the world. So they adopted this approach and I'm very happy for that. Separately, I'm waging a Don Quixote fight against the foundations of psychology. I just mentioned that in clinical psychology, I think it's a mistake not to deal with transient disorder. Similarly, in personality psychology, I believe that the very foundational concepts, the building blocks of personality psychology, are utterly wrong and counterfactual. They run against the facts, counterfactual. And these are the building blocks of the self, the individual, and personality. I think all three don't exist, actually. They don't exist even as theoretical metaphorical things. They simply don't exist. It was very wrong from the very beginning to go this path. I think people are the outcomes of interactions with other people, starting with mother, of course. But gradually the circle expands and I think these interactions, these relatedness, these relational activities, they create a feeling of separateness. They create a feeling of separateness on the one hand and a feeling of connectedness. And when you have separateness and connectedness, you have boundary between being separate and being connected. And so this boundary, of course, separates you from others and defines you as a separate entity. But the concept of self is very different because the concept of self in psychology is an internal process, not an external process. Freud, Jung, and many other self-psychologies including Kohut and many others, they describe the formation of the self as an autonomous, indigenous, internal process that is not affected, almost not affected by anything in any one in the environment. That is catastrophically wrong in my view, totally wrong. And even in object relations theory, people like Guntrip and others, to some extent Winnicott, Fairbairn, definitely Fairbairn, even they were talking about ego nuclei, there are many nuclei of ego and so it's like we are born with something that then continues in internal process and then becomes something. I don't agree at all. My perception, which I think is much, much more supported by studies than the alternative. My perception is that we are born with a potential and then this potential is activated by the environment. By the way, this is an absolutely biological model. When we are born, we have something called genes. Genes are potentials. If the environment does not act on the genes, they are not activated. That's why we can use gene therapy. Genes are activated by the environment. That's why air pollution is very dangerous because it activates cancer genes. And I think it's the same in psychology. We are born with potentials, then environment, mother, father, neighbors, teachers, role models, peers. Society as a whole operate on these genes, activate them and they start to work. And then we develop this feeling of separateness connectedness, not also known as personal boundary, but this is radically different than the self as a concept. Similarly, I think the concept of individual is a grandiose counterfactual concept. I think it's actually a nonsensical concept. There is no such thing as individual, absolutely no such thing. And when we isolate people, for example in deprivation tanks, when we take a person and we put him in a tank with water, with no connection with other people, that person becomes mentally ill, disintegrates, stops functioning. So the concept of the individual, which is think about the word individuum, to divide. The concept of the individual is that there is an entity that is totally independent from the environment, totally independent from other people. And this entity can function by itself and doesn't need anyone. It's totally self-sufficient. That is also complete nonsense. And finally, I think that the concept of personality is complete nonsense because personality assumes permanence, constancy. No humans are permanent or constant for very long. That's total nonsense. Like these people have never seen human beings. Like they are aliens and speculating from some planet. Humans are anything but permanent or constant. Humans are rivers. They're not lakes. They're like a river. They flow and you cannot enter the same river twice. So instead what I'm suggesting and promoting is a new foundational theory of psychology where I'm saying that people have states. These states are like potentials. So people have reactive potentials. Each reactive potential includes emotions, specific emotions, specific cognitions, specific values, specific beliefs. So each reactive potential is what is called schema in schema therapy. It's a scheme. So these reactive potentials are like a library, a big library. And then you go out to life and you come across a situation. The minute you come across a situation, you go back internally to your library, you take out one self-state, you activate it. And then you operate in that environment optimally using that self-state, using that potential. When the situation is over, when your intimate partner has left, when I don't know, you resign from your job, when you move to another country, when you end up mourning someone you loved who had died, you know, when the situation is over, you take the self-state that you were using, you put it back and you take out another self-state. So it's like a giant library. When we have a library, we don't read all the books all the time. We read one book at a time. It's the same in my theory of self-states. Now my theory of self-states is much better adapted to describe a disorder like borderline, much better adapted because when the borderline is classic borderline, she is empathic. She is loving. She is caring. She is compassionate. She is playful. She is wonderful. She is delightful. She is, you know, everything. She is emotional, hyper-emotional, too emotional. That's when she in a classic state. Then suddenly environment changes. Suddenly environment changes. She thinks that she is about to be rejected or abandoned. Instantly she switches. Anyone who has been with a borderline will confirm this to you. They switch. Another personality takes over. They become psychopaths. They become violent, aggressive, dangerous, risk-taking, reckless, frightening, defiant, reactant, contumacious. They become totally different people. So how can you explain this with the theory, with the current theory of personality? You cannot explain it with the current theory of personality because the current thinking about personality is that it is a stable structure across the lifespan. So how can you explain this switching in borderline? How can you explain dissociative identity disorder if you have this theory of personality? But if you adopt my theory, it's very easy to explain. The borderline has a library. In that library there's a book called secondary psychopathy. When she is exposed to stress, she is exposed to abandonment and hurt and rejection. She takes out the book from the library and the book is titled secondary psychopathy. She becomes secondary psychopathy for a month, for a night or for an hour or for three days. Then the situation is over. She puts the book back. She takes out another book, loving, empathic, emotional borderline. These books are her potentials, her schemas, her self-states. This is a much more flexible theory of personality. And any therapist and any clinician will tell you that it's much closer to reality than the assumption that you have a personality that never ever changes. And always you react the same, so you are totally predictable. And if we learn everything about you, we can analyze you and we can know everything you're going to do ever forever. This is total unmitigated nonsense. Nonsense. No one is like that. Even healthy people. We all have these libraries of self-states. I like this metaphor with the library. It's showing really clearly what is going on with us. Thank you for that. So my last question, but not the least one, speaking about BPD, borderline. How does emotional dysregulation apply to BPD? That's a much more complex question than it sounds. If you talk to clinicians who are not theoreticians, people who work in the field, then they will tell you, yeah, when borderline comes to my office and so on, or when she's confronted with stress, so she has such emotions, she cannot control these emotions, they take over her, she's overwhelmed, and she can do crazy things, or she can start to cry. That's a classic description of emotional dysregulation. But emotional dysregulation is a very, very deep phenomenon. When you're more into theory, it's a very, very deep phenomenon and very enigmatic and very unique. First of all, emotions we know today. Emotions are forms of cognition. There are thoughts. There are thoughts that are unique. Why they're unique? Because they couple with body sensations. Typical cognition, just thinking, you see, this is a glass of water. When I say this is a glass of water, that's a cognition. But typical cognition does not require sensory input or body perception, proprioception. So we can think in ways which are detached from the body or from our experience in the environment. Emotions are these types of thoughts, these thoughts that are intimately linked to sensory input and to body, propriocept, to bodily, to how you feel your body, how you experience your body. And we call these emotions. Now, because emotions are cognitions, they are subject to all the flaws and the deficits and the distortions that cognitions are. We know that our thinking is not straight. We have biases. We have deficits. We have distortions. We don't think clearly. We think wrongly. We filter out information so that it doesn't challenge our beliefs. There are types of cognitions known as beliefs and values which are resistant, resistant to any outside information. It's called confirmation bias. So we know that our cognition is very, very defective, ironically. Our cognition is very fragile, very brittle, very, very vulnerable. And so we defend it very strongly. Most of our defense mechanisms defend our cognitions. Rationalization, intellectualization, even splitting. Most of these things are about regulating cognitions. So if emotions are cognitions, then our emotions are equally defective. Then we can have emotional distortion, exactly as we have cognitive distortion. We can have emotional deficit. We can have emotional bias. In other words, we can have impaired reality testing. Our perception of reality can be wrong. But while cognitively, our perception of external reality is wrong, when we deal with cognitions, we perceive external reality wrongly. With emotions, we perceive internal reality wrongly. So it is impaired internal reality testing as opposed to external. How do I know that all this is true? Very simply, there are therapies, there are treatment modalities where we change emotions by changing cognition. There is, for example, reappraisal therapy. Reappraisal therapy is a therapy where we go to come to the patient and we teach the patient to think in new ways. We teach the patient different cognition. Shockingly, after a while, the patient loses all her previous emotions and has totally new emotions. So we know for sure that cognition leads to emotions. There is another therapy, known as exposure therapy, where we actually modify the emotion of fear. So we know that via action, behaviorally, or via cognitions, we affect emotions. So we know that emotions are derivative. They are secondary. They are not primary entities because if they were primary entities, we could not have changed them through other entities. So they are secondary. They are a derivative of primary entities which are cognitions and behaviors. And of course, behavior is cognitive. That's why we have cognitive behavior therapy. So it's all cognition. Why is this so important? Another thing I forgot to mention is that you can see something called inappropriate effect. Inappropriate effect or reduced effect display situations where people show emotions that are inappropriate for the environment or they don't show emotions at all. Naming and so on. These are also examples of cognitive distortions. So why is this so important? Because if emotions are as vulnerable to deficits and distortions and biases as cognitions, if they create a wrong perception of internal reality, then it would make it very difficult for us to understand other people. We grasp, we interact and we understand other people mainly, amazingly, mainly through emotional displays. We have many, many studies that show that cognitive exchanges have minimal impact on other people. Minimal. We are very closed. We are very shut off. That's why it's difficult to persuade the conspiracy theorist that the conspiracy is wrong. That's why it's difficult to argue about politics or sports because words, cognitions don't work. We don't interact with each other via cognition. But emotional displays, via emotions, that's the main models of communication between people. And we do this via the bridge of empathy. If our emotions are distorted, wrong, biased, subject to deficits and defects, it would mean that our interactions with other people would be very, very problematic. And what we think we are doing or feeling or experiencing is also totally wrong. In other words, it would lead to empathy deficits. In a series of truly, truly shocking studies conducted by Israel Shvili, Nannis, and I think also Agenta Fisher. Yes, Agenta Fisher. These studies are very new. They're, I think, two years old. It was discovered that the more empathy you have, the less well you understand people. Exactly opposite. The more empathy you have, the less you are able to understand people and predict them. People with maximal empathy, who like to call themselves empaths, highly sensitive people, actually don't understand other people at all. Don't read them correctly, don't predict them. Why this inverse relation between empathy and understanding other people? I mean, intuitively, intuition is if you are more empathic, you understand other people better. But the hard data, the hard science is that it's exactly opposite. The more empathic you are, the less you understand other people. Why? Well, because of emotions. The more empathic you are, the more likely you are to be emotional. There's a very strong correlation between empathy and emotions. And we just said that emotions are like cognitions. They are distorted. There are deficits. There are biases. So the more empathic you are, the more emotional you are, the less well you perceive reality. This is the connection. The less well you perceive reality. If you go back to Borderline, which is the topic of this interview when we were both much younger, if we go back to Borderline, you see this sequence. Borderlines have empathy. They are hyper-emotional. And so their reality testing, internal and external, is very damaged. It's very damaged. And this leads them to emotional dysregulation, because the feedback from the environment doesn't sit well with what they believe about the environment. It creates what is known as dissonance. When you get information from the environment that clashes conflicts with what you believe about the environment, it's dissonance. And they become dysregulated. That's more or less the sequence. Thank you so much for all of this. I'm so happy that we can hear it from you to be clear with all of this topic, especially the new things that you said today. So I'm so grateful and so happy for your time, Sam. Thank you. Thank you for having me and suffering me and so on. I know you need therapy after these three dialogues. I'm available, free of charge. Yes, so thank you one more time and thank you for listening and see you next time. Thank you again. I know that the only reason you subscribe to this channel is to follow my changing hairstyle. So today I'm giving you a special treat. My haircut. Poor on poor on the comments. Probably the only thing you care to comment about. Otherwise, those of you who are legally blind and cannot behold my haircut, please listen to the rest of this video. Today we are going to discuss late onset trauma, trauma that happens much later in life, not in early childhood, in adulthood, or even in late adolescence. Can such trauma distort and contort the personality to the point of yielding a personality disorder? The current orthodoxy in psychology is that personality disorders, at least some of them are the outcomes of early childhood abuse, trauma, breach of boundaries, inability to separate and individuate, et cetera, et cetera. In short, cataclysmic or traumatic occurrences in early childhood, usually involving one or two of the parents, typically the mother who is also known euphemistically as the primary object. Don't you just love psychology? But today we are going to ask the question, can we acquire a personality disorder much later in life, owing to some disastrous, unexpected, sudden, abrupt, all consuming, all pervading trauma. My name is Sam Batni, I'm a proper trauma, and I'm the author of Malignal Self-Love, Narcissism Revisited and also a former visiting professor of psychology. When you were all much younger, myself included, there was a diagnosis. It was known as IPCASE, E-P-C-A-C-E, and during personality changes, after catastrophic events. In 1998 Judith Herman coined the term complex post-traumatic stress disorder. And ever since then, CPTSD or complex trauma, as he had come to be known, evolved consuming other diagnoses, subsuming them. It is even about to take over borderline personality disorder. It's a form of emotional dysregulation embedded in or as the outcome of CPTSD. So CPTSD is all the rage. I myself have spent the last few years trying to recast narcissistic personality disorder as a post-traumatic condition, in effect, a form of CPTSD. One of the casualties of the emergence and the dominance of CPTSD has been IPCASE, and during personality changes, after catastrophic events. At the time, the diagnosis required the patient to have a personality change that lasts for two years after trauma. Just to clarify, IPCASE was a part of the ICD-10, the International Classification of Diseases Edition 10, but not a part of any edition of the Diagnostic and Statistical Manual, the DSM. It has been removed in the ICD-11, largely removed in the ICD-11, and merged, so to speak, or fused with the equivalent of complex trauma or CPTSD. And still, I think casting IPCASE as a form of CPTSD, while it has its merits, blurs the lines too much. And in a minute or during this video, I hope you understand why. But first, why don't I read to you, in my charming operatic voice, why don't I read to you the criteria for enduring personality for IPCASE? So it's F-62 in the ICD-10, and during personality changes, not attributable to brain damage and disease, and that excludes, of course, most politicians. I'm kidding. Disorders of adult personality and behavior that have developed in persons with no previous personality disorder, following exposure to catastrophic or excessive prolonged stress, or following severe psychiatric illness. This diagnosis should be made only when there is evidence of a definite and enduring change in a person's pattern of perceiving, relating to, or thinking about the environment and himself or herself. The personality change should be significant. It should be associated with inflexible and maladaptive behavior not present before the pathogenic experience. The change should not be a direct manifestation of another mental health disorder or a residual symptom of any antecedent mental disorder. And so this is F-62, and it continues to provide examples and to kind of expound on the behavioral changes. So, enduring personality change after catastrophic experience, and during personality change, present for at least two years, following exposure to catastrophic stress, the stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being on edge as if constantly threatened and estrangement. Post-traumatic stress disorder may precede this type of personality change but should not be conflated with it. So, the ICD gives a few examples. For example, concentration camp experiences and natural disasters, prolonged captivity with an imminent possibility of being killed, exposure to life-threatening situations such as being a victim of terrorism, torture. So, these are really extreme catastrophes. You should not and cannot diagnose it case in, for example, situations of domestic violence. Normal, regular, typical, run-of-the-mill, your neighbors, domestic violence. You could, however, diagnose it case. If the domestic violence involved captivity, now known as coercive control, and resulted in an imminent or omnipresent threat to life, it was a life-threatening type of intimate relationship. Then, perhaps, you could diagnose EAP case rather than CPTSD. Remember that EAP case is not the same as post-traumatic stress disorder. And this is where EAP case is actually the bridge between PTSD and CPTSD. PTSD is a reaction to a single event. EAP case is actually PTSD for prolonged exposure to extreme events. So, when you have very extreme, sudden, life-threatening events and they take time, they last for months or for weeks or for years, you can't diagnose PTSD. It doesn't fall within the diagnostic criteria. And on the other hand, the abuse, the torture, the coercion are so extreme that they fall outside the remit of complex trauma, CPTSD. And that's where EAP case is the bridge. So, if your spouse tried to actually kill you, should you be diagnosed with, or has been trying to kill you for years? Should you be diagnosed with CPTSD? No. Should you be diagnosed with PTSD? No. But you could have been diagnosed with EAP case before it was erroneously, in my view, discarded. Let's go to F62.1. It is a variant of EAP case, which is actually pretty common. And during personality change after psychiatric illness, personality change, persisting for at least two years, attributable to the traumatic experience of suffering from a severe psychiatric illness, the change cannot be explained by a previous personality disorder and should be differentiated from residual schizophrenia and other states of incomplete recovery from an antecedent mental disorder. This disorder is characterized by an excessive dependence on and a demanding attitude towards others, conviction of being changed or stigmatized by the illness leading to an inability to form and to maintain close and confiding personal relationships and to social isolation. Passivity, reduced interest and diminished involvement in leisure activities, kind of anhedonia. Persistent complaints of being ill, which may be associated with hypochondriasis and hypochondriacal claims and illness behavior. Dysphoric or labile moods, not due to the presence of a current mental disorder or antecedent mental disorder with residual affective symptoms and long-standing problems in social and occupational function. IP case, as distinct from CPTSD and or from PTSD, is how exposure to real catastrophe, prolonged exposure to real catastrophe, can change your personality. Again, let's provide differential diagnosis, a classification. PTSD changes in personality behaviors and cognitions attributable to a single event, a single catastrophic event, an accident, a natural disaster. CPTSD changes in personality, emotions, cognitions and behaviors attributable to very prolonged exposure to mild to moderate trauma. IP case is in between. Changes in personality, traits, behaviors, social functioning, etc., etc., attributable to catastrophic events such as equivalent of torture or the life threats or catastrophic events which take time, which are recurrent, happen again and again, and take time. So that's the bridge between PTSD and CPTSD. There's an article which I want to recommend. It's titled How Catastrophe Can Change Personality. It was published in September 2019 by Gen Tanaka and Hansen Tang. And it's a very interesting article. It was published in Psychiatric Times, Volume 36, Issue 9, and it explores why IP case is a clinically useful diagnosis. It advocates for IP case the same way I do. As I told you at the beginning, IP case has been eliminated from the International Classification of Diseases Revision 11, ICD-11. It was incorporated. The ICD-11 is a variant of CPTSD in June 2018. But as I've just explained copiously, IP case is not exactly CPTSD. It is CPTSD which is a reaction to truly super extreme radical catastrophes. IP case, say the authors, is defined as an enduring personality change lasting for a minimum of two years that a patient experiences following a catastrophic stressor. The events of the stressor must also be so extreme that one should disregard any genetic vulnerabilities or predispositions that would further influence personality changes. These experiences can include imprisonment, for example, in concentration camps, natural disasters, long-lasting capture with a persistent threat to life, etc. as I mentioned before. The ICD-10 IP case represents, say the authors, represents the experiences of a particularly vulnerable group, one marked by great loss, separation from community, and aloneness. So in Ukraine, for example, we are likely to diagnose PTSD and IP case, not CPTSD. In the population, women who are raped, children who are dislocated, soldiers who have been exposed to battle conditions for months on end, they are much more likely to be diagnosed with IP case than with either PTSD or CPTSD. The authors continue, such isolation from nourishing connections is a major dimension of deep and enduring personality change, especially in cases of massive psychic trauma, such as the Holocaust, involving the loss of an entire community and its way of life, fundamental bonds of social connection, trust and support are broken, and the individual is left profoundly alone. Such effective changes point to the insufficiency of research on survivors left in such a devastated state. I would add to this list, refugees from cults, people who have left cults or when the cult broke down, they actually display IP case, not so much CPTSD but IP case. The authors continue, an IP case based formulation can highlight such factors, as extreme helplessness and aloneness where the human agency was the cause of the catastrophic event, whether the event involved humiliation of the survivor, and whether the survivor remained in the zone of danger after the catastrophic event. These factors must be evident both individually and transgenerationally, as they are in the suffering of some of the survivors of the Holocaust who remained in areas where anti-Semitism and its dangers continued to be prevalent. Now the authors provide a history of all our attempts, our desperate attempts I could say, as professionals to cope with the aftermath and the after effects of trauma. How do we classify? I think the reason for this taxonomic battle, if you wish, I think the reason for the failure of many differential diagnosis, the blurring of the lines, the comorbidities. And essentially nonsensical terms like emotional flashbacks, I think the essence, the reason for all this is because people react differently to trauma. Trauma is not an objective thing, it's not an objective mental health clinical entity. Trauma is actually not a mental health event at all. Trauma is a reaction. It could be a reaction to an internal event such as psychiatric illness, and it could be of course a reaction to an external event. It could be a reaction to other people. It could be a reaction to triggers, et cetera, et cetera. Trauma is a reactive pattern. And when it involves dissociation, it's a protective and defensive pattern of reacting, of coping with things that events that threaten to overwhelm the individual, to dysregulate the individual someone. Trauma is an attempt to re-regulate or at the very least to freeze and avoid complete meltdown and dysregulation. And because each one of us is different. We have different haircuts. We are differently resilient. We have strengths and weaknesses of character. We have different backgrounds, different upbringing, different predispositions, genetic and otherwise, et cetera, et cetera. There are not two people who react to the identical traumatic event the same. Not two people react the same to the same event. So on the face of it, you would need millions of types of trauma reactions. But that's of course not doable. So what we do do, we have baskets. We have baskets of post-traumatic or after-traumatic reactions. One basket is CPTSD. One basket is PTSD. And we had a third useful basket, IP case, which had been discarded for some reason. In between 1988 and 1992, there was a renaissance of study of trauma. Personality changes, which were reactive to trauma, were studied very deeply by Herman and many of her colleagues and later confirmed by Beltran, Silove, Gabbard, Weine, Tedeschi, Nienhuys, Wola, Evans and many others. So I just gave you a whole bibliographic list. There was this renaissance, this flourishing of trauma studies. And trauma and dissociations were rediscovered as perhaps the engine or engines behind most mental health issues and disorders. We had the work of Dell and others later. So there was a question which arose very early on, I would say, in the late 1980s. How do you distinguish personality changes, which are the outcomes of catastrophic events, from personality changes, which are the outcomes of other things, not catastrophic, not events even, other things. And at the time there was a task force appointed by the ICD-10 committee. And the task force decided to include in the ICD-10 this diagnosis, IP case. Personality traits such as hostile or distrustful attitude towards the world, social withdrawal, chronic feelings of emptiness and hopelessness, being on edge as if constantly threatened by pervigilance, estrangement, they all separated IP case, differentiated IP case from PTSD at the time. There was no CPTSD yet. And so the committee or the task force studied, for example, victims of genocidal trauma, including the Holocaust, extreme helplessness, humiliation, the destruction of a validating community, one's identity, sense of self-worth, ultimate existential loneliness, inability to rely on others, there are no others. Everyone is out for himself, there's a struggle for survival. And there's a lifelong vulnerability to shame. And these personality traits emerge after these catastrophes and then became dominant. And what happens is they became dominant, but people learned in due time how to repress, control, regulate, somehow stabilize these unwanted artifacts and gifts of the catastrophic event. And yet, in different points at the life cycle, when triggered by disruptive events, everything re-errupted, everything re-emerged, the helplessness, the shame, the humiliation, the separation, the loss, the grief. Even news events could trigger this. Even news events. For example, Holocaust victims exposed to news reports about antisemitism reacted this way. They simply fell apart. They fell apart. Similar events result in divergent personality traits among survivors. As I said, there's a problem with that. We don't all react the same. Even with the same survivor over the lifespan or life cycle, we have a different psychological profile when there is intensification of efforts to avoid massive grief or prolonged grief, as we call it today. And at the same time, there's a counterphobic adaptation, like I mentioned, repression and denial and everything. So there's this balance, this desperate attempt to not grieve anymore, to not fall apart anymore, to somehow cope well. But the triggers are everywhere. Triggers are everywhere and they can be very slight. So actually it's not working. Beltran and his colleagues tested actually the validity of the IP case diagnosis. They conducted a survey of clinical psychologists and psychiatrists. 89% of psychologists and psychiatrists surveyed agreed that personality can be altered, can be changed by trauma, which occurs in adulthood. So almost all professionals think that late onset trauma, trauma in late adulthood, can create personality changes that amount to personality disorders. Virtually everyone, 90 to 91% agreed that something like torture, something like concentration camp exposure, or even maximum security prison with very dangerous criminals, they're likely to produce changes in personality. 72% of mental health practitioners thought agreed that war exposure could create such changes. 66% agreed that aggravated sexual assault can cause this. 57% thought that hostage situations can alter personality. 52% domestic violence, 25% natural disasters, and 24% motor vehicle accidents. Now notice the disparity. When the catastrophic event is mediated by a human being, when it's brought on by a human being, the effect is much bigger. When you are tortured by another human being, when you're sexually assaulted by another human being, when life is threatened by another human being, when human beings construct total institutions to imprison you or hold you hostage or when other human beings are involved, the trauma is much bigger, much more pervasive, much more all-invasive, much more all-consuming and changes your personality much more deeply and profoundly for a much longer period of time. When on the other hand the catastrophic event is either natural or technical-mechanical, the impact is much less reduced. Only 25%, only one quarter of psychologists and psychiatrists agreed that natural disasters and car accidents, for example, should induce a change in personality. They disagreed and they're right because these events usually generate PTSD, post-traumatic stress disorder, not EAP case. And despite these consensus, which is rare by the way, it's rare to find such a level of consensus. Only 16% of clinicians had ever used EAP case as a diagnosis, either because of ignorance or because they weren't quite sure how to apply it or because it's very rare to come across such a level of catastrophe. There's a symptom overlap, of course, between EAP case and depressive disorders, borderline personality disorder, of course, CPTSD. This symptom overlap makes it difficult, you have to be daring to say, no, this is not CPTSD, this is EAP case. EAP case is marked by stable changes in personality. Borderline and depressive disorders involve instability, they involve liability, they involve dysregulation. EAP case actually generates stable outcomes, outcomes stable for at least two years, very often across the lifespan. Post-traumatic avoidance of reminders by patients infects the clinician. The clinician realizes that some things might trigger the patient, some things might retraumatize the patient, so the clinician avoids these things. This limits the discourse and the honesty of the therapeutic alliance. The clinician begins to work on actions, especially in catastrophic trauma, and so clinicians steer away from this. They don't want to harm the patient or break the patient apart, and it's, of course, unfortunate. It's very unfortunate because EAP case characterized mostly by existential loneliness, as we said. EAP case is a breakdown in communal societal and cultural context. It's like being thrust out of your natural habitat or ecosystem, finding yourself on a totally alien and hostile planet, Venus or something. So there is consequently a transgenerational or intergenerational transmission of suffering. So EAP case would require group therapy as a vital modality. And several generations have to be treated together so that we can engender, we can foster transgenerational transmission of resilience. Beltran is one of the greatest advocates of EAP case, and in 2002 he conducted follow-up studies. He defined the broad aspects of the diagnosis, he identified the key criteria, and so on and so forth. And there were 24 mental health practitioners and clinicians. They worked with patients who experienced war and sexual assault, and also with displaced refugees. And these 24 gathered all the information. And they discovered that the key attributes are a hostile or mistrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being on edge, et cetera, et cetera, which I mentioned earlier, I mentioned before. But all these were excluded from the diagnosis of complex trauma or CPTSD. EAP case today is an extreme case of CPTSD. It is in the manuals in both the DSM and the ICD-11. But these critical features are nowhere to be seen. They're not there. So it's very difficult to diagnose EAP case. Other significant features which were largely, I mean, these features that I just mentioned are there, but not in the way that I mentioned them. So it's very difficult to kind of hone in on the difference between complex trauma and EAP case. There are some features that are not mentioned at all, somatization, self-injurious, self-damaging behaviors, sexual dysfunction, enduring guilt and shame. These are nowhere to be found in the text. While hostility, distrust, social withdrawal, emptiness, hopelessness, hypervigilance are somehow hinted at, not elaborated as they should be, but into that, the other features I just mentioned, from somatization to sexual dysfunction and self-harm, guilt, shame, they're not mentioned. They're simply not mentioned at all. And there, of course, they make the difference between EAP case and CPTSD. Manifestations of course, symptoms of EAP case differ depending on viewpoints, type of trauma, the victim. There are multiple symptoms that could fit into the same vague sentence. So for example, if I say one of the diagnostic criteria of EAP case is a hostile or mistrustful attitude towards the world, what do I mean by that? Why do I mean by that? Anger? Aggression? What do I mean by that? That's not specified, not defined. Holocaust survivors were identified as feeling as if the Holocaust experience was continuing, and these people were more likely to suffer symptoms of mental disorder. Those who avoided the traumatic memories altogether, they had a higher mortality rate due to illness. One way or another, the Holocaust continued well after 1945 and ended up killing them. Patients with EAP case, this diagnosis isolated themselves, not only from communities, but often from mental health care. So what can we do about it? What can we do about it? EAP case, as it stands now, is under-researched. It lacks specificity. It's not properly normatively validated. It's insufficiently utilized. So it was worked by Merker and colleagues and the other ones who proposed to reconceive of EAP case as a part of CPTSD, complex PTSD in ICD-11, Merker, M-A-E-R-C-K-E-R. Merker and his colleagues are responsible for subsuming EAP case under CPTSD, but was this the correct recommendation? CPTSD deals with patients with personality changes as a result to exposure to single or multiple traumatic experiences. As long as a requirement, the requirement of three core features of PTSD is met. Changes in effect, self-concept and relational function. That is CPTSD. But some of these don't apply to EAP case. When we modify the diagnostic criteria of CPTSD to consolidate EAP case and include it there, to shoo-vorn, to push, to coerce other trauma-related disorder into CPTSD, the CPTSD diagnosis, this leads to mislabelling. And also we downgrade the seriousness of some personality changes. It's not only a question of effect or self-perception or its personality changes, the whole personality changes. It's like a different person, a different person. And we, of course, overlook the potential for trans-generational transmission of these personality changes. Different experiences do produce different neurological and behavioral effects. I am not disputing this. I said it before. But it would be unwise to disregard the extent, the intensity of the event, how extreme it was, and its impact on effect. So I think we should embark on reconceiving of EAP case. We need maybe a set of diagnostic criteria. Symptoms. We need to incorporate symptoms such as somatization, self-harm, sexual dysfunction, et cetera, et cetera. And this way, we could still consider it a form of CPTSD, but with very highly specific criteria. And honestly, I don't think it should be a form of CPTSD. The current criteria for CPTSD, which, as I said, subsume the majority of people who used to be diagnosed with EAP case. You know, Keeley, K-E-E-L-E-Y, Keeley and his colleagues, they studied 18 diagnostic issues in CPTSD and the same 18 diagnostic issues in EAP case, in order to see if the two are concurrent or concomitant. They are not. EAP case and CPTSD, the reactions to these 18 issues is absolutely not the same. Another argument against including EAP case in CPTSD is symptom overlap. There's a spectrum of post-traumatic disorders. As I said, there's overlap between diagnostic categories, even between PTSD and CPTSD. Actually, CPTSD, the core of CPTSD is PTSD. There's a lot of overlap, but these overlaps and similarities don't invalidate the clinical usefulness of a diagnosis. Otherwise, we wouldn't have diagnosis. All diagnosis of overlaps, I don't know, all the lines are grandiose, exactly like most of us. So should we not have separate diagnosis? Maybe not. My view is that we shouldn't. But there are other examples. For example, in the manic phase of bipolar disorder, there's a lot of grandiosity. So should we say that bipolar and narcissism are the same? Of course not. There is overlap in symptoms because we are all human beings and we share the same wet wear, the same brain, the same processes and mechanisms. Watch my video on the IPAM model, IPAM. And so I'm not impressed or convinced by this argument. Or the symptoms are the same or largely the same. We don't need another diagnosis. We need to be parsimonious. I'm not convinced by this. Similarly, I think that the rejection of masochistic personality disorder, sadistic personality disorder, negativeistic, passive-aggressive personality disorder, all these dead diagnoses, these are mistakes. These are real clinical entities as distinct maybe from other clinical entities which appear in the DSM and which I would have eliminated without hesitation. They're not real. They are cultural artifacts. They are all kinds of fads and fashions and so on. So IP case should be a category. We should include it. With clinical reasoning, differential diagnosis, treatment planning, prognosis, everything. In the DSM-5 text revision, elements of complex post-traumatic stress disorder, complex trauma and IP case were actually incorporated in a single diagnosis of PTSD. So in the previous edition, in the DSM-4, there was an unquoting. The DSM-4 suffered from poor inter-rater reliability of personality disorder diagnosis, poor stability over time, poor discriminant validity, and poor general coverage of personality disorder as well as poor clinical utility. I agree. It was poor. The DSM-5 is poor. The DSM-4 is poor. It was poor. The DSM-5 is still poor because it incorporates the DSM-4. DSM-5 requires that adult patients being evaluated for stress disorders meet eight symptomatic criteria following exposure to trauma. Galatzel Levy and Bryant found that the current diagnosis for PTSD could give rise to, hold your breath, 636,120 unique combinations of the eight criteria listed. So the same eight criteria can give rise to essentially, and I'm repeating the crazy number, 636,120 different types of PTSD. That's not a clinical entity. That's ill-defined. And one of the reasons there's such a mess is because in the DSM-5, they try to put in the ICD-11, they try to put post-traumatic clinical entities in the same basket. Whereas many personality disorders are just facets of one underlying personality disorder, something I've been advocating for 25 years. It's not the same with trauma. It's not the same with trauma because personality disorders are induced in early childhood when we are all very much the same. Children are not that different to each other. Well, they are different, of course, but not that different. Trauma can happen at any time in life, and by the time we encounter trauma, by the time we experience it and suffer from it, we are already vastly different to each other. And this is reflected in the need to have several types of post-traumatic diagnosis. One personality disorder is sufficient to cover all adverse childhood experiences and the said outcome of personality disorder. Many, but we need three or four types of post-traumatic conditions to capture the totality of the post-traumatic experience. And because there are so many possible permutations of these eight criteria, PTSD uses a basket diagnosis. An all-encompassing definition with no specificity and no real attribution or applicability. Trauma-related disorder shouldn't be a one-size-feet-all basis. It should consider the elements of the trauma and its disparate effects on individuals. So, I think, and as you see many others think, that APKs should be restored. And the question is then following the trauma, when there are personality changes, are they comparable or do they amount to personality disorders? Are we talking about personality disorders? So there are studies, comparisons of late onset personality pathology due, for example, to wartime trauma, comparing these to prior personality disorders. So about one quarter, 24.3% of the patients had a personality disorder developed only after exposure to catastrophic events. So the answer to this is yes, major catastrophic events can create the absolute diagnostic clinical equivalent of a pre-existing personality disorder. So if you have narcissistic personality disorder from age 18, dating back to age 18, and if you have borderline personality disorder dating back to age 12, someone who is undergunned trauma such as war, torture, life threat, etc., etc., captivity, and so on, can develop actually narcissistic personality disorder, borderline personality disorder, which will be indistinguishable from yours, will be indistinguishable from the real thing, clinically diagnosable. When compared with those who had pre-existing personality disorder, those with late onset personality pathology had a three-fold higher rate of PTSD symptoms. That's a very important distinguishing feature. While in classical personality disorders, the kind we discuss on this channel, PTSD symptoms are subdued, they're denied, they're repressed, they're sublimated, they're refrained, they are converted. In people who suffer trauma in adulthood, the PTSD symptoms are very pronounced, and there are three times as pronounced, they occur three times as often as in typical personality disorders, where higher rates, for example, suicidal ideation, self-reported emotional distress was much higher. So trauma in early childhood, believe it or not, is tackled, absorbed, assimilated, and coped with much better than in late life, later in life. Adult trauma is much more severe and has much more extreme pathogenic consequences than early childhood trauma. There's been additional research shown that has demonstrated that there are physical changes to the brain and transgenerational effects that pass from parent to offspring. So there's a link between catastrophic experiences, personality, neurology, or the neuroscience of the brain, and transgenerational societal communal function. So we need, of course, something that integrates all these in a separate diagnosis. This, everything I've just said has almost nothing to do with CPTSD, and yet IP case is now part of CPTSD. Alongness, helplessness, and helplessness about being alone, feeling ashamed, humiliated, these are major risk factors across this particular illness spectrum. In post trauma, aloneness in itself leads to added grief, and persons who suffer from IP case are very vulnerable people, and this compounds these risk factors. So we need this important step of having a separate diagnosis, recognize all these differences. I refer you to the literature in the bibliography, but until then I want to read to you an abstract of an article titled, Lasting personality pathology following exposure to severe trauma in adulthood, Retrospective cohort study. It was offered by Yasna Munizah, Dolores Brithwitz, and Mike Crawford. It was published in BMC Psychiatry, Volume 19. And what do they have to say? They say early exposure to trauma is a known risk factor for personality disorder. But evidence for late onset personality pathology following trauma in adults is much less clear. We set out to investigate whether exposure to war trauma can lead to a lasting personality pathology in adults, and to compare the mental health and social functioning of people with late onset personality problems with those with personality disorders. And so they go on, they studied, I think about 182 people and so on and so forth, and they conclude. They reached some interesting conclusions. Among 182 participants with probable personality disorder, 65, it's about 36%, reported, that this problem started after exposure to war trauma as adults. The most prevalent personality problems among those with late onset pathology were borderline, avoidant, schizotypo, schizoid, and paranoid. Participants with late onset personality pathology were more likely to have schizotypo and schizoid traits compared to those with classic personality disorder. Participants with late onset personality pathology were three times more likely to have complex personality pathology across all three DSM4 clusters compared to those with classical personality disorder. After we adjust for gender, marital status and so on, the prevalence of depression and social dysfunction were as high among those with late onset personality pathology as among those with a personality disorder. And the conclusion is retrospective accounts of people with significant personality pathology indicate that some develop these problems following exposure to severe trauma in childhood. Personality in adulthood, I'm sorry, let me read this again. I'm thinking of retrospective accounts of people with significant personality pathology indicate that some develop these problems following exposure to severe trauma in adulthood. Personality related problems which start in adulthood may be as severe as those that have an earlier onset. These findings highlight the long term impact of adulthood trauma on the mental health and have implications for the way that personality pathology is classified and treated. The authors then proceeded actually after the study and they say, we further examined the relationship between the two groups, personality disorder and late onset personality problems. According to the number of cases meeting, diagnostic criteria for personality traits across the DSM4 conceptual clusters. And so they analyze various criteria and so on and so forth and they reach the following conclusions. Participants, the conclusion that I mentioned before, participants in late onset personality pathology group were likely to meet criteria in all three clusters, cluster A, cluster B and cluster C. And their pathologies, more than 80% of patients with late onset personality disorder reported having persistent feelings of emptiness, frequent mood changes and having anger regulation problems. Equally high proportion of these people, late onset personality disorder in adulthood. Equally high proportion of these people reported avoidance of social interactions and preferring doing things by themselves to minimize contacts with others. More than two thirds reported feeling cold and detached and having difficulties showing emotions. The same proportion did not feel they could trust other people. More than 80% felt that they have been treated unfairly by others, including experiencing attacks on their character and reputation. Impulsiveness and identity problems were reported by more than 60% of participants in this group. More than half of people in this group reported feeling odd and eccentric, being rigid and inflexible and being sensitive to criticism. The results say the authors suggested that anxiety, post-traumatic stress disorder, PTSD, social functioning and suicidal thoughts significantly differed between groups when the demographics of the patients were not considered in the analysis. For all variables where there was a difference, outcomes were more likely in the late onset personality pathology group than in the personality disorder group. After adjusting for gender and marital status, significant differences in PTSD and prevalence of suicidal thoughts between the two groups remained. An additional and important finding was that people with late onset personality psychopathology, following exposure to severe war trauma, were three times more likely to meet the criteria for personality problems across all three DSM4 conceptual clusters than the personality disorder group, as I mentioned before. These findings suggest that the complexity and degree of personality related problems in patients with late onset personality pathology is greater than in those with personality disorders alone. The finding indicating that a considerable proportion of patients met threshold for two or more personality traits is consistent with prior research, which suggested that most people with a diagnosis of personality disorder do not fit into a single personality disorder subcategory, comorbidity problem. Instead, people tend to meet criteria for two or more subcategories, within one cluster, or across two or even all three clusters in late onset pathology. When compared to personality disorder patient, the late onset personality pathology group had equally poor mental health and social functioning and similarly high rates of unemployment. Late onset personality pathology patients were three times more likely to suffer from PTSD than their personality disorder counterparts. These results indicate a strong need for trauma focused therapies to reduce PTSD related symptomatology, although these may not be readily available in countries devastated by war, for example. So, if we take for example suicidal ideation, 68% of people with late onset personality pathology, 68% of people whose personality change owing to trauma in adulthood, 68% considered suicide, compare this to 11% in borderline personality disorder. Or 47% across the lifespan of all people with personality disorders of all kinds. So, people with late onset personality pathology have levels of emotional distress that are higher than patients with personality disorder. These symptoms appear to be enduring. The impact of interpersonal functioning is sometimes as long as 15 years following exposure to some catastrophic trauma. This is not a minor thing. This changes you. Such traumas change you. A proportion of people who are exposed to severe trauma such as war, torture, captivity and so on, they develop personality related pathology in adulthood. Patients with late onset personality problems had equally poor mental health and social functioning when compared to personality disorder patients, as we said. And these findings highlight the long term impact of severe trauma. Long term impact on mental health and implications for the way the personality pathology is classified and treated. We need a case simply because it's very real.