 Anxiety is an irrational fear. It is the outcome of cognitive distortions, biases, and processes such as catastrophizing. Introjects which are harsh and sadistic can also cause anxiety. So anxiety could be exogenic or endogenic. In other words, anxiety can come from the outside anticipation of some event, fear of the unknown, uncertainty, indeterminate situations, something we are heavily emotionally invested in and the outcome matters to us a lot. All these generate anxiety and this anxiety is coming from the outside. It's exogenic but there is also endogenous or endogenic anxiety. Anxiety that is the direct result of experiencing internal processes and being unable to cope with them. And so Freud, of course, was the first to describe anxiety, later anxiety in rosses and he suggested that anxiety happens in two situations, two circumstances. Anxiety occurs when we repress an uncomfortable material. He called it unpleasurable material, material that is inconvenient, fearful, traumatizing. When we repress this material, when we cut it off, slice it off our consciousness, it is still down there in the unconscious. It simmers and sieves and boils and creates a lot of energy and this volcanic energy yields anxiety. And the other case said, Freud, is we become anxious and then this creates a defensive reaction, activates a defense mechanism. So according to Freud, we can become anxious because of an internal process, repression, or we can repress, we can engage an internal process to deny information that is somehow ominous and pleasant, inconvenient and we wish to forget it. So this is the classic view, the psychoanalytic view of anxiety. But today we are going to discuss some other aspects of anxiety and we're going to borrow from other schools of psychology. The core emphasis of this video lecture is how do mentally ill people cope with anxiety. Something I know everything about, trust me. My name is Sam Baknin, I'm the author of Malignant Self-Love, Narcissism Revisited and a former visiting professor of psychology, mentally ill people don't cope with anxiety the same way you do because they're mentally ill. And so they develop special ways to handle anxiety, to manage it, to sidestep it, to convert it into something more manageable, something more tolerable, something more bearable and to prevent anxiety from adversely impacting their functioning, prevent anxiety from rendering them dysfunctional. Today we know that anxiety disorders are very often comorbid with personality disorders and in some cases they underline the personality disorder. There's good grounds to believe that psychopathy is a way to cope with anxiety disorder. Anxiety disorder is extremely common in borderline personality disorder. So common in fact that it might be an inevitable feature of the disorder as we shall discuss a bit later. There are five ways that mentally ill people cope with anxiety. And briefly they are dissociation, conflation, reframing, reciprocal inhibition and externalization. Now these are all very very big words and I'm going to elaborate on each and every one of them so that by the end of this video lecture if you're mentally ill you will know how to cope with your anxiety with a whole brand new repertory courtesy of Samvaknin which is me. Okay rather than repress angziogenic content as most people do, healthy people when they come across content when they come across information or data that causes them displeasure, fear, they feel threatened, is inconvenient, they would rather forget it. When they come across such content they usually repress it and the repression itself as Freud had observed can create anxiety but the repression is such a repression is such an effective defense mechanism that ultimately the anxiety is reduced and ameliorated. Mentally ill people cannot repress efficaciously. They cannot repress efficaciously for reasons that are not going to right now but many of the defense mechanisms of mentally ill people are heavily compromised, the process known as decompensation. So actually we can define, we can say that mental illness is a situation where your defenses are not working in a way. So rather than repress the content that causes anxiety, mentally ill people adopt five dysfunctional solutions. Let's start with externalization and aggression. Sometimes when a mentally ill person becomes anxious he and I'm going to use he throughout but of course it applies to women equally. Okay get the gender thing obsession out of your mind please. So when the mentally ill person becomes anxious he wants to hand over his anxiety to other people, to outsource it, to farm it out, to share the anxiety. Misery loves company, anxiety loves company twice. So the mentally ill person wants to share his anxiety with others by rendering them, making them anxious. They are anxious, he is anxious. There's common, a commonality of anxiety which then in itself is anxiolytic, reduces the anxiety. So many anxious people for example psychopaths externalize the anxiety and become aggressive. The only way to transfer anxiety to someone else is to make them anxious and the best way to make someone anxious is by becoming aggressive. Very often anxious psychopaths are by far the most dangerous hair trigger and aggressive and violent because their anxiety is utterly intolerable and unbearable. So this is solution number one. Externalizing your anxiety via aggression causing everyone around you to become anxious and then you're just one of many and anxiety loves company and you feel safe, the safety in numbers. The second mechanism is to conflate external with internal objects. Anxiety is perceived as coming from the outside very frequently. Even when anxiety is a response to internal processes and mechanisms, we tell ourselves that it has something to do with something outside. We in other words, always attribute to anxiety external causes. We treat angiogenic content content which causes anxiety as if it were coming from the outside never from the inside and again even when anxiety is endogenic, when it comes from the inside, when the reason is internal, when the etiology is internal, when there are internal processes that cause anxiety, even then we will desperately try to find an external reason why we are feeling anxious. So one of the solutions is to conflate internal with external objects, to confuse the two, to say that this is not internal, this is external, this voice is not in my head, it's there at the corner of the room. This image is not in my mind, I see it as clearly as the day. Hallucinations, delusions, hyperreflexivity and psychosis where internal content of the mind is perceived as external and there is a kind of global cosmic merger and fusion and expanding out of the mind to incorporate the universe itself. Now why is this a solution to anxiety? Why is this process anxiolytic? Because if everything external is internal it creates an internal locus of control or actually an illusion of an internal locus of control and similarly if internal objects which are ego dystonic, discomforting, unpleasant, threatening, if these internal objects are actually perceived as external then they have no power over you. So the mentally ill person, for example the narcissist, the psychotic, what they do is they confuse internal and external objects either in order to restore a semblance, a self-delusion of control over the situation by saying these external objects are actually inside me so I can fully control them or the exact opposite by saying these internal objects which are out of control and are causing me anxiety are actually not inside me, they're external and so they have no impact on me, they cannot affect me from the inside, they cannot poison me from the inside. It's like outsourcing the poison, projecting the anxiety, throwing it away into the into the core into a corner. So the second mechanism, so the first mechanism to remind you is externalizing the anxiety causing other people to become anxious thereby sharing the anxiety and reducing your share of the anxiety so it reduces its anxiolytic. The second mechanism is to confuse or conflate internal and external objects so that you can convince yourself that you're actually in control of the situation or that the situation has nothing to do with you so you don't need to be anxious, you don't need to be afraid. The third mechanism is closely allied to the second mechanism and it is reframing reality to the point of impairing reality testing because reality is perceived as threatening, as unpleasant, as discomforting or discomforting, as frightening, you know. You don't want to be in this kind of reality, it causes you anxiety all the time especially if you're mentally ill. So one way to cope with it is to rewrite reality, to create a totally new narrative where these threats and unpleasant facts and fears don't exist. They don't have a good reason to exist because having written reality, having created a paracosm, a virtual environment, an alternative augmented reality, having done this you will have removed all the elements in reality which are anxiolytic which cause anxiety. And so one way to cope with anxiety in mentally ill people is an automatic because this is an automatic process. It's something very similar to automatic negative thoughts, it's an automatic process. So a way to cope with anxiety perceived always, you remember, as coming from the outside, is to change the outside, to impair your own reality testing, to lie to yourself about reality, to invent a new reality, to write a new script for a new movie, a new theatre play with new actors and new situations which are not threatening, which are not anxiety inducing. Reframing reality and impairing the reality testing is a third mechanism. The fourth mechanism is an example of such impairment of reality is paranoia. Paranoid ideation and paranoid personality disorder these are forms of reframing, rewriting, reinventing reality so as to render it less threatening and less anxiety producing. The paranoid convinces himself and the conspiracy theorist as well by the way. The paranoid convinces himself of two things. One, he is important, he is at the centre of events and conspiracies. He is in other words powerful. He attributes to himself potency or even omnipotence. The paranoid, paranoia, paranoid ideation is a form of narcissism. So, the paranoid impairs his reality testing by grandiosly rendering himself crucial. He develops an inflated fantastic view of himself which in his mind makes him invulnerable, untouchable, impermeable, not at risk. This is the first element of paranoia and the second element of paranoia the paranoid tells himself I'm smart. I have uncovered the conspiracy. I know exactly what they're doing and therefore they're never going to surprise me. They're never going to get to me. They have nothing on me. They're not going to touch me. It's another form of omnipotence. So these two elements of the paranoid delusion, the persecutory delusion, I am being conspired against. I am being the target of malevolent scheming because I am godlike. I am very important. And because I'm all-knowing and I have my spy network or whatever, I'm going to know everything well in advance and they're not going to surprise me. And this is an example of reframing reality and impairing the reality testing in mentally ill people as a way to mitigate and ameliorate anxiety. Again, a recap. When you teach, you learn to recap all the time. Students have a shorter and shorter and shorter attention span nowadays. Mental ill people cope with anxiety in five ways. And I've described three of them by now. Number one, externalizing the anxiety via aggression, making other people anxious so that you feel good. Your anxiety is shared so it's reduced. Number two, confusing and conflating external and internal objects so that you feel that you're in control of these objects and that they are not going to hurt you. They are irrelevant to you. The first solution, externalizing aggression is psychopathic. The second solution is narcissistic or psychotic. The third solution is to reframe reality and impair reality testing by rewriting a new narrative, a new script. You render yourself immune to the consequences of your own actions or immune to danger and threat. This is typically a paranoid solution. And so now we can move on to the fourth solution. The fourth solution is called reciprocal inhibition. It was first described by Joseph Wolpe, a South African psycho behaviorist actually. He belonged to the behaviorist school of psychology. Wolpe developed a technique to reduce anxiety by forcing or asking his subjects the minute they feel anxiety to think about something else. He realized that you cannot occupy your mind with two signals, with two messages, with two types of content. So if your mind is consumed by anxiety and then you are forced to think about something else, the anxiety will go away. And this is called reciprocal inhibition. And it was used to great effect to treat war veterans with what at the time was called worn neurosis. Worn neurosis is what we call today post-traumatic stress disorder. It is deep. So reciprocal inhibition is at the core of obsession and obsession on neurosis. Now there's a video I've made a few days ago about obsession on neurosis and I recommend that you watch it. In a nutshell, a mentally ill person, when they are confronted with anxiety, force themselves to think about something else. They force themselves to engage in a type of activity which is ritualistic, symbolic, and has content which is anxiolytic. So when the mentally ill person is confronted with a rumor, a situation, a bit of his own imagination, catastrophizing, internal processes can arise. Anything that causes him anxiety, the obsessive compulsive person, which is a type of mental illness, the obsessive compulsive person will develop intrusive thoughts. These intrusive thoughts will occupy the totality of his mind so that there's no place left for the anxiety. Simply, the intrusive thoughts displace the anxiety. Trash it. It's gone. So much time and effort and resources are invested in the recurring unwanted intrusive thoughts and in the attempts to get rid of them. That the obsessive compulsive person forgets the anxiety altogether. And this is an example of self-administered reciprocal inhibition. Moreover, the rituals of obsession compulsion, the compulsive component in obsessive compulsive disorder, washing hands all the time, relocking your door 10 times, walking on odd pavement stones, whatever. These rituals, they also involve a lot of cognition. The obsessive compulsive person says to himself, if I were to wash my hands 10 times, something bad, something bad would be prevented. Washing my hands would prevent something bad from happening to me or to my loved ones, usually to my loved ones. So the catastrophizing, the anxiety of the impending doom and gloom, they are washed away by washing your hands. The ritual or the rituals and ceremonies in obsessive compulsive disorder, they are part of larger cognitive, cognizant, conscious narratives. And these conscious narratives consume the obsessive compulsive's attention, mental resources, so that there's nothing left for the anxiety. This is precisely why obsessions and compulsions are anxiolytic. They reduce anxiety. They provide a sense of relief because they take over so much, so many of the mental resources, so much of the psychological attention of the obsessive person that there's nothing left available for anxiety, for the anxiety, and it goes away. The fourth solution is attempt to cope with anxiety via reciprocal inhibition that devolves in due time into obsession or obsessional neurosis with intrusive thoughts and then compulsions with rituals which are symbolic and have a strong component, a strong counterpart in the unconsciousness. And this preoccupation is so extreme that it leaves no place or time or energy to anything else, let alone anxiety. So the anxiety goes away. That's the fourth solution. The fifth solution is the most complex by far, and it's dissociation. The example of borderline personality disorder is the most perfect. When we discuss dissociation as an anxiolytic tool, dissociation is a way to get rid or control or ameliorate or mitigate or transform anxiety into something else. Association is the strongest tool in the strongest weapon in the arsenal, the strongest tool, strongest instrument, and it is used only in extreme cases where the anxiety is absolutely all pervasive. It debilitates the individual. It doesn't allow the pursuit of any life goals and the enactment of any daily routine. So it's an anxiety that constricts life, narrows it to almost to the point of vanishing. That the mentally ill person first tries to conflate external with internal objects. This is essentially a narcissistic defense, and it can become a psychotic defense. Indeed, many mentally ill people have psychotic micro episodes. So this is the first defense. Second defense is an attempt to reframe reality, to impair the reality testing. So there are delusions. There could be paranoid delusions, other types of delusions, rewriting reality, so as to render it more safe and less anxiety inducing. Then the third attempt, third strategy is to try to inhibit the anxiety by occupying the mind with something else, reciprocal inhibition. If I have intrusive thoughts, I don't have time for anxiety or space or energy. If I'm engaged in rituals which consume 80% of my time, of course, I don't have anything left for my anxiety. So my anxiety goes away. That's the third attempt. The fourth attempt is externalization, aggression, trying to involve other people in your anxiety somehow, usually by rendering them as anxious as you are. And when all these fail, when all these fail, the anxiety leads to dysregulation. Yes, the famous emotional dysregulation is, of course, the outcome of anxiety. The person with emotionally dysregulated person is someone who feels overwhelmed by emotions. She feels or he feels is about to drown, is about to disappear. And to counter this anxiety, and this creates a lot of anxiety, of course, and to counter this anxiety, there is dysregulation, a desperate attempt to try all kinds of intensities and frequencies of emotions in order to see what works. It's a dysfunctional method for modulating and regulating the internal environment, which leads to adverse outcomes of dysregulation. So it all starts with anxiety. And borderline personality disorder is, therefore, an anxiety reaction, which involves, first and foremost, the fifth and most extreme way of coping with anxiety dissociation. I'm going to read to you an extended segment from this book. I hope the camera catches it. It's a very big book and a very small camera. It's called Dissociation and the Dissociative Disorders, DSM 5 and Beyond, was edited by Paul Dell, John O'Neill. There's a second edition, it's a second edition, but the second edition and the first edition contain a lot of different material. So the second edition is actually a second volume, not a second edition. Don't discard your first edition when you buy the second one. You're going to miss out on a lot. I'm going to read to you from the first edition, actually. I'm going to read to you what scholars have to say about borderline personality disorder and the dissociative defense and bear in mind that at the core of all this, the reason for all this, the engine that drives all this is anxiety. The person with borderline personality organization is terrified of the power, the evasiveness and sometimes the malice of his own emotions. He's trying to counter this, he develops anxiety and this regulates. And then to forget the anxiety, simply to forget the anxiety or to dissociate himself from the anxiety, to disassociate himself from the anxiety. The person develops dissociative defenses such as amnesia, depersonalization and derealization. It's like saying I'm going to put distance between me and my anxiety. I'm not going to be me, depersonalization. This is not real. This anxiety is not real, derealization. Or I'm going to forget all about it, amnesia. And now what the scholars have to say, although much literature attributes affect this regulation in borderline patients to post-traumatic sequelae, difficulties with affect regulation are also characteristic of dissociative disorders. Moreover, dissociation can be both a cause and an effect of affect this regulation. How is dissociation related to personality disorder, especially borderline personality disorder? Kernberg in 1975 has suggested that splitting, which he views as a primitive form of dissociation, underlies the larger category of borderline personality organization that includes borderline, narcissistic, antisocial and addictive character disorders. Kernberg described these patients as having contradictory characteristics without real awareness of the conflictual nature of the material, lack of clear identity, and mutual dissociation of contradictory ego states reflecting early pathological internalized object relationships. Quite a mouthful. Kernberg's conceptualization clearly portrays a disorder of dissociated ego states. Similarly, Bromberg in 1998 views all personality disorders as based in dissociation. The underlying structure of dissociated self-states in narcissistic, psychopathic, schizoid, sadistic and masochistic personality has been discussed elsewhere. They refer to work by Blizzard and Orwell and others. Rather than focus on broader conceptions of personality or borderline organization, we will focus on the more narrowly defined borderline personality because, one, borderline patients present more frequently for treatment, and two, they have become the bec noire of many clinicians, and three, the configuration of dissociated self-states in borderline personality disorder differs from the dissociative patterns characteristic of other personality disorders and post-traumatic stress disorder. While the term borderline has been applied to many different patients, we propose that the core group of people, generally designated by this vexing term, are those stably unstable people whose sudden alterations in mood, sense of self and relationship to others are manifestations of partially or fully dissociated self-states. When dissociation is partial, there is usually one continuity of identity. Two, superficial awareness of abrupt changes in effect or behavior. Three, minimal ability to link these states in consciousness. And four, little acknowledgement of the significance of these shifting states. Often conceptualized as splitting, these shifts are not assessed by tests of dissociation, such as the dissociative experiences scale, DES. And so this is an introduction to the topic of dissociation in borderline personality disorder. And now, let's delve a bit deeper and bear in mind, all this is done to avoid unbearable, intolerable, crippling, debilitating, soul ruining, soul destroying anxiety. Anxiety, which for example, is attendant in trauma situations. When you traumatize, you become very anxious. And when you traumatize, you become anxious, because the trauma itself exacts a very heavy price, very heavy mental price. And because trauma, having endured trauma, having experienced trauma, teaches you, teaches you helplessness. Trauma leads to learned helplessness. Then you feel defenseless, you feel helpless, you feel impotent. And the world is becomes a hostile, dangerous jungle. If you are helpless and defenseless, anyone can do anything to you. It's very anxiety inducing, you become anxious. The trauma leads to anxiety. And dissociation is an attempt to get rid of the anxiety by slicing off the trauma, pushing it down as far down as possible to the unconscious. In extremes, this is exactly dissociative identity disorder. And I'll read to you the second and last segment from this book, wonderful book by the way. Although the fourth edition of the DSM considers borderline personality disorder and dissociative identity disorder to be separate disorders, the shifts between dissociated self-states in borderline and in DID are very similar. Perhaps it makes better sense to think of borderline and of DID in terms of their commonality. In other words, dissociated self-states. Rather than think of them as distinct disorders that may be comorbid. Our formulation of borderline personality disorder as a disorder of alternating dissociated self-states is consistent with the DSM's description of borderline personality disorder. This is how the DSM describes it. Profound changes in self-image affect cognition and behavior, sudden and dramatic shifts in their view of others who may alternately be seen as beneficent supporters or as cruelly punitive. There may be an identity disturbance characterized by unstable sense of self and dramatic shifts in self-image, goals, values, sexual identity and friends. Now this is known as identity disturbance. The DSM4 description of BPD closely mirrors the identity shifts that occur in DID. It is also similar to the DSM's description of DID. And again I'm quoting, the presence of two or more distinct identities or personality states each with its own relatively enduring pattern of perceiving, relating to and thinking about the environment and about the self. And so although inability to recall personal information is required in most types of DID, the definition of borderline personality disorder neither includes nor excludes this criterion. And so what are the signs that BPD can be understood as dissociated self-states? In other words, what are the signs that BPD can be understood in terms of dissociated self-states? Number one, unstable relationships, identity disturbance and effective instability can be viewed as the direct consequences of shifts among partially dissociated self-states. Number two, fear of abandonment, anxiety, separation in security is also called abandonment anxiety. Fear of abandonment, difficulty controlling anger and transient psychotic symptoms may all arise when traumatic memories are triggered and distinct self-states are activated. Mind you, if you know that you cannot control anger, if you realize how dysfunctional and dysregulated you are, that in itself, that knowledge in itself is cause for anxiety. Number three, substance abuse may serve to facilitate a shift to an emotionally numb self-state in an attempt to self-medicate overwhelming effect. Substance use also creates anxiety, by the way. Number four, sexual impulsivity may be the manifestation of a dissociative self-state reenacting earlier abuse. Dissociation is the final desperate nuclear weapon when the mentally ill person tries to cope with anxiety that threatens to devour and engulf him. And these are the five stages of dysfunctional coping with anxiety in mentally ill people. If you have identified any of them in you, don't panic, talk to a licensed therapist or a psychologist who is an expert in diagnosis, a diagnostician. Some of these dysfunctional methods or strategies of coping with anxiety happen, occur, even in healthy people, under extreme conditions of stress when stressors are present, for example, divorce or pending imprisonment. So don't be alarmed if they do. The bigger context is needed. There is a clinical picture of mental illness and then one or more of these strategies, there's ways to cope with anxiety, which either generates the mental illness or is its outcome. So I know this lecture caused you a lot of anxiety and you may wish actually to try reciprocal inhibition. Whenever you're anxious, force yourself to think of something else. Just sit down, tell yourself, now I'm going to think about whatever, but make sure that you think only about this. Generate artificially an intrusive thought. You will see that it works. Joseph Wolpe, W-O-L-P-E, for those of you who are interested to learn more about reciprocal inhibition. This inhibited lecture that at its end, I wish you all reciprocity and love.