 My name is Sam Vaknin. I'm 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? Or 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. If your abuser is special, you're special. If there's no one as demonic as your abuser, then poor you. Poor you is 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 prey. 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. 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. He's 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 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 attachments, dissociative self-states, arrested development, infantilism, regression to infantile states, cognitive deficits and emotional and affective dysregulation, being overwhelmed by emotions or suppressing them all together 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 Fisler 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 Fisler. 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 resource 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 are 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. 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, 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. I see all these spoiling, pampering, all these don't allow the child to separate from you and to become an individual, the 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 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, you'll 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, 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, are proposed 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 and interpersonal hardship. Ask 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, plus 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 the 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 of an active underlying trauma? I would go even further. Isn't borderline personality disorder, all its manifestations, lack of impulse control, object inconstancy, splitting, acting out, self-harm and self-mutilation up to suicide. I mean, 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, you know, emotional dysregulation, D is there, acting out, negative self-cognitions, all this mess, and 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? It's a 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, 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. 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. If someone comes to you with CPDs, D, he is not likely to be afraid of abandonment, terrified, 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, ego in. He is 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're 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 persecutory ideation. They create persecutory 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. There's heterogeneity of the diagnosis. It's so gigantic, so enormous that the diagnosis is actually polythetic. In other words, it's not monovilent. 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, dysregulation, 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 effect is dysregulated. So if we have all these, 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 behavioral and trait dimensions. There are those who go as far, like Kulkhauni, they go as far as suggesting to scrap, 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 Kulkhauni'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 neighbors aren't told me that I'm traumatized. 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, 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 than 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 judge. 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. 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. I think it's a matter of quantity, not of quality. While in complex PTSD, there would be dissociative symptoms, you will lose minutes. So 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. So 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. 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 all of this, but the emphasis is on the trauma, on PTSD. He continues, Bryant, 2010. Whereas some studies of borderline personality reporting creased 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, 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 defined, 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 Bryant. Complex PTSD is also conceptually similar to disorder of extreme stress not otherwise specified. That's a diagnosis in the DSM. So 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 Bryant admits, is very similar to this. And so groups of scholars decided enough is enough, including Bryant, 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 classes of people. And so LCA is short for 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 one, two, three. There's factor analysis, for example, for personality. It has five factors. But five, no continuity, just one, two, three, four, five, 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. The late 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. Now 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 old symptoms, kind of simmering post-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. They 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 CPT, 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. Four, 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, Caracias and Chevelin, 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've 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 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 Karacius 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 of re-experiencing avoidance and hypervigilance, in addition to three disturbances of self-organization symptoms defined as emotional dysregulation, interpersonal difficulties, and negative self-concept. As borderline personality disorder shares similar features to disturbances of self-organization presentations. And as 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 a statistical test. 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 personalities 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. 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 impairment, 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? That 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, anti-social, 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 single post-traumatic state. It may lead to express 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, a hostile world and its reactions. 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 anti-social. 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.