 Okay. Thank you very much for having me in this second conference on stress and depression management. My name is Sam Vaknin. I am a professor of psychology in Southern Federal University in West Devon Don in Russia, and a professor of finance and a professor of psychology in the outreach program of SEAPS, Center for International Advanced and Professional Studies. Today I want to discuss the concept of anxiety from a variety of angles, including the philosophical angle, which will be towards the end. But I want to start with a quote, a quote from a book titled, Nerve, Poise under Pressure, Serenity under Stress, and the Brave New Science of Fear and Cool. The book was authored by Taylor Clark and published in 2011, 10 years ago, by Little Brown. And here is a quote, at the turn of the millennium, as the nation stood atop an unprecedented summit of peace and prosperity, anxiety surged past depression as the most prominent mental health issue in the United States. America now ranks as the most anxious nation on the planet, with more than 18% of adults suffering from a full-blown anxiety disorder in any given year, according to the National Institute of Mental Health. On the other hand, in Mexico, a place where one assumes there's plenty to fret about, only 6.6% of adults have ever met the criteria for significant anxiety issues. Stress-related ailments cost the United States an estimated 300 billion per year in medical bills and lost productivity, and our usage of sedative drugs has shot off the charts. Between 1997 and 2004, Americans more than doubled their yearly spending on anti-anxiety medications, like Xanax and Valium, from 900 million to 2.1 billion. As the psychologist and anxiety specialist Robert Lee had pointed out, the seeds of modern worry get planted early. The average high school kid today has the same level of anxiety as the average psychiatric patient in the early 1950s, wrote Lee. Security and modernity haven't brought us calm. They have somehow put us out of touch with how to handle our fears. So anxiety is a major issue. In my forthcoming presentations, I'm going to use gender pronouns to reflect clinical facts. Most people diagnosed with narcissistic personality disorder are actually men, but women are catching up recently. Still, I'm going to use the male gender pronoun. Everything I say applies to women as well. Let's start with anxiety disorders. The most common is of course generalized anxiety disorder, GAD. And GAD is often misdiagnosed as narcissistic personality disorder. Why is that? How come this confusion between anxiety and narcissism? Anxiety is uncontrollable and excessive apprehension. Anxiety disorders usually come replete with obsessive, intrusive thoughts, compulsive and ritualistic acts, restlessness, fatigue, irritability, difficulty concentrating and somatic manifestations, such as an increased heart rate, sweating or in panic attacks, chest pains. By definition, narcissists are anxious. They are anxious all the time. They are anxious for social approval. They are anxious for retention called narcissistic supply. The narcissist cannot control this need and the attendant anxiety because he is addicted to narcissistic supply. He requires external feedback to regulate his internal environment, his labile sense of self-worth. And this dependency makes narcissists irritable. Narcissists fly into rages and have a very low threshold of frustration. And exactly like patients who suffer from panic attacks and social phobia, another form of anxiety disorder, exactly like these patients, narcissists are terrified of being embarrassed, of being criticized in public, of being mortified, of being narcissistically injured. They are constantly on their toes. They are in a state called hypervigilance. They monitor the environment all the time. They scan. Is anyone going to insult me? Is anyone going to criticize me? Is anyone going to disagree with me? Is anyone going to attack me? They constantly scan like a radar. And so this creates a lot of anxiety. Most narcissists fail to function well in a variety of settings, social, occupational, romantic settings. Many narcissists develop obsessions and compulsions. Exactly like people who suffer anxiety disorders, narcissists are perfectionists. They are preoccupied with the quality of their performance and the level of their competence. As the diagnostic and statistical manual puts it, patients with generalized anxiety disorder, especially children, are, I'm quoting, typically overzealous in seeking approval. And they require excessive reassurance about their performance and their other worries. And this sentence could easily be applied to narcissists. Both classes of patients, anxious patients and narcissistic patients, they are paralyzed. They are paralyzed by the fear of being judged, of being found inadequate, of failing, of being criticized as imperfect or as lacking. Narcissists, as well as patients with anxiety disorders, constantly fail to measure up to an internal, harsh, sadistic critic in a grandiose, inflated self-image. The narcissistic solution, of course, is to avoid comparison and competition altogether and to demand special treatment to claim the narcissists' claims that he is unique cannot be compared to anyone. The narcissist's sense of entitlement is incommensurate with the narcissist's true accomplishments and true investment and commitment, which are close to zero. The narcissist withdraws from the rat race, withdraws from competition, because he doesn't deem his opponents, his colleagues, his peers worthy of his cosmically significant efforts. This is what we call grandiosity. But as opposed to narcissists, patients with anxiety disorders are heavily invested in their work. They are dedicated to their profession. To be exact, anxious patients are over-invested. They are too invested, too committed, too devoted. Their preoccupation with perfection is counterproductive. And ironically, it renders them under achievers. It is easy to mistake the presenting symptoms of certain anxiety disorders. It's easy to mistake it, confuse it with pathological narcissism. Both types of patients, the anxious and the narcissistic, are worried about social approval and approbation. Both types of patients, the anxious and the narcissistic, seek approval, seek feedback, actively, adulation, admiration, affirmation, applause. Both types of patients present a haughty, impervious facade to the world, see if I care, I don't care. Both are dysfunctional. Both are weighted down by a history of personal failure on the job and in the family. But the narcissist is ego-syntonic. He is proud and happy to be who he is. The anxious patient is the opposite. The anxious patient is ego-dystonic. He is distressed. He is looking for help in a way out of his or her predicament. And this is an important part of the differential diagnosis. The narcissist will never ask for help, will never admit that something is wrong with him. On the contrary, his misbehavior is an advantage. His obnoxiousness, his abrasiveness, his antisocial traits, impulsivity, recklessness, their evolutionary advantages, says the narcissist and the psychopathic narcissist. The anxious person is neurotic in the classic sense. He has auto-plastic defenses. He blames himself. He's unhappy about who he is. He regards his anxiety as a deformity, a deficiency, a disability, and he wants to cure it. He wants to heal it, contrary to the narcissist. Abandonment of separation anxiety is the outcome of object inconstancy. The infantile belief that the physical absence of a love object is forever and that it portends, predicts an imminent emotional absence. So far from sight, far from mind. If the love object is gone, it means the love object is going to abandon you. And this is where a baby cries when mommy leaves the room. The baby catastrophizes. The inner narrative of doom is mommy will never return. She will never love me anymore. Consequently, I'm bound to die. Non-normal healthy people, they sublimate urges. They sublimate drives. They convert powerful emotions and drives and attendant anxieties into socially acceptable forms. They redirect the energy into other activities, sports, writing, gardening, giving lectures in conferences. Adults with mental health disorders, unhealthy adults, react to abandonment anxiety, react to object inconstancy in two major ways. Codependence and borderlines. People who suffer from dependent or borderline personality disorders. They cling. They cling. They become needy. They become demanding. They blackmail. They seek to micromanage and control their intimate partners, significant others in their lives. They emotionally blackmail. They are drama queens. They are labile. They have modulated aggression. Or they outright offer brides like sex, money, power. I cannot live without you is the typical manipulative but battle cry of these personalities. And there's a lot of anxiety in such a strategy. Narcissists and psychopaths, on the other hand, dissociate. They mentally delete the intimate partner. They ignore. They are indifferent to the source of frustration, anxiety, discomfort and threat. They avoid emotional depth and continuity. They have shallow or flat effect. They have no intimacy, no emotional investment. And this guarantees little pain or no pain when they are, ultimately, inevitably abandoned, separated when there's the ineluctable breakup. These narcissists and psychopaths simply move on to the next partner. They sexualize their anxiety. They sexualize their frustration by becoming promiscuous and histrionic. They say out of sight, out of mind. And so anxiety, anxious people, they want object relations. They want intimate relations. They want families. They want love. They want romance. They don't have these dysfunctions that I've just described. Karen Horner's greatest contribution was the concept of anxiety. Freudian anxiety is a primitive mechanism, a reaction to imaginary threats arising from early childhood sexual conflicts. Karen Horner argued convincingly that anxiety is a primary reaction to the child's very dependence on adults for his survival. If you depend on people for your survival like a baby, it creates anxiety. Children are uncertain. They are uncertain of love. They don't know if they're going to get protection, food, nourishment, nurturance, anything. Children are dependent totally and they cannot control any facet of the behavior of the adults around them. So they become very anxious. They develop psychological defenses to compensate for the intolerable and gradual realization that adults are merely human. They have flaws. They make mistakes. They have shortcomings. They are sometimes capricious, arbitrary, unpredictable, unreliable, absent, indifferent, hostile, even abusive. This creates enormous amounts of anxiety in the child. And the child defends against his anxiety. And these defenses provide both gratification and a sense of security. The problem of dangerous dependence still exists, even with the defenses, but it is one stage removed. When the defenses are attacked, when the defenses are perceived to be attacked, for example in therapy, anxiety is reawakened. When the defenses survive into adulthood, we have narcissists and borderlines and codependence and many personality disorders. So you could say that personality disorders are post-traumatic conditions involving defenses against anxiety. Childhood defenses against anxiety which survive into adulthood are actually an integral part of personality disorder. In philosophy, in existentialist philosophy, they connected existentialist philosophers like Sartre, Camus, others. Here, they connected human existence to anxiety. They said that human existence, just to exist, creates angst, anxiety, anguish. And they said that anxiety has two important aspects or implications. First, they said that emotions and feelings are not culturally determined, not intellectually mediated. Emotions and feelings are ways for the individual to connect with himself and with his own existence. And so the locus of anxiety would be in emotions and feelings. They will trigger anxiety. Kierkegaard was the first to suggest this idea and Heidegger developed it in his discussion of mood. And so that's the interface between existentialism and psychology. The understanding that individuals interact with themselves and with their existence, with the world, with reality, via intellect, via cognition, which is mediated, which is not pure, which is influenced by culture and society, and via emotions, which are pure, direct, in a way, more infantile. Anxiety also stands for a form of existence that is recognition of being on its own. Being on its own means that there's irrelevance or negative influence of rational thought, moral values, empirical evidence, when it comes to making fundamental decisions concerning one's existence. So when you are too influenced by the world, when you are too affected by external objects, by society, by peers, by parents, by loved ones, by your boss, by your workplace, when you are not yourself, when you lack authenticity, authenticity is actually another way of saying the good life in Greek thought, in ancient Greek thought. When you are not true to your nature, when you are faking it just to fit in, when you are playing a role, when you have a mask to use Govman's phrase or when you have persona to use Jung's phrase, you have anxiety. Lack of authenticity creates anxiety, but authenticity also creates anxiety. Because when you are authentic, you are able to recognize, you are able to affirm the nature of your existence. And you recognize the nature of existence not only intellectually as a kind of detached observation, but you live, you exist within your being. Your being means your full involvement in your own nature and in the way this nature, your nature, manifests and expresses itself in your life. So authenticity may be conceived as a form of individualism and it involves being on one's own, being alone in effect, sustaining your uniqueness, sustaining your difference, sustaining your independence from other people, rejecting roles imposed on you by society, rejecting other people's expectations, rejecting their demands, becoming Nietzschean Superman. Authenticity means being totally alone, which of course creates enormous anxiety. So whether you are authentic, loyal to your nature, faithful to yourself, or whether you are faking it, trying to belong to fit in by imitating other people, by complying with society's requirements and expectations, in both conditions there is anxiety. Anxiety, in other words, is utterly inevitable. Anxiety is an essential component of existence, bad faith existence in authentic existence and authentic existence. There's no way to avoid anxiety because anxiety is the main ingredient of life. It is an indicator of the choices we make when we live. And because authenticity implies aloneness, implies Nietzschean Superman, we are beginning to understand why, how narcissism enters the picture. To be authentic is to be to some extent grandiose and to a large extent so lexistic and therefore narcissistic. It implies some problem with object relations. We are beginning to see that anxiety cannot actually be separated from personality disorders such as narcissism, narcissistic personality disorder, which explains perhaps why diagnosticians keep codiagnosing these two conditions. Majority of people with personality disorders also suffer from anxiety and depression, and why many diagnosticians confuse the two, misdiagnose, because anxiety is such a core element of personality disorders that to take it away, little is left. Anxiety is intimately connected to the schizoid core of personality disorder, to the need to maintain an authentic existence, and it's intimately connected to narcissistic spectacle, to displays of grandiosity, to attempts to solicit narcissistic supply, whichever way you go, you end up with anxiety. I will terminate my presentation with a quote from the amazing film, The House the Jack Built, it's a film from 2018. The film touches upon a very important point, sometimes we need to be anxious, sometimes we want to be anxious. Being anxious is a way of feeling alive, it's a form of self-mutilation actually, similar to self-mutilation in borderline. So, being anxious has its functions, it keeps you on your toes, it keeps you alert, it's an alarm system. It's life's alarm system, it's an indicator and a symptom of much deeper problems and issues. It also releases energy like a valve, a steam valve, it releases negative energy and converts it into anxiety. So, anxiety has many functions, especially within personality disorders, and here's the quote from the film. I was a very sensitive child, profoundly afraid of playing. For example, hide and seek in the case of hide, I always chose to run in near panic into a field of reads in order to hide. I see something, so his interlocutor says, I see something other than a scared kid, I see a kid with a more mysterious goal. The choice of the dash through the reads was an escape, true, but also an open invitation to your pursuer, to your hunter, because of the clear path of broken reads you had left behind. Was there an element of come and catch me in you as a child or perhaps more importantly in you as a person? Was there never a tiny grain of disappointment about the great rain that washed away your tracks so you couldn't be caught? Thank you for listening. Thank you. Thank you so much Aliza for giving me this opportunity and first of all, I would like to thank