 esteemed colleagues, dear organizers, thank you for inviting me to speak in the 33rd edition of the International Conference on Psychiatry and Mental Health. Today I would like to explore, in brief, subject to my time constraints, I would like to explore a conundrum, an enigma, in mental health. We know that all cluster B personality disorders, narcissistic personality disorder, borderline personality disorder, antisocial personality disorder and even its malignant form, psychopathy and histrionic personality disorder, we know that all of them remit, all of them vanish or get ameliorated or mitigated with age. Most patients, for example, vast majority of patients diagnosed with borderline personality disorder, lose the diagnosis spontaneously or with the help of dialectical behavioural therapy. Even without DBT, without therapy, within 20 or 30 years by age 40, 45, these individuals, 81% of them, no longer qualify as patients with borderline personality disorder. And yet, they retain the dysfunctional behaviours associated with borderline personality disorder. Same goes for narcissistic personality disorder, the grandiose overt narcissist, spontaneously remits, spontaneously heals, if you wish, loses his or her narcissism as they age, as they grow older, which is not the case, by the way, for covert narcissists. Covert narcissists do not change over the lifespan, they remain the same, they have the same psychodynamics, same dysfunctional behaviours, nothing changes. But covert narcissists today are perceived as compensatory and therefore they are the real narcissists. Overt grandiose narcissists are increasingly perceived as psychopaths. So, in the nexus of psychopathy and narcissism, we see people with dark triad personalities and these people change as they age. In the fourth decade of life, in the fifth decade of life, in the sixth decade of life, they become different people. They lose the diagnosis, they can no longer be diagnosed using our common structured interviews, diagnostic procedures and psychological tests. They lose the diagnosis, but they continue to behave the same way. And this of course raises two questions. Number one, what is the meaning of healing when the dysfunctional behaviours persevere? If someone continues to behave the same way, how do we know? How can we tell that that person had changed, that there was a process of healing or cure in place? Can there be healing without behaviour modification? If a narcissist continues to behave abrasively, if a psychopath continues to act anti-socially, defiantly and recklessly, can we say that these people are no longer narcissists and psychopaths? What's the connection between behaviours and the core, the core of the pathology? That's question number one. And of course, a much more important question or interesting question at least. Why this disconnect? Why this disparity? Why this break between internal pathological or pathologised landscape and behaviours? Why can we cure, heal, treat, change the internal world, the internal landscape, the psychology? Why does the psychology ameliorate, the psychodynamics ameliorate over time, with age, and yet the behaviours remain the same? I will attempt to answer these two fraught difficult conundrums, these two difficult questions. Let's first define healing. Healing is a permanent alteration in the clinical profile of the patient and in her psychodynamics. So both elements must exist. The clinical profile must change so that using standardised psychological tests, and using structured interviews, and using diagnostic procedure in clinical settings, we can no longer diagnose the personality disorder in the client or in the patient. So the clinical profile changes dramatically from a pathologised pathological profile to a relatively healthy and functional profile. And the second element in healing is a change in psychodynamics, a change in moods, in effects, in emotions and in cognitions within shamas, a change that is easily observable in clinical settings. The processes, the internal processes, which give rise to emotions, cognitions and moods, change and consequently the emotions, cognitions and moods are no longer the same. If we have these two elements together, a change in clinical profile, and a change in psychodynamics, we can safely say the client or the patient is healed. In healthier clients, such changes induce behaviour modifications. In other words, if we change the profile, the personality profile of a healthy person, the behaviour of that healthy person will change accordingly. If we change the psychodynamics of a healthy person, for example in cognitive behavioural therapy, if we can get rid of negative automatic thoughts, which is a change in psychodynamics, if we do this, the behaviours change. The behaviours of that healthy client also change. In healthy people, A leads to B, change the clinical profile, you change the behaviour, change the psychodynamic, you change behaviour, change cognitions, change emotions, you change behaviour. Behaviour in healthy people is the mirror, is the reflection, or if you wish, is the symptom of what's happening inside. There's no divorce between inside and observable outside. But this is not the case in personality disorders. All personality disorders. I'm going to focus on cluster B, but whatever I say applies to cluster C. For example schizoid personality disorder applies to paranoid personality disorder, avoidant personality disorder, all of them. But I'm going to focus on cluster C, because that's my field of study. In cluster B, we have a situation of either or. It's a proposition of either or. Either behaviour modification or healing. Either behaviour modification or healing. We cannot accomplish both. If we modify behaviours, there is no mirror image, there is no reciprocal change in the internal landscape. It's like the behaviour is imitated, emulated, but it has no impact on the internal world of the patient. Similarly, if we modify, if we change, if we improve, if we cohere, if we integrate the internal world of the cluster B patient, for example in borderline. This will have no effect on behaviour. The behaviours will remain the same. If the borderline is promiscuous, she will continue to be promiscuous. If she is reckless, she will continue to be reckless. If she is violent and aggressive, she will continue to be violent and aggressive, regardless of the fact that clinically she had lost her borderline personality disorder diagnosis. Why this disconnect? How does this happen? Several very important reasons. Cluster B personality disorders can be easily conceived or reconceived as post-traumatic conditions. With the exception perhaps of psychopathy, all other cluster B personality disorders are the outcomes of early childhood trauma and abuse. Abuse is any situation where the child's boundaries are breached, where the child is not allowed to separate from the parent and to individuate. The self in the child is not constellated and not integrated. It's fragmented and broken. And this is the outcome of abuse and trauma. As I said, abuse is any situation where boundaries are disrespected. So instrumentalising the child, parentifying the child, spoiling the child, pedestalising, idolising the child, is a form of abuse. Because it doesn't allow the child to get in touch with reality, establish clear boundaries and through the friction of reality develop a functioning self later with object relations. So these people with cluster B personality disorder having gone through, having suffered through early childhood abuse and trauma, they develop dissociative self-states. They develop the rough equivalent of multiple personalities but they are not full-fledged personalities. They are aspects of the personality. Each aspect is a self-state and each aspect is separated from the other aspect via a dissociative partition or a dissociative wall involving for example amnesia or depersonalisation or derealisation. These sub-personalities, these pseudo-identities come to the fore, emerge, take over the patient. When the patient is exposed to stressors, to stress, to abandonment, to rejection, to humiliation, in the case of modification in narcissism. So dissociative self-states are the first reason why behaviour and clinical settings, behaviour and clinical profile do not match. When we interfere or when we intervene therapeutically in borderline personality disorder, when we administer therapy for example, we may change the internal composition of the various self-states and the way they interact. But we may even accomplish integration of the self-states into a single cohesive self. Even this is doable. But the dissociation will remain and will not allow this internal change to filter through to external behaviours. It's very reminiscent of switching in multiple personality and dissociative identity disorder. So the internal world of the borderline does not inform her behaviours. Her behaviours are exogenously determined, they are reactive, they are not proactive, they are not imminent, they don't come from inside her. And so when we change the inside, we don't change the outside, we don't change her behaviours. Similarly with narcissists, narcissists interact with internal objects only, narcissists do not interact with external objects, for example other people. What they do, they internalise external objects and then they continue the interaction with internal objects, with the introjects, with self-states, but never with the outside. So when we change the inside of the narcissists, which is extremely difficult to do, almost impossible, but when the narcissists changes the grandiose overt narcissists, the psychopathic narcissists, changes with time, with age, the inside changes, the interrelationship between self-states, the dialogue between internal objects and introjects changes, becomes perhaps more socially acceptable, less abrasive, less antisocial. The narcissists becomes an easier, a much better person, but this is an internal state. Internally, everything is smoothed out, shored up, shored off, everything is organised now, everything is integrated, everything is coherent, there is ego congruence. The narcissists are in a much better place as far as the internal environment, but it has zero impact on his behaviours. It has zero impact on his behaviours because it's dissociative. The internal states, the internal objects, the introjects are cut off from his behaviours. They do not inform his behaviours. It's very difficult to comprehend because the question arises what determines the behaviours and the answer is the outside. In borderline personality disorder, in narcissistic personality disorder and so on, there is an external locus of control. There is an outsourcing of ego functions to other people. The outside, mainly other people, determine the behaviours of the narcissists, the borderline, the psychopath, the histrionic, because they don't have an internal regulatory system. They don't regulate their internal world. In the psychopath's case, he has no access to his internal world. In the narcissist's case, the internal world is self-sufficient, self-contained and solipsistic, so he has no interaction with the outside world. In borderline, self-regulation is totally absent. The borderline is totally dysregulated. There is an external locus of control. All ego functions, which are normally internalized in healthy people, they're all imported from the outside. They're all solicited from other people, hence the borderline's neediness and clinginess. So if you take the dissociative self-states, you add to this the external locus of control and the outsourcing of ego functions. It becomes clear why there is no bridge between internal processes and psychodynamics and observable external behaviours. Another reason is anxiety. Anxiety and its concomitant depression, but mainly anxiety. Anxiety is intolerable, even in healthy people. Even healthy people resort to dysfunctional behaviours to reduce anxiety. And in the case of cluster B, this may involve substance abuse, promiscuity, there's a variety, a monopoly of possible behaviours which are essentially anxiolytic. Anxiety ameliorating and anxiety reducing and anxiety mitigating. Now the anxiety is an internal process, it's an internal construct and it does inform behaviour. It's the only case in cluster B where there is a connection between internal and external and it is an unambiguous connection. A leads to B, but anxiety also forces cluster B personalities to develop internal defences and one of the most important and prevalent internal defences is a rich fantasy life. The borderline has a rich fantasy life. The narcissist is his fantasies. Narcissism is an extreme fantasy defence to the point that fantasy had taken over and had devoured the narcissist and left nothing behind. So a rich fantasy life is another attempt by cluster B individuals to somehow control their anxiety. In due time, fantasy as a strategy becomes dominant and reality is renounced. Because reality is renounced, because reality grates upon the individual, reality is abrasive, forces the individual to cope and so cluster B personalities, dysregulated and broken as they are, give up on reality and substitute fantasy for reality. And this rich fantasy life means that the cluster B person becomes schizoid, withdraws from life, gives up on reality, gives up on the world and inhabits and resides in his own mind. It is there that all the important interactions take place, but of course behaviour has to do with reality, behaviour has to do with the world, behaviour has to do with other people. So there's a breach, there's a divorce, there's a schism, there's a break between fantasy life and actual realistic behaviours. Reality testing is impaired to the point that behaviours are not only dysfunctional but they are rendered irrelevant, in other words not self-efficacious. To summarise this, people with cluster B personality disorders such as borderline or narcissistic or histrionic and so on, they try to cope with reality in order to reduce anxiety. They try to behave in reality, they try to act in reality to maximise favourable outcomes and to reduce anxiety but they keep failing. Having failed, they retreat to a fantastic inner universe, a paracosm and they inhabit, they wander, they're like nomads, like vagabonds in this fantastic space and this fantastic space excludes the world and impairs reality testing. Consequently, the borderline or the narcissists live utterly in fantasy and have no contact with reality. And when they have to behave, because they have to behave somehow, they need food, they need to go to work, they get married, they have children, they need somehow to function. So when they behave, their behaviours look very odd, very out of place, very incomprehensible because they are not linked to the inside. They are utterly provoked by the outside, their scripts are wrong because the scripts of the borderline, of the narcissists or the psychopath or the histrionic are not determined by anything identifiable as a psychodynamic. The scripts are determined by social mores and dictates, by expectations, by imitation and emulation and above all by feedback from the outside. It's a self-reinforcing feedback loop that is external to the individual, external locus of control. Of course, the main problem of people with the cluster B personality disorders is identity disturbance. They don't have a core identity. They have a shape-shifting wannabe, kaleidoscopic thing, entity, landscape that tries to substitute for a core identity but is hampered, fails because of dissociation. Identity is crucially dependent on continuous memories. If memories are disrupted to the extent that they are in cluster B personality disorders, there is no way for identity to form. There's no identity formation and there is identity disturbance. There's autobiographical amnesia. There's a shifting between values and beliefs. There's instability and unpredictability and in constancy, both object in constancy and self in constancy. The self is not constellated, not integrated. There's no self in effect. There's a schizoid empty core where a person should have been. Of course, if there's no person, if there's nobody there, there's nobody who can determine external behavior. There is a flow from identity to behavior. Behaviors are determined within the identity space. In the absence of identity, behaviors are essentially random and they're dictated by imitation or by feedback. If the feedback is wrong, the behavior is wrong. If the cluster B personality disorder person imitates the wrong role model or the wrong movie or the wrong book or the wrong guidance from parents, gurus, role models, she's likely to misbehave. And so gradually, over time, most patients with cluster B develop reactants. Reactants can wear many forms. In the case of the psychopath, reactants is, of course, in your face defines conchumatiousness. In the narcissist, reactants has to do with deficient narcissistic supply. In the borderline, reactants has to do with abandonment anxiety, anticipated abandonment and rejection and humiliation. But reactants becomes a core feature. Gradually, via reactants, the patient rejects the world. He rejects other people. He rejects situations. He rejects circumstances. He rejects jobs. He rejects his own family. He rejects his children or her children. He rejects everything. And of course, when you reject everything, you become very inefficient. It leads to low personal autonomy and low self-efficacy. You can't reject the world and act in the world efficiently. To act in the world self-efficaciously, you need to be integrated in the world. You need to be a part of the world. You need to know the world. You need to understand the world. You need to read the world. How do you do that when you don't have empathy? Like narcissists and psychopaths. You have only cold empathy. You don't understand emotions. You don't do emotions. How can you understand the world? So, low self-efficacy, low personal autonomy and learned helplessness. Ironically, these people, these braggadachos and machos and gogetters and daring doers and daredevils, they have very low self-esteem and they have learned helplessness. Because they are not efficient, they are not self-efficacious, they fail repeatedly to guarantee and to garner favorable outcomes. They fail in their careers. They fail in their relationships. They fail to regulate their internal environment. They feel bad all the time. They feel helpless. So, this kind of trajectory, life trajectory, leads ultimately to schizoid withdrawal, learned helplessness, low personal autonomy, low self-efficacy, external locus of control, outsourcing of ego functions, reactance, identity disturbance, withdrawal and retreat into rich fantasy life as a substitute to reality, constant anxiety, and, to put all these together, re-traumatization. This is the reason. These are the reasons why even if age or therapy change the internal psychodynamics of the cluster B patient, it will have little bearing on his behaviors and on his over-relationships. Thank you for listening. I will now read some, refer you to some bibliography, some literature. My name is Sam Vaknin. I am a professor of psychology in Southern Federal University in the West Ovan Don, in the Russian Federation, and I am a professor of psychology and a professor of finance in the outreach program of SEAPS, Center for International Advanced and Professional Studies. And here is my recommended list of literature. I would read articles by Robert Bischin, for example, the Lifetime Course of Borderline Personality Disorder in the Canadian Journal of Psychiatry, July 2015. Zanarini and allies, Frankenberg, Hennan, Zanarini had written a lot with her colleagues on exactly the topics that I have raised in this presentation. So, for example, there is an article she had written, she and her colleagues had written, the McLean study of adult development, MSAD, overview and implications of the first six years of prospective follow-up. This was published in Journal of Personality Disorders in 2005. Another scholars which I would recommend are Skodal and Gunderson and she. Each one of them, separately, had written about the progression and prognosis of cluster B personality disorder. There is an article, all three of them had written together, the collaborative longitudinal personality disorder study, which is overview and implications in the Journal of Personality Disorders in 2005. Gunderson, together with Stout, McGlushan and others, wrote a few articles. One of them is a 10-year course of Borderline Personality Disorder, Psychopathology in Function from the Collaborative Longitudinal Personality Disorder Study. It was published in Archives of General Psychiatry in 2011, it's a bit more recent. I would also recommend to read Paris, Zweig-Frank, these are two scholars, they had collaborated and also written separately. So, for example, Paris and Zweig-Frank had written an article titled, A 27-Year Follow-Up of Patients with Borderline Personality Disorder, it was published in Comparative Psychiatry in 2001. Zanarini, Frankenberg and Reich had written the article, The Sub-Syndromal Phenomenology of Borderline Personality Disorder, 10-Year Follow-Up Study, American Journal of Psychiatry 2007. And finally, I would recommend, in my reading list, I would recommend Hopwood, Mori, Donilon and others. And one of the articles, for example, is a 10-Year Rank Order Stability of Personality Trades and Disorders in a Clinical Sample, the Journal of Psychiatry 2013. Cluster B Personality Disorders are by far the most intractable forms of mental problem or mental issues. Not to say mental illness. And one of the reasons is that we cannot reach in in order to change the outside. And changing the outside has no inward implications. It's like we have to deal with two spheres, the internal and the external, separately. It's very frustrating because we can do a great job. For example, with all the main or core features of borderline personality disorder, anything from self-mutilation to dysregulation, we can do a great job with victims of complex post-traumatic stress disorders, complex trauma, which resemble, who resemble borderlines very much. And yet, this great work, this change in internal landscape, this reshaping and remoulding, this reframing, which is very successful, this removal of the diagnosis from the patient's life has little bearing on the patient's relationships and behaviors. And so we have to have a second goal, teaching the patient how to behave, how to manage her relationships, her attachment style, everything. Same with narcissists, same with psychopaths, same with histrionics, with schizoids, with paranoids, with schizotypals, with all people with personality disorders. It's very disheartening. It's very disheartening because in other mental health issues and even illnesses, even in the extremes, let's say schizophrenia or major depression, in all these cases, we firmly believe that intervention in internal via medication, via talk therapy should manifest as behavioral change and should improve the patient's prognosis when it comes, for example, to relationship quality. That's not the case with cluster Bs. It's a Sisyphean effort, and it's never ending because there's an infinite number of behaviors. It's like you have to teach them one behavior at a time, one relationship at a time, and it's never ending. Many therapists, many psychologists, many clinicians, many psychiatrists, just give up on these patients. Give up on these patients because it looks hopeless. But of course it's not hopeless. Behavior modification is possible even without getting rid of the diagnosis. We should fight. We should strive in my own modest way or immodest way. I've come up with a new treatment modality called therapy, which re-traumatizes the patient and exposes the patient to change on a total scale, internal and external, but that's a risky strategy. It's a risky strategy because it could lead to severe decompensation, suicidal ideation and reckless life endangering acting out. It seems, though, that re-traumatization is what it takes. These patients are not permeable to intervention, however well-meaning. Thank you for listening, and I'm now open to your questions.