 Right? There we go. We can start. Sorry. Okay. Very good. Now that's fine. I'm recording. It's okay. Okay. Thank you. Sorry. Apologies to everyone. Not at all. So Dr. Sandback Nin, he's going to be talking to us about predicting a covert borderline. Narcissistic mortification as a post-traumatic dissociative bridge between overt and covert cluster B personality disorders. You know, one of these things you're going to have to do is first explain the title to us. But anyways, Dr. McDean, he is the author of Malignant Self-Club, Narcissism Revisited, as well as many other books and e-books about topics in psychology, relationships, philosophy, economics, international affairs, and award-winning short fiction. He's a visiting professor of psychology at the Southern Federal University in Rostov, Undone, Russia, and professor of finance and professor of psychology at the Center for International Advanced and Professional Studies. It's a real privilege and honor to welcome Dr. McDean. I know very little about you, except that you come highly recommended. So I hope I am waiting to hear what you have to say. I turn things over to you, Dr. McDean. I'll ask everybody to turn your cameras and your microphones off so that and then finally we'll see you back again during the discussion period. Dr. McNean, the stage is yours. First of all, I'm honored and delighted to appear to make an appearance here. You said you know very little about me. That makes two of us. And you said that the title bears elucidation. There are a few people who understand this title, and I'm not one of them. But jokes aside, let's plunge writing. My presentation is divided in the following way, just to provide the skeleton. I'm going to start with an overview of what I call a standard model of cluster B personality disorders. It's a very presumptuous name, very hubristic, but I hope you will bear with me. I'm then going to delve into each of the elements of the model, including, as the title implies, narcissistic modification, collapse states, and so on so forth. But before I do, a disclaimer or two, I live in Europe. I teach in Russia, in a variety of other countries in Europe. So we in the continent, this is continental psychology, we in the continent are much more narrative, much more literary. We are less experimental, and we are still under the influence, under the influence of, for example, the object relation schools, the French, the great school of French psychoanalysts, et cetera, et cetera. Now I know that this hardly comes as a recommendation, because in today's world, experimental psychology, statistics, laboratories, codes, I mean, we've gone back to the end of the 19th century, the German brand of psychology, but here's a disclaimer. Number two, disclaimer number two, is please forgive my thick accent. I will be doing my best to eradicate it in this video, but in this lecture, but I doubt very much if I will succeed. And finally, I have prepared capsule case studies, but the time is short, and I have left it to the end in case we don't get there. They're available in any form that you wish in writing or maybe we will meet again. Okay, let's plunge writing. We're all aware of the problems in the diagnostic and statistical manual, especially edition four and text revision of edition four. And unfortunately, edition four carried forward into edition five, almost unmolested. We have problems of comorbidity. We have problems of heterogeneity, the polythetic problem. There is a multiplication of clinical entities, which implies that our field is non-parsimonious, doesn't obey Occam's razor. It's an alarm, it's an alarming sign. And there are clear indications, therefore, that we may have strayed from the right path somehow. Now, in my other head, I'm a practicing astrophysicist. And physics and chemistry were exactly in this place before. In physics, for example, during the 1920s and 30s and 40s, there was a multiplication of elementary particles. In chemistry, in the 19th century, there was a multiplication of elements. And no one knew how to put them together. In physics, we came up with a standard model. And in chemistry, we came up with a periodic table. The standard model and the periodic table allowed us to predict future entities, future elementary particles, future chemical elements, not only to predict their existence, but to predict their properties surprisingly accurately. I think it is high time for psychology, or at the very least, not to be too, you know, at least the psychology of personality disorders. It's time for the psychology of personality disorders to come up with its own standard model, with its own periodic table, which will allow us, on the one hand, to unify, to minimize the number of clinical entities while still accounting for the monopoly of phenomena. And on the other hand, to predict other clinical entities. So I want to suggest half tongue-in-cheek, half seriously. I want to suggest one such possible model today. I call it the 3 by 2 and the 2 by 3 standard model of cluster B personality disorders. I reduced it a lot so as to remain rigorous, and within my field of expertise. So the 3 by 2 and 2 by 3 model is an organizing principle, but also in her minutic principle. It pertains to cluster B, dramatic, erratic, personality disorders. It has three states, covert, sorry, overt, collapsed, and covert. It has two emotions or effects. Shame, master some, envy, climb. So by now we have three states, overt, collapsed, and covert. We have two regulating emotions, shame and envy. Two reality principles. And both reality principles impair reality testing in cluster B. The first reality principle is confusing internal with external objects. The other reality principle is the opposite, confusing external with internal objects. There are two traumatic bridging or transitional processes, collapse and modification. And there are three cognitive perceptual deficits or defense mechanisms or trades depends from which school you come. Dissociation, grandiosity, and paranoia. Now these are the elements of the model. And if we take these elements and put them together in a variety of ways, we are able to perfectly describe most existing all actually existing cluster B personality disorders, and to predict a few more. But by doing this, we actually are also able to demonstrate that the unifying properties or qualities of these personality disorders are such that they actually form a dimension or a spectrum. So this model allows us to predict the existence of a covert psychopath, which is identical with secondary facto two psychopath. And I refer you to recent literature that discusses the possibility that borderline personality disorder is actually a form of facto two psychopathy, especially among women. For example, the article borderline personality disorder with psychopathic traits, a critical review by Lopez Villatoro, Palomares, and allies. So already there are harbingers, harbingers of this kind of conflation or unification. We are beginning to reconceive of borderline as possibly a facto two for a facto two form of psychopathy. The model also predicts a covert histrionic and a covert borderline, which I will discuss later time permitting. And so the issue of confusing external and internal objects, which of course was first raised by Melanie Klein at the time. This issue is an underlying fundamental principle of the model and of course can explain not only cluster B, it could be extended, for example, to psychotic disorders. Any confusion of external and internal objects gives us access or understanding or deeper understanding of a family of disorders, depending on the type of confusion, the extent of the confusion, the color of the confusion, and so on and so forth. Hyperreflection in psychotic patients is an example of one type of confusion between external and internal objects. And in narcissism, the narcissist confuses external objects with internal objects. He tends to internalize external objects, while the psychotic, of course, tends to externalize internal objects. I've been suggesting since 1995 that there should be a single clinical post-traumatic entity, let's call it personality disorder. And this single clinical entity will have overlays or emphasis or more precisely, self-states, could be a narcissistic, antisocial, borderline or histrionic self-state or overlay or whatever else you want to call it. And we have recent work by the likes of Judith Herman, for example, in complex trauma, where she notes the fact that people who had gone through or experienced complex trauma, CPTSD, complex post-traumatic stress disorder, these people are literally indistinguishable from patients with borderline personality disorder. They have dysregulation, they have vulnerability, they have many facets of borderline personality disorder. There seems to be a linkage between trauma including complex trauma and personality disorders. And this is, of course, part and parcel of the trauma model of personality disorders, which I will discuss a bit later. These people who have undergone complex trauma, long-term trauma, repeated trauma, these people also develop what Robert Millman, the late Robert Millman called situational narcissism. They develop this empathy, lack of empathy and they show clear signs of secondary psychopathy. It seems that the first principle is confusion of external and internal objects. The second principle must be trauma. It seems that personality disorders, more specifically cluster B, can be reconceived totally and accurately as post-traumatic conditions rather than personality disorders. And the dimensional approach in the DSM-5 and of course the dimensional, the pronounced dimensional approach in ICD-11, the next edition in 2022, they are moving in this direction. We are going there. We are moving in the direction of unifying all personality disorder, placing them on a spectrum and with emphasis or overlays or, as I will try to argue a bit later, self-states. I refer you to a recent study by Gabbai, Hameiri, and other Israeli scholars published in Personality and Individual Differences, Volume 165, October 2020, titled The Tendency for Interpersonal Victimhood, The Personality Construct and Its Consequences. So we have discussed trauma, we have discussed confusion of internal and external objects, we have discussed overlays. The overlays, which today we call personality disorders, the overlays of this unified clinical entity have three states. They can be overt or collapsed or covert. These are reactions, of course, the transition, the phase transitions, the transitions between these states are reactive to stressors and reactive to modification. Now modification is a kind of what people say, hitting rock bottom, when you hit rock bottom. So stressors that lead to modification and later we will discuss modification, force these patients to transition between overlays and between states of overlays. And this would perfectly explain comorbidity, because every patient can be narcissistic, psychopathic, borderline, and histrionic, subject to the stressors and subject to the process of modification. And within each state, within each overlay, every person can assume one of the three states. This is the kaleidoscopic nature of personality disorders and that's why we have this comorbidity. These people are never confined to a single categorical type. That was a critical mistake in the DSM-4 which regrettably had been replicated in the DSM-5. People cannot be delineated and demarcated and separated. The clinical entities overlap not because there is some Venn diagram of overlap, but because they recur, they happen, they occur in the same person, subject to the environment. So the transition between the states and the overlays is a reaction to stressful gaps, intrusion of internal reality, intrusion of external reality, some overwhelming failure. These undermine fantasy defenses, they undermine narratives and they push the patient to collapse, then to modification, then to transition to another type of overlay and another state of overlay. The transition from overt to covert to collapse to overt to covert is never ending. It's cyclical and it is mediated via the collapse and the mortification. It has to do a lot with attempts to revert the locus of control, but I will not go into it in this lecture or this presentation. Why do people transition from overt to covert and back to overt? Why do they do this? Why don't they remain type constant and state constant? Covert states by nature are unstable. They're unstable and they degenerate or they evolve depending on your point of view to an overt state. This is even more common when there is substance abuse or use and covert states are unstable because they are not self-efficacious. Covert states fail to secure the necessary rudiments to maintain the precarious balance in the various personality disorder. While a covert narcissist is in the covert state, he cannot secure narcissistic supply, which is a crucial element in the maintenance of the narcissistic personality. When if he is a psychopath, as a covert psychopath, he is not self-efficacious in obtaining goals. He cannot secure favorable outcomes from the environment. If he is a histrionic or she is a histrionic, she cannot secure sexual partners or at least partners to seduction and flirtation. She cannot display her emotions effectively, etc. So covert states are inefficient states. They degenerate very fast to overt states and they degenerate. They move to overt states via collapse and modification. In the case of the borderline personality disorder, for example, the covert borderline is unable to secure intimacy or object constancy within the relationship. And because object permanence is impaired, the covert borderline is forced to become an overt borderline. Same applies to dependent personality disorder. Same applies to schizoid personality disorder. Same applies to paranoid personality disorder, which in my view is a form of narcissistic personality disorder. All personality disorders encountered this phenomenon. So let us now, with your kind permission and patience, discuss some of the elements in the model. I hope I've been clear in delineating both the constituents of the model and the mechanics of the model. But now we need to discuss them a bit further. Let's start by discussing trauma and dissociated self-states. American Psychiatric Association, in the latest edition of the DSM, defines dissociation as a discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. So one could say that the DSM committee had explicitly adopted the trauma model of dissociation. I refer you to work by Dallenberg, by Gleaves, and others. Gisbert's criticism of the trauma model of dissociation had been implicitly rejected. Now, there is a variant of the trauma model of dissociation, which is a sociocognitive model, and it holds that social, cultural, and cognitive variables combine to foster a credible personal narrative of multiple cells. When you put the two together, the trauma model, the sociocognitive model, you actually get my standard model, or my proposed standard model. Because my proposed standard model adopts the premises of the trauma model, dissociation, dissociated states related to trauma, the ways of coping with trauma, et cetera, et cetera. That's the trauma model. But my standard model also adopts the perception of personality disorder, the reconceiving of personality disorder, as narratives with multiple self-states and narrative that is intended to cope with trauma-induced dissociation. So the two of them are combined in my standard model. The source of confusion, in my view, the source of criticism of the trauma model, and I think it's because we tend to think of trauma as an external event, or at the very least a reaction, a reactive pattern to an external event. But trauma can be internal. Trauma could be, for example, a reactive pattern or a reaction to chronic illness, to mental illness, to internal psychodynamic processes. We can traumatize ourselves. We can self-traumatize. Trauma does not require an external source. And as we shall see later when we discuss the concept of narcissistic modification, this is precisely why we have two forms of modification, internal modification and external modification. Now, of course, if you insist that trauma is environmental, comes from the outside, or is objective, ontological, for example, it's genetic. There's a genetic propensity to develop trauma. If you insist on these things, the trauma model is dubious, is questionable, and elements of the trauma model can be contested and so on. But if you accept that trauma is both external and internal and involves the aforementioned confusion between entities, between objects, internal objects and external objects, it opens a whole new vista. Philip Bromberg, in his work on dissociation and so on, starting in 1993, if my memory doesn't fail me, Philip Bromberg suggested that personality disorders are narratives. They are narratives intended to paper over, to disguise identity diffusion and discontinuities. And these discontinuities are induced by post-traumatic dissociation. So in other words, according to Bromberg, personality disorders are post-traumatic conditions. Post-traumatic conditions with emphasis on a narrative, a bridging narrative, often a confabulatory narrative. Confabulation is very common, especially in cluster B. So consider, for example, the constructs of narcissism and psychopathy. We can reconceive of pathological narcissism. We can think of it as a universal reaction, a universal reaction to internally generated trauma caused by other mental health issues, for example, by mental illness or to an external trauma. So people can develop pathological narcissism simply because they are experiencing internally induced and generated trauma. Narcissistic defenses mask, disguise the core issues. They allocate scarce mental resources and they protect the individual from decompensation, acting out and ultimately, as Otto Kemberg had observed, psychosis. Borderline personality disorder and narcissistic personality disorder are empty and fully described as post-traumatic conditions with multiple self-states, therefore. Psychopathy. Psychopathy would be one of these self-states. It would be a protective ego resource and it would put itself at the disposal of people who are suffering from dissociative identity disorder, borderline personality disorder, narcissistic personality disorder, histrionic, and paranoid personality disorder. In all these cases, we will have a psychopathic self-state and it will be a protective self-state and it will be a resource at the disposal of these individuals. What is the compensation needs? The compensation is owing to intolerable anticipated or actual stress or trauma and so grandiose and fantasy defenses crumble and following the compensation, we often have acting out and in the case of borderline personality disorder, at least, we have very common suicide, 11% of people with diagnosed borderline commit suicide, so we need a protector. It's very similar to what used to be called multiple personality disorder where there was a host personality and one of the personalities was a protector. He was defiant, he was assertive, he was aggressive. So this is the psychopathy can be conceived as a self-state and the emergence of a psychopathic protective self-state is very common. For example, in borderline, I again refer you to the literature I've mentioned. Borderline, people with borderline personality disorder suffer from extreme abandonment anxiety and when they experience abandonment and rejection or when they anticipate it, they switch exactly like in DID, they're switching, it's visible switching, they switch to a psychopathic state, it's a protective state. Now, it's fact or tool psychopathy, it's not a primary psychopath, it's not the robot hair psychopath, it's not the Harvey Cleckley psychopath, but it's still a psychopath. The psychopath protects, for example, the narcissist from narcissistic injury, from modification, the psychopath encourages hypervigilance and the idea is to prevent the narcissist from gaining contact to trauma traces, access to repressed emotions. So because when and if the narcissist undergoes actual decompensation and then modification and so on, as Grotstein had observed, the narcissist becomes a borderline with increased heightened suicide risk. It tends to reason that we will have a protective self-state. When I say we, I mean patients with cluster B would have a protective self-state. It stands to reason it's very useful, positive adaptation. Similarly, the protective psychopath will protect the paranoid from threat, from paranoid ideation and persecutory delusions taken to the extreme, protect the borderline from abandonment and rejection and protect the histrionic from rejection and injury. But when the protective self is overactive, when the protective self is the only self-state or resource available, we are beginning to get hybrid types. We are beginning to get comorbidity. Now many, many scholars had observed this comorbidity. I'm referring you to Eric From, Herbert Rosenfeld, Otto Kernberg, who came up with the proposed diagnosis of malignant narcissists. It's a hybrid, it's a comorbidity. Milan has the unprincipled narcissist. Milan has the disingenuous histrionic, the impulsive borderline. These are all hybrids, comorbid states. They are all comorbidity of self-states. Back to narcissism. Narcissism is a core feature of the personality. Primary narcissism in infancy is of course critical to the formation of the self, at least according to Jung and others. Healthy narcissism helps us to regulate our sense of self-worth and guarantee self-efficacy. But like cancer, exactly like cancer, narcissism can become malignant. It can be triggered in its sick form, in its pathological form, by any trauma and by any mental illness. It acquires the features of the underlying primary core mental health issue. It serves as an overlay, a veneer, a coat of paint. It is a misleading facade presented to the world and to diagnosticians of course. So pathological narcissism in the footsteps of Bromberg and others can be conceived as a narrative intended to disguise discontinuities in memory and discontinuities in identity, fostered by post-traumatic recurrent dissociation. One of the main functions is to present a facade of normalcy and to self-delude the narcissists that he is all but normal. It's a form of virtual signaling, if you wish. It also of course glamorizes the dysfunction in the case of the narcissists. So children with impaired and incompetent or disorganized personality, honorary children, self-defeating children, honorary temperament, these kind of children suffer a lot. They're shunned, they're ridiculed, they're bullied, they're rejected by their own parents very often. And to compensate for these painful experiences, they sometimes recast their freakish idiosyncrasies as choices and restore the internal locus of control. Similarly, the person with schizoid personality disorder or autism spectrum disorder, they boast grandiosly about self-sufficiency, emotional impotability, resilience, razor sharp focus, extreme IQ, social selectivity and asexuality. They boast, they brag about it. It renders them superhuman in their own eyes. And so this is a form of narcissism. We see how narcissism is colored by the underlying condition. So the sadist brags about his altruism, rationality, invulnerability, perspicacity, imperviousness to weakness, to pain. What I'm trying to say is this, drill down and you find that narcissism is compensatory probably in all cases, not only in compensatory narcissism but in all cases. It's a fantasy, it's a fantasy aggrandizing veneer, superimposed on other mental health disorders and the lifelong cost of these disorders, including the single clinical entity that I had mentioned, personality disorder. So coming back to summarizing the issue of trauma, the model, my model suggests that trauma induces dissociation and that personality disorders are post-traumatic narratives intended to disguise the dissociation and in this are not innovating. This is Bromberg's suggestion. And as a consequence, we have a situation with an underlying condition. The underlying condition could be the single entity, the single clinical entity personality disorder, but it could be something else. It could be bipolar disorder. It could be autistic spectrum disorder. It could be an eating disorder with an underlying disorder and the overlays are personality disorders. Personality disorders in other words are secondary, not primary. They are narrative, not real in the clinical sense. And so they cover, they paper over an underlying condition and it must be a condition that had induced internal trauma or was induced by an external trauma and it must involve dissociation. On we go, internal and external objects. When a person has poor boundaries, for example, in case of disrupted phase of separation individuation, when a person has ego-distonic introjects, ego-distonic imagos, as Kohut used to call them, ego-distonic internal objects. For example, an inner critic or what Freud used to call a sadistic superego. So when there are poor boundaries, when there are ego-distonic internal objects, when there are dysfunctional constructs, or when there is a process of merger and fusion with internal objects, for example, internalizing an external object and then merging and fusing with the internal representation, I call these anxiolytic inner representations because they reduce anxiety, but merger and fusion are very common independent personality disorder, for example. So in all these four situations, I repeat, poor boundaries, ego-distonic internal objects, dysfunctional constructs, and merger and fusion with internal representations of external objects. In all these situations, we have a problem of attribution because many internal objects used to be external objects. The person who has these deficits is very confused. What is external and what is internal? And of course, this confusion leads to psychosis or to a narcissistic defense, psychotic defense or narcissistic defense. The psychotic mistakes internal objects, such as introjects, other types of constructs. So he mistakes internal objects for external ones. He thinks that his internal objects are actually out there via hyperreflection. The narcissistic patient says the opposite process. He mistakes external objects for internal ones. He snapshots. He takes a snapshot of the external object. He internalizes this snapshot as part of a process called co-idealization. And then he renders the external object an extension of himself. He then becomes totally confused what is external and what is internal exactly like the psychotic patient. Otto Kernberg was among the first to make this observation. He had suggested in 1975, for example, he had suggested that borderline and narcissistic patients are actually pseudo-psychotic. They are on the border of psychosis. And this could be very well explained, applying the Kleinian model of internal and external objects that are confused. Similarly, the schizoid. The schizoid patient has no access to objects. He has an impoverishment of objects. What Kernberg and many others call emptiness. The borderline is an interim condition between narcissistic and psychotic. She sometimes confuses internal for external and external for internal. And what is the typology of these mysterious internal objects? Putting Klein aside because strangely Klein never bothered to fully explicate the nature and character of these objects. So we can borrow, for example, Jungian archetypes. Jung had suggested that there is one privileged internal object and that is the self. The self is the authentic voice. Jung said, the shadow, the wise old man, the child, the mother, and her counterpart, the maiden, and lastly, the anima in men and the animus in women. Those are the internal, those are the archetypes. So we could have the self, we have the self as a privileged observer. We have the persecutor, the sage, the infant, the mother, the gender, sex, which is vulnerability, which is life, death, Thanatos, and so on and so forth. All these are used, they are archetypes, but we can easily think of them as internal objects. And so one of the most important internal objects in cluster B, and that is why I'm about to focus on it in this presentation, is the persecutory object. The persecutory object is an internal object that represents persecution, represents internalized paranoia. Actually, it generates paranoia as well. It can represent the intimate partner, it can represent some others, and it can represent the person himself. It can be an internal, interiorized internal object. So the persecutory object is usually, we believe, the outcome of early childhood attachment dysfunctions emanating from childhood abuse, but the childhood abuse doesn't have to be classical child abuse, like sexual abuse, or it could be simply when the parent for selfish or narcissistic reasons, or because she is emotionally absent, Andre Green called it the dead mother, when the parent refuses to allow the child to separate, individuate, and develop boundaries. That's a form of extreme abuse, actually. So in all these forms of abuse, there is the child introjates, internalizes the abuser, and he converts the abuser into a permanent persecutory object. And so they trauma bond, they trauma bond with this tormenting voice, even when the original bully, of course, is long out of their lives. This would become this pattern of internalizing the abuser, internalizing an external abuser, and converting it into an internal object. This pattern persists throughout life, and this is what Freud called repetition compulsion. If the patient is mentally ill, or has mental health disorders, and so on, he could perceive his own chronic condition as an abuser, and he would tend to generate an internal object corresponding to this internal abuser. In other words, he would tend to generate a self-referential persecutory object. And I'm sure that all of you, when you're listening to me, those of you who are listening to me, immediately can see the implications of what I'm saying. Paranoid personality disorder, perhaps, and so on. So this conflation of external and internal, and paranoid ideation of persecutory delusion that it provokes, referential ideation, hypervigilance, in all cluster B personality disorders, they push from the inside. And the pressure from the inside is so enormous that it's irresistible. The confusion between objects, the need to maintain the narrative to disguise discontinuities, dissociative discontinuities, the need to pretend to have a cohesive and coherent identity where in actuality there is identity disturbance or identity diffusion. In other words, the need to pretend to be normal. The need to be self-efficacious and experience agency. All these are enormous pressures, enormous pressures on the individual and an individual that anyhow is fragile and vulnerable to start with because it's usually an individual who had been exposed to extreme forms of abuse and is traumatized. And so these internal processes push cluster B personality disorder people to the state of collapse. This is how there is a transition, inevitable, ineluctable, inevitable transition that happens time and again and again and again from overt to collapsed. And you remember that the collapsed state leads to the covert state. The covert state is not self-efficacious, cannot guarantee, cannot generate the necessary input to maintain the cluster B personality. So the covert state degenerates to the overt state and the cycle recommences. Covert degenerates becomes overt. Overt is under huge pressures that I just mentioned, huge internal stressors challenged by reality all the time, so has to invest a lot of work in creating an airtight confirmation bias, fending off countervailing information, avoiding injuries and so on and so forth. Finally, there is a collapse. The person is simply, the patient is simply depleted. The collapse is a state of depletion. The collapse state is dramatic. It is an abrupt reduction in self-efficacy, sense of agency and personal autonomy. All cluster B personality disorder end up in collapsed states and they evolve what Lenz Perry called the schizoid style. They all end up there withdrawing from reality, withdrawing from the world, becoming schizoid loners as a defense. And so the narcissistic collapse state, for example, is an outcome of such disruption in a dialogue. The sadistic perfectionist, inner critic, super ego, whatever you want to call it, sets the narcissists up for failure because it poses unattainable unrealistic goals. In adversity and crisis, the narcissist becomes psychotic, experiences psychotic micro-episodes. I refer you to Kernbergen later, later writings. The narcissist misperceives this voice. The persecutory object is external. He projects it and he feels victimized. And I keep mentioning the narcissist, one, because that's my area of study, but two, because as I've said before, I believe narcissism is the glue, the glue that holds everything together. The narcissistic defense is the cavalry. It's the number one and two and three family of defenses to be provoked in any mental illness, but especially, of course, in personality disorders and more especially in cluster B disorders. And so this leads to splitting. Whenever external objects get in touch with internal objects, they generate revividness. They generate what we call flashbacks. And that's PTSD. It's a form of really, it's a form of psychosis. Whenever an internal object gets in touch with an external object, it leads to trauma and modification, as I will discuss in a minute. Contacts in cluster B personality disorders. The confusion between external and internal objects is such that if contact is made between internal objects and external object, it can generate trauma. It can generate trauma. The trauma can be extreme and lead to PTSD. And the trauma could be more, you know, dystemic in nature. It could be low level, low key, simmering trauma. And then we have complex trauma, as Judith Herman had observed. Of course, cluster B personality disorders use a host of primitive infantile defense mechanisms to prevent internal objects from getting in touch with external ones or external objects from impinging on internal ones. They are desperately trying to isolate what I call the ego system from reality. Of course, this impairs their reality testing, but it's a functional solution. It's an adaptation. They withdraw into the internal space or they are completely in the external space. They do their best not to mix the two. And this is, of course, the primitive defense mechanism of splitting. Now splitting, it's been documented in numerous studies. Splitting leads to dissociation. Splitting is a highly correlated with depersonalization and derealization, where the splitting prevents the construction of a dialogue between inner and outer. Splitting leads to amnesia. We kind of kill the environment, but when we split it, it's all bad. So splitting is intimately connected with amnesia, with dissociative states. Let's put it this way. We have a similar situation in addiction, but that's subject for another conversation. So this is the collapsed state. This is the collapsed state. And I can give you later, if there is time and if you wish, I can give you case studies of collapsed covert narcissists, the collapsed histrionic, and so on. Definitely, there is a collapsed state in each and every overlay in my model, in each and every overlay. In each and every overlay, there is a collapsed state. So these collapsed states have been described extensively with borderline and with narcissists, but they have not been described at all with the histrionic patient and with a psychopath or antisocial patient. There's no literature about this, but of course it tends to reason that if the narcissist has a collapsed state, the borderline is a collapsed state, the histrionic should have a collapsed state, and the psychopath should have a collapsed state, especially if they are all overlays over a single clinical entity. And this leads me to modification. At each and every stage, I will try to reiterate the guideposts. So we have trauma, which leads to dissociation, which leads to a desperate attempt to disguise the whole thing with personality disorders. And these personality disorders are overlays on a basic single clinical entity, and they have several states and they fluctuate between these states. And what causes them to fluctuate, what causes them to transition between states is an accumulation of injuries or a single injury, which lead to a process called narcissistic modification. Now, the literature discusses narcissistic modification, especially in the 50s, only in relation to the narcissist. But this is wrong. We all have healthy narcissism. We all have narcissistic defenses. We all exhibit and deploy these defenses whenever we are damaged and hurt and we are in pain, whenever we are narcissistically injured. Narcissism, even the pathological manifestations of narcissism, narcissism is universal. Every single human being on earth uses narcissistic defenses. Everyone is narcissistically injured. Everyone has this. Actually, it's the way the narcissist reacts to these universal artifacts that renders him a narcissist, not the psychodynamic processes which are common to all mankind, but how the narcissist reacts to these processes. That's an important distinction. So when I'm talking, I will talk now about narcissistic modification, please bear in mind it's common to all personality disorders, I mean cluster B at least, and in some measure, it can occur in the general population. Narcissistic modification was defined by Freud, who else, and reiterated by Ronnigstam in 2013, and she wrote paraphrasing Freud, it's an intense fear associated with narcissistic injury and humiliation. The shocking reaction when individuals face the discrepancy between an endorsed or ideal view of the self and a drastically contrasting realization. So the source of narcissistic modification, either to, exactly like the source of trauma, had been considered to be external. When we discuss trauma, we think of something that happened outside. When we discuss narcissistic modification, we think of something that had caused it coming from the outside. And I beg to differ. Trauma and modification can be caused endogenously, internally. I gave an example of someone who is a chronic illness or a mental illness, that's traumatic. And if it is extended and if it impinges on self efficacy, it could lead to modification. It does not have to come from the outside, does not have to be in other words triggered. This is a common definition of trigger. Rothstein wrote, modification is the fear of falling short of ideals with a loss of perfection and accompanying humiliation. So Rothstein is closer, I am closer to the way Rothstein sees it, he sees it also as possibly an internal process. The fear extends to intimacy in interpersonal relationships, I refer you to Fiscalini, unrealized or forbidden wishes and related defenses or wits. And as Kohut so aptly summarized it as he usually did, fear associated with rejection, isolation and loss of contact with reality and loss of admiration, equilibrium and important objects. Kanberg augmented this list by adding fear of dependency and destroying the relationship with the analyst, discussed therapy, fear of retaliation of one's own aggression and destructiveness and fear of death. Now, cystic modification is therefore a sudden sense of defeat and loss of control over internal and external objects or realities caused by an aggressing person or by a compulsive trait or behavior. It produces disorientation, terror, not anticipatory fear, terror and a damning up of libido, destudo, multido and so on. The entire personality is overwhelmed by impotent ineluctability and a lack of alternatives in ability to force objects to conform to or rely on their goodwill. Modification reflects the activity of infantile strategies of coping with frustration or repression such as grandiosity and the attainment or the attain the attendant psychological defense mechanism, for example, splitting denial of magical thinking. And so this is modification. Bergler and Maldonado remind us that pathological narcissism, secondary narcissism, is a reaction to a loss, the loss of infantile omnipotent delusions and good and a good meaningful object associated in the child's mind with ideals. And it's a loss that threatens continuity, stability, coherence and well-being in the self. In adulthood, a self-inflicted internal modification, usually founded on these distortions of reality, compensates for an external one and disguises it and vice versa. And internal modification is what Freud and others called auto-plastic. It's auto-plastic defense. Internal modification is when the patient says, it's on my fault. I made it happen. It restores grandiose illusion of control, mastery over an external modification. While a persecutory delusion is an external modification, it replaces an internal modification and the patient will say, I have evil and hateful thoughts towards people or malicious envious people had done this to me. So, modification is a crucial mechanism. I have prepared a long presentation here, but I'm running out of time. So, the narcissist copes with modification in one of two ways. He renders it external, casting himself as the helpless victim of malicious, envious, mentally ill people. And this preserves the self-image as good and morally upright. But it leads to depression. The second way, the narcissist renders the modification internal and accepts his contribution to the mortifying event and his ensuing responsibility. Such reframing restores his sense of mastery and control over the situation, but results in hypervigilance, paranoid and referential ideation and persecutory delusion. Neuroplastic auto-plastic solution. Okay. So, we have modification and modification leads to collapse and we have modification in all cluster B, possibly in other types of personality. Now, the model predicts three additional covert states and accounts for the known covert state. There is one covert state known as covert narcissist. The covert narcissist is fragile, vulnerable, closet narcissist, shy, introverted, etc. It is well described in literature. It is in the DSM, by the way, in the alternative model of narcissistic personality disorder. The DSM refers to the covert narcissist in page 767. So, it's well accepted. It was first described by the late Cooper and Akhtar in 1989 and expounded on by Masterson in 1993. So, this is the covert narcissist. There's little argument about this subtype, but I believe, I mean, the model predicts that there should be a covert borderline personality disorder and a covert psychopath. The covert, I will focus on the covert borderline personality. I'll try to compress it. I don't know if it's doable. The shy or the quiet borderline internalizes her struggles rather than externalize them. And this is a suggested diagnosis. She becomes the exclusive target of her own turmoil. She acts in rather than acts out. But the classic and covert borderline, they act out. So, the covert borderline actually acts out exactly like the classic borderline. Now, I'm going to read to you the traits and so on of the covert borderline. I don't have time to discuss the construct, but I'll at least give you a taste of it. The covert borderline is his false self and his grandiosity where the classic borderline has identity diffusion and inferiority. The covert borderline is preoccupied with fantasies of outstanding love. He has undue sense of uniqueness, feelings of entitlement, alloplastic defenses. Of course, the classic borderline has morose self-doubts and ego dystony or ego discrepancy, wrongness, and he has auto-plastic defenses. You're beginning to see the wide gap between the overt borderline, the classic borderline, and the covert borderline. Covert borderline is a hybrid with antisocial and narcissistic traits. The covert borderline has an internal locus of control and seeming self-sufficiency and self-efficacy. Of course, the overt, the classic is the opposite as an external locus of control. And the overt, the classic borderline has a marked propensity towards feeling ashamed or guilty or to blame. She's ego dystonic and she's fragile and she's vulnerable and she relentlessly searches for safety and completion and she regulates her internal environment, her emotions, her moods via the intimate partner. The covert borderline similarly has moodlability and has emotional dysregulation, but his reaction is not to use an intimate partner to regulate. He regulates by being, by rationalizing, by intellectualizing, and he is reactant. He is reactant, he is defiant, he's contumacious, he is reckless, so he's psychopathic. He is a hybrid with primary psychopath. Now emotional dysregulation in a classic borderline leads to numbing and disempathy and the borderline is alexithemic in all probability. The covert borderline has a low threshold of boredom and frustration, low tolerance for boredom and frustration, also, again, common to psychopaths and many narcissists. This is also common to the classic borderline. Now the classic borderline has depression and has anxiety, very classic, very common comorbidity, while the covert borderline externalizes internalizes. He plays with externalization and internalization to regulate his anxiety and his moods. A covert borderline has no suicidal ideation, no self-mutilation, no attempted suicide. All his aggression is other directed, is externalized and, of course, it's exact opposite of the classic borderline, which has suicidal tendencies and his internalizes externalizes, exactly the opposite. The covert borderline may be hypochondriac, may be addicted to substances or some other behaviors, but will never self-harm and will never abuse substances in order to cause himself damage, to self-trash or self-destroying. Will never engage in dangerous reckless behaviors, such as egregious promiscuity under the influence of substances or reckless driving or so. He is much more stable in this sense. The covert borderline has dissociative self-states like all cluster B, mainly selective attention, confabulation, repression or denial, primary psychopathic protector, which I had mentioned at the beginning. The classic borderline has dissociative self-states as well. She has realization, depersonalization, dissociative amnesia and so on. As far as interpersonal relationships, the covert borderline has paranoid ideation and numerous but shallow relationships. The classic borderline has inability to genuinely depend on other people and to trust them. She's hyper-vigilant and she prefers instant or fake intimacy, which connects her so to speak with a histrionic. Sometimes, and so borderlines would engage in casual sex, much more than histrionic, for example. The covert borderline has an intense need for love, which is surprising. He is a people pleaser because he seeks love. The borderline, the classic borderline is a mirror image. There's abandonment anxiety, which is overwhelming. But the covert borderline has a lack of real empathy, similar to the primary psychopath, especially when he is in the primary psychopathic self-state. The covert borderline doesn't have a problem with empathy. She has full-fledged empathy, reflexive, cognitive and emotional, but she's afraid of engulfment. She has engulfment anxiety and she's afraid of intimacy. The covert borderline values children. Actually, he values children above any other type of inter-relatedness and this is owing to narcissistic defenses, the children providing with supply, and because he is schizoid in nature. He has a conflict between schizoid style and narcissistic psychopathic needs, which creates his borderline state, actually. He is unable, because of his schizoid underlying schizoid condition, is unable to genuinely participate in group activities. The classic borderline is chronically envious of other people's talents, possessions and capacity for object relations, similar to the narcissist. He has similar type of envy. The covert borderline is not. The covert borderline is passive-aggressive, sullen, surly, self-denying. He's cunning and his malevolence is premeditated. The borderline is more off-handed. The borderline might cause harm, might cause pain, but it will be like absent-mindedly. She disregards other people's limitations, obligations, resources. She's unreasonably demanding. The covert borderline engages in intermittent reinforcement while the classic borderline is merely unpredictable. The covert has scorned for other people, often masked by pseudo-humility. All coverts have pseudo-humility. They all have false modesty as a kind of facade, protective facade. The classic borderline has explosive behavior, which the covert lacks, but he has histrionic attention-seeking. She is impulsive. He is merely reckless, and his recklessness is aimed at hurting or affecting other people. He is sadistic. The covert is sadistic, punitive, goal-oriented, and may engage in triangulation. The borderline engages in triangulation to restore the relationship or to please people. The covert has object in constancy. He goes through idealized devalued, discard, revert, or replace cycles. The classic has approach avoidance, repetition compulsion, and preemptive abandonment. She also has object in constancy, and she's a drama queen, which the covert is not. As far as social adaptation, the covert is socially charming and charismatic, while the classic is nagging and aimless, and has social anxiety. He is a hard worker, and he is consistent, because he seeks admiration. This is pseudo-sublimation, while the covert is shallow and has no vocational commitment. The covert is intensely ambitious. The classic is dilettant. The covert is often successful. The classic has multiple but superficial interests, and never succeeds to carry out anything to the end. The covert is preoccupied with appearances. The classic is preoccupied with boredom, and has an aesthetic taste, but it is often ill-informed or imitative. The covert is idiosyncratically and unevenly moral. He has caricatured modesty. He may be an activist. There was a study in British Columbia in Canada not long ago linking secondary and even primary psychopathy to social justice activism. So the covert borderline may be an activist, and has apparent enthusiasm for social political affairs. The borderline, the real borderline, the classic couldn't care less. She is ready to shift her values to gain favor. She is a pathological liar, while the covert is not necessarily a liar, just as ethic and moral relativism. The classic covert has a materialistic lifestyle, while the covert borderline may display contempt for money in real life. He may feign spirituality. He may attain a guru status. He is not delinquent like the classic, but both of them have irreverence towards authority. The covert has marital instability, and the borderline, the classic, is unable to stay in love. The covert is called greedy seductive. He has extramarital affairs, is promiscuous, and he has an uninhibited sexual life and sexual preferences. He is disinhibited. The classic borderline is an impaired capacity for viewing the romantic partner as a separate individual with his or her own life, interests, rights, values, and inability to genuinely comprehend the insistible and occasional sexual perversions, so they are not that different with the exception of perhaps extramarital affairs where the covert is more dominant. The cognitive style. Ask you to conclude in a couple of minutes so we can have an opportunity. I'm about actually to conclude. I apologize. No, you're right. You're absolutely right. I'm misbehaving. What can you expect? So the covert borderline has dichotomous thinking, splitting, is impressively knowledgeable, is egocentric perception of reality, fondness for shortcuts to acquisition of knowledge, is decisive and opinionated, and he has a love of language, is strikingly articulate. This is in contrast to the regular or classic borderline, which has a dichotomous thinking, also splitting, but is catastrophizing. Her knowledge is limited to trivia, headline intelligence. She's forgetful of details, especially names, impaired in capacity for learning new skills, has a tendency to change meanings of reality when faced with a threat to self-esteem, and her language of speaking is used to regulate self-esteem rather than communicate. So these are the two types. I have another type which I will not discuss, owing to time limit, and that is the covert antisocial or the covert psychopath. That's the model. These are the ingredients that go into the model. The covert diagnosis are what comes out of the model. It's nothing revolutionary. It's an amalgamation of many previous scholars and thinkers, but because I'm a physicist, perhaps, I organize it in a structured way, very similar to the standard model, and it's like a table, and each rubric, each cell in the table gives you a different so-called personality disorder, so-called state of personality disorder, so-called affect, emotion, cognition. So the standard model in its graphic form is very, very efficient because it's a kind of theory of everything when it comes to class to be. Thank you for your inordinate patience. I taxed it, and I misbehaved. Please accept my apologies. Not at all, Dr. Vacnina. I'd like to congratulate you for your presentation and for your courage. It's not the kind of presentation that is always going to leave us wanting for more, so I hope you're not expecting more frustration. I'd like to ask people, turn on their cameras, I'd like to see as many faces as possible, please, and you are free to direct your comments or your questions to Dr. Vacnina. Please go ahead. May I? No, you're holding back. Go ahead. I can see you're holding back. They're all traumatized. They dissociated the whole lecture. Oh, we have Dr. Vacnina as well. I look forward to her comments. Go ahead, Dr. Vacnina. Very, very briefly. I would like to thank you for this mind-expanding lecture, which I cannot say that I understood everything. Actually, I probably did not understand most of what you said, but it certainly led me to think a lot. One of the questions that I have, I have many, but the one that I will ask is, only one, is you mentioned that these states, you have covert and overt, and I think there was a collapsed, especially covert and overt, which is the two states that you contrasted in borderline, that covert states are unstable and they tend to revert to overt state. The vignette or the description of traits that you described to contrast covert and overt, not narcissists, but borderline, this seems to me so strikingly opposite. You said that you have cases, vignettes, to a case where the same individual will transition from a covert to an overt. It seems very difficult for me to see because the traits that you describe seem fairly stable. I guess that's my question. How can you explain how somebody can go from covert to overt in such striking opposite? As I said at the end, and that was not false modesty, there was nothing I said today that is not very close to the orthodoxy. For example, I refer you to the latest edition of Encyclopedia of Personality and Individual Differences published by Wiley, where the authors, hundreds of authors actually say that transition between overt and covert are not stable states and the transition is very common in multiple entries. Moreover, at the very beginning of the presentation, I refer you to an article about borderline personality disorder as a psychopathic state, as a facto 2 psychopathy, where actually they document and describe such transitions from borderline to psychopathy. Now, if there is any bigger contrast between two mental conditions, I'm not aware of it. Borderline is the absolute opposite of psychopathy, but it seems that people fluctuate between now. The reason for your question, the underlying assumption is trait constancy, attribute constancy, and that is of course highly debatable. I mean, I don't need to tell you that there is vast literature with serious debate and argument whether traits are constant, especially over the lifespan, and especially in reaction to stressors in traumatic situations, post-traumatic reactions, et cetera, et cetera. There's a huge debate on this. And of course, my model assumes that diagnosis are not stable, are not real, actually my model assumes that diagnosis are not real constructs. They're not political entities. They are overlays in the sense that there is a pool of traits to choose from and people transition between traits and between states and between effects and between regulatory regimes and between cognitions. And so my perception is that the very concept of individual or personality, if you wish, should be challenged in view of, definitely in view of the last 20 years of cumulative knowledge. This underlying presumption or assumption of stability, of unity, of core, of identity, of I mean, it's challengeable. So it's documented in the literature plus IFK studies and so on. I don't flinch and I don't hesitate to say that someone can transition from covert to overt because this is well documented in narcissism, where the transition from covert narcissists to overt narcissists proliferates in the literature. Just Google, Google scholar, you don't need more than that. And the two subtypes are dramatically different. One of them is outgoing, assertive, near psychopathic, defiant, and one of them is shy. One of them is avoidant. The covert narcissists can easily be described as avoidant personality disorder, easily. Hyper-vigilant with regards to criticism, dysregulates in reaction to disagreement and criticism. I mean, it's total avoidant hybrid of avoidant and borderline. And the classic narcissist is exactly the opposite. Exactly. One is introverted. The other is extroverted. I mean, totally and yet it's documented beyond any doubt that covert transitions to overt and overt to covert subject, for example, to extreme narcissistic injury and definitely to modification. And that's exactly the work of Libby, L-I-B-B-E-Y. Libby described reactions to modification. And she said that the narcissistic reaction to modification can choose internal modification or external modification. And when you read the description of internal modification, it's covert narcissism. And when you read the external, it's classic narcissism. So it seems that modification mediates the transition, creates the bridge. It also seems, I agree, that there is no trade, no such thing as trade consistency. I agree. And that's a philosophical question. Let's see if we have another question. Let's see. Dr. Meacham is almost in her camera. Does she have a question? Dr. Bergeron comments. Other people, I don't mean to single anybody. I'm just subconscious of the time. I would love to. Unfortunately, I need to step away. I want to thank you for this incredibly thoughtful, deep dive into what we lack very often, which is a theoretical, academic, intellectual conceptualization of the people we work with every day. And I hope you come back and you talked to us about clinical applications, models of work, how we work with it. That's Dr. Tophik. According to you, what you think of mentalization-based treatment, transference-focused therapies, and all the other gold standards with personality disorders, particularly borderline. But I can't thank you enough for now. And unfortunately, I have to step out. But again, please come back. One comment to your very kind comment. On my YouTube channel, there is a video that I've just made about 12 treatment modalities for cluster B, where I analyze these treatment modalities. It may be of interest, I don't know. Absolutely, I am. Thank you again. Thank you. Deshan, please go ahead. I was just thinking, how does all this jive with whether somebody is called criminally in touch with reality or not? How does all this jive with personal responsibility and criminal responsibility in decisions of those? This may be off the topic, but it came to my mind. Actually, it used to be a pet topic of mine. I wrote and published about the insanity defense. So this is kind of on the fringe of the insanity defense. The tests which are used in the insanity defense, when they are applied to cluster B personality disorder disorders, they establish full accountability. I mean, these people are able to tell right from wrong at any given moment. They're able to modify or control their impulses at any given moment. Let me give an example. Narcissists and psychopaths who end up in prison. And these are the studies by Robert Hare and numerous others. Even Harvey Clackley in his inpatient residential facility where he conducted most of his studies of psychopaths and Robert Hare and others. Narcissists and psychopaths modify their behaviors without the benefit of any therapy. They immediately modify their behaviors. If you are in prison and you continue to be a narcissist or a psychopath, something happens to your life expectancy. And so it seems that fear modulates, modulates their behavior, appropriate trade constancy. Suddenly they become empathic. Suddenly they become receptive, responsive. Suddenly they, you know, so if they can moderate, modulate their behavior in what we call total environments, total institutions like hospital, army, prison, then clearly they can modify and they just don't want to modify their behavior. They don't care. Moreover, it's not true to say that cluster B or narcissists and psychopaths don't have empathy, which is how you have it in the in the diagnostic and statistical manual form. The fifth edition is a little better in the alternative model, but they do have empathy. They are, they just lack the emotional component of the empathy. They have full, fully developed, actually overdeveloped cognitive empathy and reflexive empathy. They can scan you, read you well and spot your vulnerabilities, the chinks in your armors, your intrusion points and so on and so forth. They could have, they're not, they're not idiots. They could have leveraged this cold empathy to realize that, you know, if someone is sad or if someone is in a bad shape, you shouldn't do something to them. They could have translated their cold empathy into behavioral mores or they could have conformed it to summarize. These are choices. These are absolutely choices. And these are choices motivated by the lack of emotional empathy and by extreme goal orientation. And in the case of the narcissist, the goal is to avoid modification by buttressing grandiosity. And in the case of the psychopath, the goal is real life goal, like, you know, sex, money, power, they are goal oriented, they're goal focused, goal directed. Absolute criminal responsibility, 100%. I strongly, I strongly disagreed with the court in Britain, in the case of Brian Blackwell, where they said that narcissistic personality disorder is a mitigating circumstance, implying that at some point, he was not in touch with reality. He didn't know what he was doing. It's after unmitigated months. I regret to be so rude, but our time has come and we have to close, but I'm gathering that we can certainly listen to you a lot more. Certainly, it would be very helpful to have case examples, so that we can talk more about things rather than concepts. So, you know, let's see how we can do that, how we can keep in touch with you and bring you back and to dialogue a bit more. Thank you very much and thank you for your patience as well with us. Thank you very much. Thank you for having me and thank you all for being present and for your patience. I mean, thank you. See you soon. Okay. Okay. Bye everyone. Take care.