 Okay, Fanpanim, today we are going to discuss borderline personality disorder for a change. We're going to ask the question, is borderline personality disorder a form of dissociative identity disorder? Dissociative identity disorder used to be called multiple personality disorder. And so the question boils down to, is borderline personality disorder a form of multiple personality disorder? We're going to focus on one particular form of DID, of dissociative identity disorder, something known as OSDD. My name is Sanbaknin, I'm the author of Malignant Self-Love, Narcissism Revisited. I'm a former and current professor of psychology in different institutions. And a proper professor of psychology, many of you have written to me and there are even threads on Reddit asking the question, what is the difference between professor and visiting professor? I don't want to spend too much time on this. I used to be a visiting professor at a university in Russia. And so if you go to the description, I posted a link to an external site that explains the differences between professor and visiting professor. And I hope this will help you to navigate the mysterious hierarchies of Akadem, the academic world in its ivory towers. And without further ado, let's plunge right into the no less mysterious world of the borderline's mind, or shall I say, fragmented mind. Before we go there, I would like you to watch a bookmark, the video, How Trauma Breaks You Apart. How Trauma Breaks You Apart, Structural Dissociation. This video is available on my channel and it is a good introduction to dissociation. Fragmentation is the key mechanism behind dissociative identity disorder and increasingly we are beginning to believe that it is also the engine of the borderline fragmentation and fracturing of the mind, which can easily be described as proto-psychotic, prodromal or pseudo-psychotic. That's what Kernberg at least thought about it, and that's why the word borderline, borderline is between rosses and psychosis. Before we go further, anyone who has spent some time with a borderline, especially in intimate settings, knows about the phenomenon of switching. Before I proceed, all gender pronouns, masculine and feminine, are interchangeable. I'm going to use the feminine gender pronouns, she, hers, her, etc, etc, because until recently the majority of people diagnosed with borderline personality disorder were female or women. And yes, I agree, it is an example of culture-bound gender bias in psychology and psychiatry, which should not be there. But still, I'm going to use she throughout this text, feel free to replace it with he. It's equally valid. So anyone who's been with a borderline noticed this phenomenon, switching. It's when she suddenly changes her facial expression, her facial micro expressions, her very body language, the way she talks, sometimes her vocabulary, her values, her beliefs, everything changes on a dime within a split second. This is a manifestation of a phenomenon known as identity disturbance, but it is usually so abrupt that it is unsettling. It's disconfiting, it's sometimes terrifying or frightening. Usually such switching precedes a process called decompensation when the borderline's defence mechanisms crumble and then she acts out. Now there's a video on this channel dedicated to acting out, the historical background of the concept and how it evolved in modern times, I recommend that you watch it. But acting out simply means crazy making, doing crazy things, I don't know, sleeping with a total stranger, destroying property, running away for four days. So the process is switching from one self state to another, decompensation, crumbling of defence mechanisms and then acting out. Today we are going to discuss the first phase, the switching phase. Now in classic borderlines, the switching is so discernible, so conspicuous, ostentatious and visible that you can't make a mistake. It's clear that one personality is gone, had vacated and another personality took its place. I don't call these personalities, I call them self states. The most common switching in borderline personality disorder is between a borderline self state and a protector secondary psychopathic self state and again there's a video of course on this channel that describes this transition, the borderline as a secondary psychopath. So the switching in this case is unmistakable, but there are borderlines whose switching is almost imperceptible, almost glacial, it's kind of switching that leaves you in doubt. You ask, you said yourself, she has changed somehow, something is not the same. I feel some oddity or strangeness in the air about her, but you can't put your finger on it, you can't pinpoint the alteration. And this is what led many scholars, starting about 20 years ago, Dale, others, led many scholars to speculate that borderline personality disorder is a close kin of what is known as other specified dissociative disorder or OSDD. OSDD made its appearance in the Diagnostic and Statistical Manual, edition four actually, but it had a different name then. And it was called this, it acquired the label in the fifth edition of the DSM. And the ICD, the International Classification of Diseases, calls it Other Dissociative and Conversion Disorder. So all major psychiatric diagnostic texts or major diagnostic manuals recognize the existence of OSDD, which used to be called, for many years, Dissociative Disorder, not otherwise specified, DD and OS. And so we're going to discuss OSDD, and as we discuss OSDD, most of you will begin to see the amazing similarities, the striking similarities between borderline personality disorder and OSDD. So let me quote from the Diagnostic and Statistical Manual, edition five text revision published last year. The code for OSDD is f44.89. This category says the DSM, this category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate, but do not meet the full criteria for any of the disorders in the dissociative disorders diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder. And this is done by recording OSDD followed by the specific reason. Examples of presentations that can be specified using the other specified designation include the following, number one, chronic and recurrent syndromes of mixed dissociative symptoms. This category says the DSM includes identity disturbance associated with less than marked discontinuities in sense of self and agency or alterations of identity or episodes of possession in an individual who reports non-dissociative amnesia. I'm going to repeat this because this encompasses more or less 40% almost half of all people diagnosed with dissociative disorders. So OSDD is by far the most common diagnosis of dissociative disorder there is. So let's repeat what the DSM says. It says it's an identity disturbance. The person changes her values, her beliefs, her speech, her body language, everything changes and this is kind of switching. But in OSDD the switching is very, very subtle. It's like the tip of an iceberg. There is discomfort. It causes discomfort to observers and intimate partners and so on, but they can't tell exactly why it's an uncanny valley kind of thing. And so there is an identity disturbance, but it is associated says the DSM with less than marked, not explicit, not ostentatious, not very clear discontinuities in sense of self and agency. When you talk to a borderline who actually switches in this manner, a borderline who is very close in clinical presentation to someone with OSDD, that borderline would say that her sense of continuous self has not been interrupted. She says I haven't changed. I'm the same. I feel the same. I'm equally agentic, efficacious, strong, decisive, make choices, insist on boundaries. So this kind of borderline who is the twin of OSDD or perhaps OSDD, this kind of borderline would deny that she's switching, would deny that there's another self state who is taking over, would insist that she hasn't changed, is still the same, and would usually project and she would say I haven't changed. You have. It's something with you. You drank too much. You're angry at me. You hate my guts. You want to break up with me. You met someone else, et cetera, et cetera. So she would project the switching onto the intimate partners. Similarly, there would be no alteration in identity or if you're religiously inclined, there would be no episode of possession. There would be no alteration of identity and there would usually be no dissociative amnesia. In other words, the databases of common memories, of common of emotions, of cognitions, these databases remain intact and they're accessible as a shared resource to all the self states of the borderline so that she doesn't feel that she is transitioning from one self state to another because both self states have the same memories, share the same identity so to speak. So in this kind of subtle switching in borderline personality disorder, the patient usually insists that nothing has happened, that she is still absolutely the same. She has forgotten. She has forgotten nothing. She remembers everything. She is continuous. She is the same. She is herself and would usually blame the therapist or the intimate partner or her friends or the environment or circumstances or the situation or something. She would blame them. She would say, you're misperceiving me. I'm the same. I haven't changed. So she would deny her identity disturbance, which leads me to the next presentation of OSDD. Identity disturbance due to prolonged and intense coercive persuasion. The DSM says individuals who have been subjected to intense coercive persuasion may present with prolonged changes in or conscious questioning of their identity. Now, before you jump, there is a concept called coercive control. Coercive control is a crime in some countries. Coercive control is simply prolonged, premeditated verbal abuse intended to manipulate or alter the consciousness of the victim, usually occurs in intimate relationships. OSDD cannot be induced by coercive control. That's a common mistake. I saw it online. That's not what the DSM says. The DSM gives examples of the kind of coercive persuasion that can result in OSDD. Let me put it this way. Coercive control cannot force a borderline, someone with a borderline, to switch. It cannot induce a change or alteration or transformation or transition in such states. For a borderline to transition under conditions of coercion, the coercion has to be super extreme. The DSM gives the following examples, brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, recruitment by sects or cults and recruitment by terror organizations. The coercion has to be this extreme to induce switching in the borderline. Actually, most cases of switching in the borderline are the outcomes of the twin anxieties, the abandonment anxiety or separation in security and the engulfment anxiety or enmeshment anxiety. When the borderline is trapped in an approach avoidance repetition compulsion, she often switches as a defense or a protection against dysregulated overwhelming emotions. In short, switching between self-states is always a combination of an internal, a set of internal processes coupled with environmental cues, but they are never induced by environmental cues alone and the environmental cues have to be overpowering, overwhelming, dominant and inescapable. Again, as the DSM says, a terror organization has to capture you, you have to be politically imprisoned for life, you have to be tortured, etc., only under these conditions can OSDD be artificially induced in the borderline. Now the third presentation in the DSM is acute dissociative reactions to stressful events. This category says the DSM is for acute transient conditions that typically last less than one month and sometimes only a few hours or a few days. These conditions are characterized by constriction of consciousness, depersonalization, derealization, perceptual disturbances, for example, time slowing or macropsy, microamnesias, transience to poor and or alterations in sensory motor functioning, for example analgesia or paralysis. This is the third presentation and the fourth presentation is known as dissociative trans. This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotype behaviors, for example finger movements or ticks, of which the individual is unaware and or that he or she cannot control as well as transient paralysis or loss of consciousness. Dissociative trans is not a normal part of a broadly accepted collective cultural or religious practice. Let's summarize this part before we proceed. SDD, which is essentially other specified dissociative disorder, is a form of dissociation that manifests, that expresses itself in four ways. The first one is chronic and recurrent syndromes of mixed dissociative symptoms of which the patient is unaware and denies. The second is identity disturbance due to prolonged coercive extreme persuasion, not coercive control, coercive persuasion. Number three, acute dissociative reactions to stressful events. Number four, dissociative trans. Now, let us try to link these presentations to what we know about switching between self-states and borderline personality disorder. Start with the journal and there's a bibliography or literature in the description. Start with the European Journal of Trauma and Dissociation Volume 1, Issue 1, January, March 2017. There's an article there, complex trauma, dissociation and borderline personality disorder working with integration failure, it's authored by Moschera and Steele. I would like to read to you some segments from the article because it's very instructive. A history, start with the abstract. A history of childhood trauma and ongoing dissociation are common in clients with borderline personality disorder. For example, self-harm, suicidality, hearing voices, alterations in sense of self and states of consciousness, amnesia, depersonalization, chronic dysregulation, relational destabilization, phobic avoidance of traumatic experiences, all these are typical to borderline personality disorder and also typical to complex trauma, CPTSD and also typical to OSDD, in other ways to dissociative disorders. That's why today there is a convergence of emotional dysregulatory disorders such as borderline personality disorder, post-traumatic conditions including an especially complex trauma or CPTSD, and dissociation such as OSDD, we are beginning to think that these are three faces of the same coin. Ok, let's continue with the abstract. While many approaches focus on symptom management in borderline personality disorder, we say the authors will describe a practical trauma-informed approach that emphasizes the need to identify and work with the individuals unintegrated in a structural organization as a means to address the root causes of the symptoms. It's a very good article and I want to quote with your kind permission, with asking you, I want to quote a few paragraphs. Dissociation and borderline personality disorder. Dissociation is a symptom, say the authors, and also as a division of personality and borderline personality disorder also have a significant relationship. A body of research has indicated that dissociation and dissociative disorders are in fact very common in borderline personality disorder. I would just add that one of the criteria, diagnostic criteria for borderline personality disorder is dissociation actually. The authors continue. For example, Ko Zekwa, Jesus. Ko Zekwa and colleagues noted that 24% of a sample of borderline clients do not report dissociation. 29% experience mild dissociation, amnesia, depersonalization. 24% met the full criteria for dissociative disorder. These are huge numbers. It means that three quarters of patients with borderline personality disorder actually also suffer from what could easily be diagnosed as OSDD. And then the question arises, if so many borderlines have OSDD, why keep the separateness of these diagnosis? Why not merge them into a single diagnosis? The authors, Mosqueira and Steele, continue to write. Given that dissociation and trauma are common in borderline, the question can then be asked, what treatment approaches are helpful in clients with borderline personality disorder who also have comorbid complex trauma, CPTSD, or dissociation, dissociative disorder. While many clinicians focus on treatment of specific symptoms, self-harm, suicidality, dysregulation, conflicts of our dependency. In this article, we lay out a practical theoretical approach of working with dissociative and other symptoms. I do recommend to read the article. So what about triggers? It seems that switching is responsive to triggers. There are two types of switching, divisible, shape-shifting type of switching where it's unmistakable and suddenly there's another person sitting opposite you. Your intimate partner has vanished and another one has come to the fore and not under the influence of vodka or gin and tonic. Yeah, it's water. Sorry to disappoint. So there's this type of switching and there is a subtle, tectonic, slow, incremental, gradual type of switching at the end of which there's the same outcome, but it is so imperceptible and glacial and slow that you may miss the boat. You may not notice the switching. So what triggers switching? Triggers occur, say the authors, when unresolved experiences are reactivated, evoking reactions to apparently neutral stimuli in the here and now. Triggers can be related to internal experiences as well as to external cues. For example, a feeling of sexual arousal can trigger panic, compulsive sexual acting out, or self-harm. When the arousal reactivates memories of early sexual abuse, a kind of circularity occurs in which unresolved experiences trigger unresolved trauma and old coping mechanisms. Research indicates that clients with borderline have a generally lower capacity for self-reflection, less accurate perceptions of reality, and less ability to think logically than those with patients with dissociative identity disorder. In other words, borderlines are more broken, the more damaged, the more disorganized and chaotic than even patients with multiple personality disorder. However, say the authors, we propose a more nuanced formulation. Clients with borderline and clients with complex dissociative disorders such as OSDD can be found on a continuum of reflective functioning and reality testing when not undistress, higher functioning clients exist in both categories. What about internal conflict and trauma-related phobias? The authors, Mascara and Steele, say lack of integration of the personality is present in borderline to varying degrees, ranging from unintegrated mental representations to ego states, what I call self-states, to dissociative parts. This lack of integration manifests in internal conflicts among parts and this is a prime focus of treatment. Traumatic experiences generate dissociative responses, that's a given. And so dissociation of a personality and therefore dissociation of these responses is maintained due to internal conflict, phobia of some inner experience, a lack of realization. Okay, the conclusions of the article are trauma and dissociation are frequent in borderline personality disorder. Those with personality disorders, including borderline, have more severe deficits in the integrative functioning of their personality than those with only complex trauma or dissociative disorders. Dissociation of the personality is a typical type of integrative failure that is on the far end of a continuum of personality organization with mental representations, schema modes and ego states. All of these integrative failures of self and personality underlie these disorders. What these authors are saying is what I've been saying for decades. Personality disorders, especially narcissistic and borderline personality disorders, are in my opinion much worse than any other mental illness I'm aware of with the exception of psychotic disorders. Personality disorders and especially cluster B, narcissistic and borderline personality disorders are way, way less functional, less integrated than even patients with severe extreme dissociation that used to be known as multiple personality. Someone with a narcissistic, someone with a borderline has less of a core identity. The identity such as it exists is more disturbed. The continuities are more manifest and abysmal than in anything else I know and that I think would include psychotic disorders. So in some respects there is no mental illness, more grave than narcissistic personality disorder and borderline personality disorder again perhaps with the exclusion of schizophrenia, paranoia which is fully treatable with medication. Condition can be stabilized and reversed even with medication, not so with narcissistic and borderline personality disorder. And so this is beginning to be evidenced by research. I'm going to read to you the abstract of an article published in October 2014. The article is titled, it was published in the journal Borderline Personality Disorder and Emotional Disregulation 2014 and the article is titled Chronic Complex Dissociative Disorders and Borderline Personality Disorder Disorders of Emotional Disregulation And here is the abstract. Emotional Disregulation is a core feature of chronic complex dissociative disorders as it is for borderline personality disorder. Chronic complex dissociative disorders including dissociative identity disorder and OSDD that we mentioned other specified dissociative disorder. So these disorders end borderline personality disorder. What they have in common is emotion dysregulation. Borderline, say the authors, is a common comorbid disorder with dissociative disorder although preliminary research indicates the disorders are some distinguishing features as well as a considerable overlap. This article focuses on the epidemiology, clinical presentation, psychological profile treatment and neurobiology of chronic complex dissociative disorders with emphasis placed on the role of emotion dysregulation in each of these areas. Trauma experts conceptualize dysregulation more precisely they conceptualize borderline symptoms as often being trauma based. I'm going to repeat this very important sentence 2014, 10 years ago. Trauma experts conceptualize borderline symptoms as often being trauma based and the same applies to chronic complex dissociative disorders. And so these are the conclusions of the article. Emotion dysregulation may be a mechanism linking trauma to dissociation. It is also an important feature of dissociative disorders and borderline personality disorder. Epidemiological, assessment, neurobiological and treatment outcome research need to focus on emotion dysregulation in disorders with dissociative symptomatology to enhance our understanding of the similarities and differences between dissociative disorders and borderline personality disorders and to lead to research that can clarify causal mechanisms or targeted treatments, etc. Another article published last year written by Kosekwa, the aforementioned Kosekwa and the eminent scholar of dissociation, Paul Dell. Dell is the number one scholar of dissociation. The article is titled, Is dissociation an integral aspect of borderline personality disorder or is it a comorbid disorder? Now this is a chapter in the second edition of the Magisterial Book, Dissociation and the Dissociative Disorders published last year by Rookledge. I strongly recommend this book. The abstract of this chapter says although two-thirds of people diagnosed with borderline personality disorder have dissociative symptoms, the nature of borderline personality disorder dissociative experiences, their mechanisms and their relationship to borderline pathology are not well understood. The risk factors for borderline are diverse. The dissociative symptoms vary greatly and the symptoms of borderline are heterogeneous. We propose this heterogeneity is best addressed by studying subgroups of borderline for example those with low, moderate and high levels of dissociative symptoms. A quarter to one-third of persons diagnosed with borderline personality disorder have negligible dissociative symptoms. In the high group, less than a quarter have dissociative identity disorder. The middle group, the 50% of borderline cases with moderate dissociative symptoms seem to involve a diverse and confusing mixture of neurodevelopment, attachment, genetic stress and trauma factors. Examination of these three groups suggests that borderline personality disorder and complex dissociative disorders are separate disorders that are sometimes comorbid. As I said, many others beg to differ but Dell is definitely the leading authority on dissociation and trauma and I chose to end this lecture with what he has to say because at this stage, at least, he is the authority. Thank you for listening.