Covert Borderline Predicted: Standard Model of Personality Disorders (McGill University)

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.

Hyper reflection 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 emphases, or more precisely, self-states. It 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, CBT, is the complex post-traumatic stress disorder. These people are literally indistinguishable from patients with borderline personality disorder. They have dysregulation. They have brutal ability. 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 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, Hamayari, 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 mortification. Now, mortification is a kind of what people say, hitting rock bottom, when you hit rock bottom. So stressors that lead to mortification, and later we will discuss mortification, 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 mortification. 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, because people are never confined to a single categorical type. That was a critical mistake in the DSM-IV, which regrettably had been replicated in the DSM-V. 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 co-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 mortification, 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.

So 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 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.

Covert states are inefficient states. They degenerate very fast to overt states and they degenerate. They move to overt states via collapse and mortification.

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 applied to paranoid personality disorder, which in my view is a form of narcissistic personality disorder.

All personality disorders encounter this phenomenon.

So let us know with your kind permission and patience, discuss some of the elements in the model.

I hope I have 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 Dalenberg, by Gleaves, and others. Gisbrecht'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 socio-cognitive model, and it holds that social, cultural, and cognitive variables combine to foster a credible personal narrative of multiple selves.

When you put the two together, the trauma model, the socio-cognitive 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, etc., 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 mortification, this is precisely why we have two forms of mortification, internal mortification and external mortification.

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 Kahnberg 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? It's 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 would be diagnosed with 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 factor two psychopathy. It's not a primary psychopath. It's not the Robert Hare psychopath. It's not the Harvey Cetley psychopath, but it's still a psychopath. The psychopath protects, for example, the narcissist from narcissistic injury, from mortification. 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 mortification and so on, as Grotstein had observed, the narcissist becomes a borderline with increased heightened suicide risk. It stands 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 Fromm, Herbert Rosenfeld, Otto Kernberg, who came up with the proposed diagnosis of malignant narcissist. 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 diagnostators 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 narcissist 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 narcissist.

So children with impaired and incompetent or disorganized personality, ornery children, self-defeating children, ornery 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 grandiosely about self-sufficiency, emotional imperturbability, 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, 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 the 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, my model suggests that trauma induces dissociation and that personality disorders are post-traumatic 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're 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 egodystonic, introjects, ego-dystonic imagos, as Kohut used to call them, ego-dystonic 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 egodystonic 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 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-dystonic 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 construct. So he mistakes internal objects for external ones. He thinks that his internal objects are actually out there via hyper reflection.

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 two 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 clinian model of internal and external objects that are confused.

Similarly, the schizoid patient has no access to objects. He has an impoverishment of objects, what Kernberg and many others called 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 topology 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 has 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 man and the animus in woman, 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, and Ray 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, the child introjects, internalizes the abuser, and he converts the abuser into a permanent persecutory object.

And so they trauma bond with this tormenting voice, even when the original bully, of course, is long gone, 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 persecretary 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 persecretary 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-references and experience agency. All these are enormous pressures, enormous pressures on the individual, 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, an 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-references, 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 collapsed 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 Len Sperry 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, superego, whatever you want to call it, sets the narcissist up for failure because it poses unattainable unrealistic goals.

In adversity and crisis, the narcissist becomes psychotic, experiences psychotic micro-episms. I refer you to Kernberg and later writings.

The narcissist misperceives his voice, this voice, the persecutory object is external. He projects it and he feels victimized.

And 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, object gets in touch with an external object, it leads to trauma and multiplication as I will discuss in a minute.

Contacts between in cluster B personality disorders.

The confusion between external and internal objects is such that if contact is made between internal object and external object, it can generate trauma. It can generate trauma. The trauma can be extreme, I mean, and lead to PTSD and the trauma could be more, you know, distemic in nature. It could be low level, low key, simmering trauma.

And then we have complex trauma to determine and observe. 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 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 collapse histrionic, and so on. Definitely, there is a collapsed state in each and every overlay in my model.

In each and every overlay, there is a collapsed state. And 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 the 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 has 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 mortification. I teach in 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 leads to a process called narcissistic mortification.

Now, the literature discusses narcissistic mortification, 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 mortification. 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 mortification was defined by Freud, who else, and reiterated by Ronigstam, Ronigstam 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 mortification either to like 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 mortification, we think of something that had caused it coming from the outside.

And I beg to differ. Trauma and mortification can be caused endogenously internally.

I gave an example of someone who has 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 mortification.

It does not have to come from the outside. It does not have to be, in other words, triggered.

This is a common definition of trigger.

What's Chine wrote, the mortification is the fear of falling short of ideals with a loss of perfection and accompanying humiliation.

So Ross Chine is closer, closer, I am closer to the way Ross Chine sees it.

He sees it also as possibly an internal process. The fear extends to intimacy in interpersonal relationships.

I refer you to Viscerini. 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.

Cairnberg augmented this list by adding fear of dependency and destroying the relationship with the analyst. He discussed therapy, fear of retaliation of one's own aggression and destructiveness, and fear of death.

Now, sadistic mortification is therefore a sudden sense of defeat and loss of control over internal and external objects of 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, motido, and so.

The entire personality is overwhelmed by impotent ineluctability and a lack of alternatives, inability to force objects to conform to or rely on their goodwill.

Mortification reflects the activity of infantile strategies of coping with frustration or repression, such as grandiosity, and the attainment or the attendant psychological defense mechanism, for example, splitting, denial, and magical thinking.

And so this is mortification.

Bergler and Maldonado remind us that pathological narcissism, secondary narcissism, is a reaction to the loss of infantile, omnipotent delusions 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 mortification, usually founded on these distortions of reality, compensates for an external one and disguises it, and vice versa.

An internal mortification is what Freud and others called autoplastic. It's autoplastic defense.

Internal mortification is when the patient says, it's on my fault. I made it happen. It restores grandiose illusion of control, mastering over an external mortification.

While a persecutory delusion is an external mortification, it replaces an internal mortification. And the patient will say, I have evil and hateful thoughts towards people, or malicious, envious people had done this to me.

So, mortification is a crucial mechanism. I have prepared a long presentation here, but I'm running out of time.

So, the narcissist copes with mortification in one of two ways. He renders it external, casting himself as the hapless victim of malicious, envious, mentally ill people. And this preserves his self-image as good and morally upright, but it leads to depression.

The second way, the narcissist renders the mortification internal and accepts his contribution to the mortified 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 persecretary delusion, neuroplastic, autoplastic solution, neurotic autoplastic solution.

Okay, so we have mortification, and mortification leads to collapse. And we have mortification in all Cluster B, possibly in other types of personality disorder.

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 on 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 borderline personality. There's little argument about this sometime.

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 at least give you a taste of it.

The covert borderline is his false self and has 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 distantly or ego discrepancy, wrongness. And he has autoplastic defenses.

You are beginning to see the wide gap between the overt borderline, the classic borderline, and the covert borderline.

The 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 borderline has a marked propensity towards feeling ashamed or guilty or to blame is, she's ego-distorted 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 has reactance, he is defiant, he's contumacious, he's reckless, so he's psychopathic. He's a hybrid with primary psychopath.

Now, emotional dysregulation in a classic borderline leads to numbing and disempathy. And the borderline is alexithymic 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. It plays with externalization and internalization to regulate his anxiety and his moods.

The covert borderline has no suicidal ideation, no self-mutilation, no attempted suicide. All his aggression is externalized. And, of course, it's the 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-destroy. We'll never engage in dangerous reckless behaviors, such as egregious promiscuity under the influence of substances or reckless driving also, 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 covert, 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 hypervigilant and she prefers instant or fake intimacy, which connects her, so to speak, with the 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 interrelatedness, and this is owing to narcissistic defenses, the children providing with supply, and because he's schizoid in nature.

He has a conflict between schizoid style and narcissistic psychopathic needs, which creates his borderline state, actually. So he is unable, because of his schizoid, underline schizoid condition, he's 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 is cunning, and his malevolence is premeditated. The borderline is more off-handed. The borderline might cause harm, might cause pain, but it will be absentmindedly.

She disregards other people's limitations, obligations, resources. She's unreasonably demanding. The covert borderline engages intermittent reinforcement, while the classic borderline is merely unpredictable.

The covert has scorn for other people, often masked by pseudo-humility. All converts 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 inconstancy. He goes through idealize, devalue, discard, revert, or replace cycles. The classic has approach, avoidance, repetition, compulsion, and preemptive abandonment. She also has object inconstancy, 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 dilettante. 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, his caricature 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.

The covert borderline may be an activist and has apparent enthusiasm for socio-political affairs.

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, he's 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 insistable 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.

We asked 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 is 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 anti-social or the covert psychopath. That's the model.

These are the ingredients that go into the model.

The covert diagnoses 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 organized 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, 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 cluster B.

Thank you for your inordinate patience. I taxed it, and I misbehaved. Please accept my apologies.

Not at all, Dr. Vaknin. You know, I'd like to congratulate you for your presentation and for your courage. It's not the kind of presentation, you know, it's 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 to 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. Vaknin.

Please, go ahead. I know 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. Vaknin as well. I look forward to her comments.

Go ahead, Dr. Vaknin. Very, 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 collapse, 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.

And so the vignette or the description of traits that you described to contrast covert and overt, not narcissist, but borderline, I mean, this seems to me so strikingly opposite that I would love, if you could direct me to a, 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. And so I guess that's my question, is how can you explain how somebody can go from covert to overt in such striking opposites?

Yes, 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 referred you to an article about borderline personality disorder as a psychopathic state, as a factor to 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 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, etc. There's a huge debate on this.

And of course, my model assumes that a 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 I have case 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 narcissist to overt narcissist proliferates in the literature, just Google, Google scholar, you don't need more than that.

And, and in the two subtypes are dramatically different. One of them is outgoing, assertive, near psychopathic, defiant, and so on. And one of them is shy, one of them is avoidant.

The covert narcissist can easily be described as avoidant personality disorder, easily.

Hypervigilant 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. 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 mortification. And that's exactly the work of Libby. Libby described reactions to mortification. And she said that the narcissist in reaction to mortification can choose internal mortification or external mortification.

And when you read the description of internal mortification, it's covert narcissism. And when you read the external, it's classic narcissism.

So it seems that mortification mediates, mediates the transition, creates the bridge.

It also seems, I agree, that there is no trade, no such thing as trade consensus. I agree. And that's a philosophical question.

Is he about to meet you and is almost in your camera? Does she have a question?

Dr. Bergeron, comments, other people?

I don't mean to single anybody. I 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 Dr. Tofik, 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, 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.

I was just thinking, how does all this jive with, you know, in, in, in whether, in, you know, whether somebody's coldly in touch with reality or not.

So in how does all this jive with, you know, personal responsibility and criminal responsibility in decisions of those.

This may be off the topic, but it came to my mind.

Actually, just to be a pet, a pet topic of mine, I wrote and published about about the insanity defense. So this is kind of the fringe of the insanity defense.

The tests which are used in the insanity defense, when they're replied 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 here and numerous others, even Harvey quickly in his inpatient residential facility where he conducted most of his studies of psychopaths and Robert here 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 the behavior, a report, a portrait constantly. Suddenly they become empathic. Suddenly they become receptive, responsive. Suddenly they, you know, so if they can moderate, modulate their behavior in, 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, narcissists and psychopaths don't have empathy, which is how you have it in the Diagnostic and Statistical Manual form. The fifth edition is a little better in the alternative model, but they do have empathy.

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 idiots. They could have leveraged this cold empathy to realize that, you know, if someone is sad or if someone is in 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 mortification 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 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 utter unmitigated nonsense.

Dr.

Vaknin, I regret to be so rude, but we are, time has come and we have to close, but I'm getting, I'm gathering that we can certainly listen to you a lot more.

Certainly, it'd 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 patients as well with us. Thank you very much. Thank you. Thank you for having me.

And thank you all for being present and for your patients. I mean, thank you.

We'll see you soon, okay?

Okay, be safe everyone. Take care.