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How Mentally Ill Cope With Anxiety

Uploaded 4/24/2023, approx. 28 minute read

Anxiety is an irrational fear. It is the outcome of cognitive distortions, biases and processes such as catastrophizing.

Introverts, which are harsh and sadistic can also cause anxiety.

So anxiety could be exogenic or endogenic. In other words, anxiety can come from the outside, anticipation of some event, fear of the unknown, uncertainty in determinant situations, something we are heavily emotionally invested in and the outcome matters to us a lot. All these generate anxiety and this anxiety is coming from the outside. It's exogenic.


But there is also endogenous or endogenic anxiety, anxiety that is the direct result of experiencing internal processes and being unable to cope with them.

And so Freud, of course, was the first to describe anxiety and later anxiety neurosis and he suggested that anxiety happens in two situations, two circumstances.

Anxiety occurs when we repress uncomfortable material. He called it unpleasurable material, material that is inconvenient, fearful, traumatizing. When we repress this material, when we cut it off, slice it off our consciousness, it is still down there in the unconscious. It simmers and sieves and boils and creates a lot of energy. And this volcanic energy yields anxiety.

And the other case, Freud, is we become anxious and then this creates a defensive reaction, activates a defense mechanism.

So according to Freud, we can become anxious because of an internal process, process repression, or we can repress, we can engage an internal process to deny information that is somehow ominous, unpleasant, inconvenient, and we wish to forget it.

So these are the classic views, the psychoanalytic view of anxiety.


But today we are going to discuss some other aspects of anxiety. And we're going to borrow from other schools of psychology.

The core emphasis of this video lecture is how to mentally ill people cope with anxiety. Something I know everything about. Trust me. My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited and a former visiting professor of psychology, mentally ill people don't cope with anxiety the same way you dobecause they're mentally ill.

And so they develop special ways to handle anxiety, to manage it, to sidestep it, to convert it into something more manageable, something more tolerable, something more bearable, and to prevent anxiety from adversely impacting their functioning, prevent anxiety from rendering them dysfunctional.


Today we know that anxiety disorders are very often comorbid with personality disorders. And in some cases, they underlie the personality disorder. There's good grounds to believe that psychopathy is a way to cope with anxiety disorder.

Anxiety disorder is extremely common in borderline personality disorder. So common, in fact, that it might be an inevitable feature of the disorder, as we shall discuss a bit later.

There are five ways that mentally ill people cope with anxiety. And briefly, they are dissociation, reframing, reciprocal inhibition, and externalization.

Now these are all very, very big words, and I'm going to elaborate on each and every one of themso that by the end of this video lecture, if you're mentally ill, you will know how to cope with your anxiety with a whole brand new repertoire courtesy of Sam Vaknin, which is me.

Okay, rather than repress angiogenic content, as most people do, healthy people, when they come across content, when they come across information or data that causes them displeasure, fear, they feel threatened, is inconvenient, they would rather forget it. When they come across such content, they usually repress it.

And the repression itself, as Freud had observed, can create anxiety. But the repression is such an effective defense mechanism that ultimately the anxiety is reduced and ameliorated.

Mentally ill people cannot repress efficaciously. They cannot repress efficaciously for reasons that I'm not going into right now.

But many of the defense mechanisms of mentally ill people are heavily compromised, aknown as decompensation.

So actually, we can define we can say that mental illness is a situation where your defenses are not working in a way.

So rather than repress the content that causes anxiety, mentally ill people adopt five dysfunctional solutions.


Let's start with externalization and aggression.

Sometimes when a mentally ill person becomes anxious, he and I'm going to use he throughout, but of course, it applies to women equally.

Okay, get the gender thing obsession out of your mind, please.

So when the mentally ill person becomes anxious, he wants to hand over his anxiety to other people to outsource itto farm it outto share the anxiety, misery, loves company, anxiety, loves company twice.

So the mentally ill person wants to share his anxiety with others by rendering them anxious. They're anxious.

He is anxious. This commonality of anxiety, which then in itself is anxiolytic, reduces the anxiety.

So many anxious people, for example, psychopaths externalize the anxiety and become aggressive.

The only way to transfer anxiety to someone else is to make them anxious.

And the best way to make someone anxious is by becoming aggressive.

Very often, anxious psychopaths are by far the most dangerous hair trigger and aggressive and violent, because their anxiety is utterly intolerable and unbearable.

So this is solution number one, externalizing your anxiety via aggression, causing everyone around you to become anxious.

And then you're just one of many and anxiety loves companyand you feel safe, the safety in numbers.


The second mechanism is to conflate external with internal objects.

Anxiety is perceived as coming from the outsidevery frequently. Even when anxiety is a response to internal processes and mechanisms, we tell ourselves that it has something to do with something outside.

We, in other words, always attribute to anxietyexternal causes. We treat anxiogenic content, content which causes anxiety as if it were coming from the outside, never from the inside.

And again, even when anxiety is endogenic, when it comes from the inside, when the reason is internal, when the etiology is internal, when there are internal processes that cause anxiety, even then we will desperately try to find an external reason why we are feeling anxious.

So one of the solutions is to conflate internal with external objects, to confuse the two, to say that this is not internal, this is external. This voice is not in my head, it's there at the corner of the room. This image is not in my mind.

I see it as clearly as the day. Hallucinations, delusions, hyper-reflexivity in psychosis, where internal content of the mind is perceived as external.

And there is a kind of global cosmic merger and fusion, an expanding out of the mind to incorporate the universe itself.

Now why is this a solution to anxiety? Why is this process anxiolytic?

Because if everything external is internal, it creates an internal locus of control or actually an illusion of an internal locus of control.

And similarly, if internal objects which are egodystonic, discomfiting, unpleasant, threatening, if these internal objects are actually perceived as external, then they have no power over you.

So the mentally ill person, for example, the narcissist, the psychotic, what they do is they confuse internal and external objects either in order to restore a semblance, a self-delusion of control over the situation by saying these external objects are actually inside me so I can fully control them. Or the exact opposite by saying these internal objects which are out of control and are causing me anxiety are actually not inside me. They're external.

And so they have no impact on me. They cannot affect me from the inside. They cannot poison me from the inside. It's like outsourcing the poison, projecting the anxiety, throwing it away into a corner.

So the second mechanism.

So the first mechanism to remind you is externalizing the anxiety, causing other people to become anxious, thereby sharing the anxiety and reducing your share of the anxiety. So it reduces its anxiety.

The second mechanism is to confuse or conflate internal and external objects so that you can convince yourself that you're actually in control of the situation or that the situation has nothing to do with you. So you don't need to be anxious. You don't need to be afraid.

The third mechanism is closely allied to the second mechanism. And it is reframing reality to the point of impairing reality testing.

Because reality is perceived as threatening, as unpleasant, as discomforting or discomforting, as frightening. You don't want to be in this kind of reality. It causes you anxiety all the time, especially if you're mentally ill.

So one way to cope with it is to rewrite reality, to create a totally new narrative where these threats and unpleasant facts and fears don't exist. They don't have a good reason to exist because having rewritten reality, having created a power course, a virtual environment, an alternative augmented reality, having done this, you will have removed all the elements in reality which are anxiogenic, which cause anxiety.

And so one way to cope with anxiety in mentally ill people is an automatic, because this is an automatic process. It's something very similar to automatic negative thoughts. It's an automatic process.

So a way to cope with anxiety perceived always, you remember, as coming from the outside, is to change the outside, to impair your own reality testing, to lie to yourself about reality, to invent a new reality, to write a new script for a new movie, a new theatre play with new actors, and new situations which are not threatening, which are not anxiety inducing.

Reframing reality and impairing the reality testing is a third mechanism.

The fourth example of such impairment of reality is paranoia. Paranoid ideation and paranoid personality disorder, these are forms of reframing, rewriting, reinventing reality so as to render it less threatening and less anxiety producing.

The paranoid convinces himselfand the conspiracy theorist as well, by the way. The paranoid convinces himself of two things.

One, he is important, he is a dissenter of events and conspiracies. He is, in other words, powerful.

He attributes to himself potency or even omnipotence.

The paranoia, paranoia, paranoid ideation is a form of narcissism.

So the paranoid impairs his reality testing by grandiosely rendering himself crucial. He develops an inflatedfantastic view of himself which in his mind makes him invulnerable, untouchable, impermeable, not at risk.

This is the first element of paranoia.

And the second element of paranoia, the paranoid tells himself, I am smart, I have uncovered the conspiracy, I know exactly what they are doing and therefore they are never going to surprise me, they are never going to get to me, they have nothing on me, they are not going to touch me.

It is another form of omnipotence.

So these two elements of the paranoid delusion, the persecutory delusion, I am being conspired against, I am being the target of malevolent scheming because I am godlike, I am very importantand because I am all-knowing and I have my spy network or whatever, I am going to know everything well in advance and they are not going to surprise me.

And this is an example of reframing reality and impairing the reality testing in mentally ill people as a way to mitigate and ameliorate anxiety.

Againa recap, you knowwhen you teachyou learn to recap all the time. Students have a shorter attention span nowadays.

Mental ill people cope with anxiety in five waysand I have described three of them by now.


Number one, externalizing the anxiety via aggression, making other people anxious so that you feel good, your anxiety is shared, so it is reduced.

Number two, confusing and conflating external and internal objects so that you feel that you are in control of these objects and that they are not going to hurt you, they are irrelevant to you.

The first solution, externalizing aggression, is psychopathic.

The second solution is narcissistic or psychotic.

The third solution is to reframe reality and impair reality testing by rewriting a new narrative, a new script, you render yourself immune to the consequences of your own actions or immune to danger and threat.

This is typically a paranoid solution.

So now we can move on to the fourth solution.

The fourth solution is called reciprocal inhibition. It was first described by Joseph Grannon, a South Africanbehaviorist, actually. He belonged to the behaviorist school of psychology.

Granon developed a technique to reduce anxiety by forcing or asking his subjects the minute they feel anxiety to think about something else. He realized that you cannot occupy your mind with two signals, with two messages, with two types of content.

So if your mind is consumed by anxiety and then you are forced to think about something else, the anxiety will go away.

And this is called reciprocal inhibitionand it was used to great effect to treat war veterans with what at the time was called war neurosis. War neurosis is what we call today post-traumatic stress disorder. It is deep.

So reciprocal inhibition is at the core of obsession and obsession and neurosis.

There's a video I've made a few days ago about obsession and neurosisand I recommend that you watch it.

In a nutshell, a mentally ill person, when they are confronted with anxiety, force themselves to think about something else. They force themselves to engage in a type of activity which is ritualistic, symbolicand his content which is anxiolytic.

So when the mentally ill person is confronted with a rumor, a situation, a bit of his own imagination, catastrophizing, internal processes can arise, anything that causes him anxiety, the obsessive compulsive person, which is a type of mental illness, the obsessive compulsive person will develop intrusive thoughts. These intrusive thoughts will occupy the totality of his mind so that there's no place left for the anxiety. Simply, the intrusive thoughts displace the anxiety. Trash it. It's gone. So much time and effort and resources are invested in the recurring unwanted intrusive thoughts and in the attempts to get rid of them.

The obsessive compulsive person forgets the anxiety altogether and this is an example of self-administered reciprocal inhibition.


Moreover, the rituals of obsession compulsion, the compulsive component in obsessive compulsive disorder, washing hands all the time, relocking your door ten times, walking on odd pavement stones, whatever, these rituals, they also involve a lot of cognition. The obsessive compulsive person says to himself, "If I were to wash my hands ten times, something bad would be prevented. Washing my hands would prevent something bad from happening to me or to my loved ones, usually to my loved ones."

So the catastrophizing, the anxiety of the impending doom and gloom, they are washed away by washing your hands.

The ritual and ceremonies in obsessive compulsive disorder, they are part of larger cognitive, cognizant conscious narrativesand these conscious narratives consume the obsessive compulsive attention, mental resources, so that there's nothing left for the anxiety.

This is precisely why obsessions and compulsions are anxiolytic. They reduce anxiety. They provide a sense of relief because they take over so many of the mental resources and so much of the psychological attention of the obsessed person that there's nothing left available for the anxietyand it goes away.


The fourth solution is attempt to cope with anxiety via reciprocal inhibition, that devolves in due time into obsession or obsessional neurosis with intrusive thoughts and then compulsions with rituals which are symbolic and have a strong component, a strong counterpart in consciousness.

And this preoccupation is so extreme that it leaves no place or time or energy to anything else, let alone anxiety.

So the anxiety goes away. That's the fourth solution.

The fifth solution is the most complex by far and it's dissociation.

The example of borderline personality disorder is the most perfect.

We discuss dissociation as an anxiolytic tool. Dissociation is a way to get rid or control or ameliorate or mitigate or transform anxiety into something else.

Dissociation is the strongest weapon in the arsenal, the strongest tool, the strongest instrumentand it is used only in extreme cases where the anxiety is absolutely all- pervasive, it debilitates the individual, it doesn't allow the pursuit of any life goals and the enactment of any daily routine.

So it's an anxiety that constricts life, narrows it almost to the point of vanishing.

The mentally ill person first tries to conflate external with internal objects. This is essentially a narcissistic defense and it can become a psychotic defense.

Indeedmany mentally ill people have psychotic micro- episodes. So this is the first defense.

Paranoid defense is an attempt to reframe reality, to impair the reality testing. So there are delusions, there could be paranoid delusions, other types of delusions rewriting reality so as to render it more safe and less anxiety inducing.

The third attempt, third strategy is to try to inhibit the anxiety by occupying the mind with something else.

Well inhibition, if I have intrusive thoughtsI don't have time for anxiety or space or energy. If I'm engaged in rituals which consume 80% of my timeof courseI don't have anything left for my anxietyso my anxiety goes away. That's the third attempt.

The fourth attempt is externalization, aggression, trying to involve other people in your anxiety somehowusually by rendering them as anxious as you are.

And when all these fail, when all these failthe anxiety leads to dysregulation.

Yesthe famous emotional dysregulation is of course the outcome of anxiety. The person with the emotionally dysregulated person is someone who feels overwhelmed by emotions. She feels or he feels is about to drown, is about to disappearand to counter this anxiety and this creates a lot of anxiety of courseand to counter this anxietythere is dysregulation, a desperate attempt to try all kinds of intensities and frequencies of emotions in order to see what works. It's a dysfunctional method for modulating and regulating the internal environmentwhich leads to adverse outcomes of dysregulation.

So it all starts with anxietyand borderline personality disorder is therefore an anxiety reactionwhich involves first and foremostthe fifth and most extreme way of coping with anxiety, disassociation.


I'm going to read to you in extended segments from this book. I hope camera catches it. It's a very big book and a very small camera. It's called Dissociation and the Dissociative Disorders, DSM 5 and Beyond, was edited by Paul Dell, John O'Neill.

There's a second edition, there's a second edition, but the second edition and the first edition contain a lot of different material. So the second edition is actually a second volume, not a second edition. Don't discard your first editionwhen you buy the second one. You're going to miss out on a lot.

I'm going to read to you from the first editionactually. I'm going to read to you what scholars have to say about borderline personality disorder and the dissociative defense and bear in mind that at the core of all this, the reason for all this, the engine that drives all this is anxiety.

The person with borderline personality disorder is terrified of the power, the pervasivenessand sometimes the malice of his own emotions.

I'm trying to counter this. He develops anxiety and dysregulates and then to forget the anxiety, simply to forget the anxiety or to dissociate himself from the anxiety, to disassociate himself from the anxiety.

The person develops dissociative defenses such as amnesia, depersonalization and derealization.

It's like saying, I'm going to put distance between me and my anxiety. I'm not going to be me. Depersonalization.

This is not real. This anxiety is not real. Derealization. Or I'm going to forget all about it. Amnesia.

And now what the scholars have to say.

Although much literature attributes affect this regulation in borderline patients to post-traumatic sequelae, difficulties with affect regulation are also characteristic of dissociative disorders.

Moreover, dissociation can be both a cause and an effect of affect dysregulation.

How is dissociation related to personality disorder, especially borderline personality disorder?

Kannberg in 1975 has suggested that splitting, which he views as a primitive form of dissociation, underlies the larger category of borderline personality organization that includes borderline, narcissistic, antisocial and addictive character disorders.

Kannberg described these patients as having contradictory characteristics without real awareness of the conflictual nature of the material, lack of clear identity and mutual dissociation of contradictory ego statesreflecting early pathological internalized object relationships.

Quite a mouthful.

Kannberg's conceptualization clearly portrays a disorder of dissociated ego states.

Similarly, Bromberg in 1998 views all personality disorders as based in dissociation. The underlying structure of dissociated self-states in narcissistic, psychopathic, schizoid, sadistic and masochistic personality has been discussed elsewhere. They refer to work by Blizzard and Awell and others.

Rather than focus on broader conceptions of personality or borderline organization, we will focus on the more narrowly defined borderline personality because 1) borderline patients present more frequently for treatment and2) they have become the pet noir of many clinicians and 3) the configuration of dissociated self-states in borderline personality disorder differs from the dissociative patterns characteristic of other personality disorders and post-traumatic stress disorder.

While the term borderline has been applied to many different patients, we propose that the core group of people generally designated by this vexing term are those stably unstable people whose sudden alterations in mood, sense of self and relationship to others are manifestations of partially or fully dissociated self-states.

When dissociation is partial, there is usually one continuity of identity, twosuperficial awareness of abrupt changes in affect or behavior, threeminimal ability to link these states in consciousness andfourlittle acknowledgement of the significance of these shifting states.

Often conceptualized as splitting, these shifts are not assessed by tests of dissociation such as the dissociative experiences scale.

This is an introduction to the topic of dissociation in borderline personality disorder.

Nowlet's delve a bit deeper and bear in mind all this is done to avoid unbearable, intolerable, crippling, debilitating, soulruining, souldestroying anxiety. Anxiety whichfor exampleis attendant in trauma situations.

When you traumatize, you become very anxiousand when you traumatize, you become anxious because the trauma itself exacts a very heavy price, very heavy mental priceand because trauma, having endured trauma, having experienced trauma teaches you helplessness.

Trauma leads to learned helplessness. Then you feel defenseless, you feel helpless, you feel impotentand the world becomes a hostile, dangerous jungle.

If you are helpless and defenseless, anyone can do anything to you. It's very anxiety inducing, you become anxious.

Trauma leads to anxietyand dissociation is an attempt to get rid of the anxiety by slicing off the trauma, pushing it down as far down as possible to the unconscious.

In extremes, this is exactly dissociative identity disorderand I will read to you the second and last segment from this book, wonderful bookby the way.

Although the fourth edition of the DSM considers borderline personality disorder and dissociative identity disorder to be separate disorders, the shifts between dissociative self-states in borderline and in DID are very similar.

Perhaps it makes better sense to think of borderline and of DID in terms of their commonality, in other words, dissociated self-states.

Rather than think of them as distinct disorders that may be comorbid, our formulation of borderline personality disorderas a disorder of alternating dissociated self-statesis consistent with the DSM's description of borderline personality disorder.

This is how the DSM describes it.

Profound changes in self-image affect cognition and behavior, sudden and dramatic shifts in their view of otherswho may alternately be seen as beneficent supportersor as cruelly punitive.

There may be an identity disturbance characterised by unstable sense of self and dramatic shifts in self-image, goals, values, sexual identityand friends. This is known as identity disturbance.

The DSM's description of BPD closely mirrors the identity shifts that occur in DID. It is also similar to the DSM's description of DIDand again I'm quoting the presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating toand thinking about the environment and about the self.

And so, although inability to recall personal information is required in most types of DID, the definition of borderline personality disorder neither includes nor excludes this criterion.

And so what are the signs that BPD can be understood as dissociated self-states?

In other words, what are the signs that BPD can be understood in terms of dissociated self-states?


Number one, unstable relationships, identity disturbanceand affective instability can be viewed as the direct consequences of shifts among partially dissociated self-states.

Number two, fear of abandonment, anxiety, separation insecurity is also called abandonment anxiety. Fear of abandonment, difficulty controlling angerand transient psychotic symptoms may all arise when traumatic memories are triggered and distinct self-states are activated.

Mind you, if you know that you cannot control anger, if you realize how dysfunctional and disregulated you are, that in itself, that in itself, that knowledge in itself is cause for anxiety.

Number three, substance abuse may serve to facilitate a shift to an emotionally non-self- state in an attempt to self-medicate overwhelming affect. Substance use also creates anxiety by doing.

Number four, sexual impulsivity may be the manifestation of a dissociative self-state reenacting earlier abuse. Dissociation is the final desperate nuclear weapon when the mentally ill person tries to cope with anxiety that threatens to devour and engulf him.

And these are the five stages of dysfunctional coping with anxiety in mentally ill people.

If you've identified any of them in you, don't panic, talk to a licensed therapist or a psychologist who is an expert in diagnosis, a diagnostician.

Some of these dysfunctional methods or strategies of coping with anxiety happen, occureven in healthy peopleunder extreme conditions of stress when stressors are present, for example, divorce or pending imprisonment.

So don't be alarmed if they do. The bigger context is needed. There is a clinical picture of mental illness and then one or more of these strategies is ways to cope with anxiety, which either generates the mental illness or is its outcome.

So I know this lecture caused you a lot of anxiety. You may wish actually to try reciprocal inhibition. Whenever you're anxious, force yourself to think of something else. Just sit down, tell yourself, now I'm going to think about whatever, but make sure that you think only about this.

Generate artificially an intrusive thought. You will see that it works.

Joseph Wolpe, for those of you who are interested to learn more about reciprocal inhibition. This disinhibited lectureat its end. I wish you all reciprocity and love.

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