New discoveries in neuroscience, the science of the brain, seem to support something I've been saying for three decades.
I've been proposing that narcissistic personality disorder, borderline personality disorder at the very least, are post-traumatic conditions. They involve a disruption in the formation of the self, identity disturbance, empty schizoid core, the famous emptiness reported by most borderline patients.
And so I attributed the disruption in the formation of a self or an ego, depending which school of psychology you adhere to. I attributed this disruption to adverse childhood experiences, trauma in early childhood.
And I've been advocating, I've been suggesting that the mediating mechanism, the mechanism that links trauma to a disruption in the formation of the self is dissociation.
But in the absence of any proof or evidence, this was just speculation, a lot of speculation.
The suggestion to recast cluster B personality disorders as post-traumatic conditions was very appealing. Later on, it was joined by the likes of Judith Herman, the mother of complex trauma and CPTSD studies. But none of us had any proof to anything we were saying until recently, the last three years.
We have seen an avalanche, a flood of studies of the brain that have established almost beyond doubt a connection between trauma, especially early childhood trauma, dissociation, including depersonalization and derealization and lack of disruption in the sense of self, a lack of sense of self, which is of course one of the main hallmarks of borderline personality disorder and narcissistic personality disorder, borderline personality disorder.
We also have emotional dysregulation. But I think we could argue that dysregulation, lability, instability are the outcomes of a lack of a core, a lack of a self, a unitary something, a nucleus, a kernel, a regulatory mechanism. The absence of this center of gravity is the reason for dysregulation.
So dysregulation in my view in borderline personality disorder is secondary.
And the main problem is the non-existence of a self. Absence defines borderline and narcissistic personality disorders in my view also, antisocial, histrionic, schizotypal, the paranoid and so on and so forth. These are all disorders of absence, a failure to become, a failure to materialize, a failure to grow, a failure to realize potentials, to self actualize in Maslow's terms.
So the video you're about to see describes the latest leading edge, cutting edge studies that finally prove the hypothesis.
Now theory that trauma, especially adverse childhood trauma, adverse childhood experiences trauma leads to dissociation, depersonalization, derealization and amnesia, which then leads to the inability to form a continuous sense of self. And that creates the emptiness, which then results in dysregulation, in addiction, in a panopoly of other clinical features and phenomena.
So they're writing into the strange and amazing and weird world of neuroscience, the last frontier, the universe that's more complex than anything, the brain and the mind.
At any given time, I'm on the organizing committee or the scientific committee of well over 50 international conferences, the world over. But I have never seen, witnessed or heard anything like the November annual meeting of the Society for Neuroscience. It lasted five days and more than 25,000 people have participated.
Where else in Washington, DC. One could say that the focus of the annual meeting revolved around trauma one way or another and this is today's topic.
The latest on post-traumatic stress disorder, cutting edge, bleeding edge, apropos trauma. And why am I on so many scientific committees?
Because I'm Sam Vaknin, the author of Malignant Self-Love: Narcissism Revisited, a former visiting professor of psychology in Southern Federal University and currently on the faculty of CIAPS, Commonwealth Institute for Advanced Professional Studies.
And we start with childhood. Normally childhood adversity, early life adversity, based on the amazing and humongous study known as ACE, childhood experiences study. This larger study to the best of my knowledge, larger study in the history of psychology has taught us that events in childhood have long lasting consequences. They raise the risk for depression, substance abuse, and even to some extent, personality disorders.
And so a new discovery is that there is a pathway, a brain pathway in mice that governs the link between early life or early childhood adversity, bad experiences, abuse, absence, neglect, and so on and so forth, and symptoms of depression in adulthood. I have no idea how do you diagnose depression in mice, but I would tend to trust the scientists who claim that they have and linked it to the bad childhood of the particular mice with the particularly depressed mice.
So brain imaging studies of children and teens during the COVID-19 pandemic have shown an increased thinning of the outer layer of their brains, particularly among girls, by the way.
Now, there's a history of imaging of brains of teens and children, and it is not as sinister as it sounds. And thinning is actually a normal process. It's part of the maturation of the brain.
But during the COVID-19 years, the thinning accelerated dramatically. It reduced the amount of time that the brain has to develop cognitive skills crucial for later, proper development.
It seems, therefore, that trauma does have an effect on the brain, but not necessarily the kind of effect that we have imagined either to, not a disruption or a destruction, but rather an acceleration of normal maturation processes in a way that prevents orderly structured goal-oriented development.
So teenage years, let alone childhood, are very crucial periods in brain development, and any impairment during these years can and does have long-term consequences.
And so in the study that I mentioned before with mice, the presenters of the study showed that mice that experience a lot of stress during puberty have problems in the postpartum period later on, with animals showing greater signs of anxiety and struggling to care for the young, compared with unstressed mice.
So if you're a mother who's been stressed in her childhood or adolescence, your ability to take care of your children seems to be reduced, at least if you're a mouse.
Now, preliminary evidence also suggests that separating young rats from their mothers increased the likelihood of risk-taking behaviors in adolescence. The rats became antisocial. We would call them psychopaths in the human equivalent.
So we need to focus on a better nosology, a better classification, taxonomy and characterization of early childhood adversity, because many behaviors, many parental behaviors that today are not perceived as abusive and traumatizing are actually very abusive and traumatizing.
Spoiling the child, pedestalizing the child, idolizing the child, imposing on the child unrealistic expectations, micromanaging the child's life, preventing the child from interacting with peers or from confronting reality, however abrasive and painful it may be. All these are forms of abuse not included in the ACE study.
We need to expand our understanding and definition of early childhood adversity or early life adversity and we need also to transition from non-human animals, mice, rats to human animals.
And this way hopefully find the link.
Anyhow, this was the opening statement.
Today we're going to dive deep and delve deep into many more amazing discoveries and sum up the latest fount of knowledge with regards to trauma, severe trauma, which usually creates post-traumatic stress disorder or if it is prolonged regular creates complex trauma, CPTSD.
So the first study I would like to mention is by Lanius and Terpu. It is titled The Sense of Self in the Aftermath of Trauma, Evidence from the Default Mode Network in Post-Traumatic Stress Disorder.
Of course, the first question would be what the heck is the default mode network, DMN for short.
The article was published in the European Journal of PsychotromatologyJournal of Psychotraumatology three years ago in 2020 and I would like to, as is my habit when the article is well written, I would like to read to you the abstract and the introduction. I think they're very interesting and very relevant and very well written.
Trauma, say the authors, can profoundly affect the sense of self where both cognitive and somatic disturbances to the sense of self are reported clinically by individuals with post-traumatic stress disorder. These disturbances are captured eloquently by clinical accounts such as I do not know myself anymore, I will never be able to experience normal emotions again and I feel dead inside.
That is very reminiscent of borderline by the way. Self-related thoughts continue the authors. Self-related thoughts and experiences are represented neurobiologically by a large-scale cortical network located along the brain's midline and referred to as the default mode network, DMN.
Recruited predominantly during rest in healthy participants, the DMN is also active during self-referential and autobiographical memory processing, processes which collectively are thought to provide a foundation for a stable sense of self that persists across time and may be available for conscious access.
In participants with PTSD, however, the DMN shows substantially reduced resting state functional connectivity as compared to healthy individuals with greater reductions associated with heightened PTSD symptom severity.
Now that's a mind boggling statement. What the authors are saying is that trauma disrupts your sense of self mediated via a particular pathway or structure in the brain which is the DMN.
But never mind that. That is something I have been saying for well over 25 years.
Trauma is a disruption in continuous identity. Trauma is therefore a form of dissociation.
Okay, let's proceed.
The authors continue in the article.
Critically, individuals with PTSD describe frequently that their traumatic experiences have become intimately linked to their perceived sense of self, a perception which may be mediated in part by alterations in the DMN.
Accordingly, identification of alterations in the functional connectivity of the DMN during rest and during subliminal trauma- related stimulus conditions has the potential to offer critical insight into the dynamic interplay between trauma and self related processing in PTSD.
Here in this article, we discuss DMN related alterations during these conditions, pointing further towards the clinical significance of these findings in relation to past and present centered therapies for the treatment of post-traumatic stress disorder, PTSD.
So what the authors are saying is that trauma may impact significantly an individual sense of self.
The default mode network in the brain is taught to confer a stable sense of self and the authors discuss alterations in the connectivity and activity in this network, in the DMN network in conditions of PTSD and the clinical significance of this as to the ability to maintain a sense of self.
Amazing. Finally, the brain connection missing in all the theories that link trauma to disrupted selfhood, to dissociation.
Now, I'm going to read to you the introduction. I think this is one of the best, the most well-written articles ever come across.
Trauma, say the authors, can profoundly affect the sense of self and they refer to work by Schor, 2003, leaving a lasting imprint on both the cognitive and the somatic domains of an individual's sense of self.
There are many references, inline references in the article. I just recommend that you visit the article and follow through on the various references if you want to peruse additional literature.
"Cognitively," say the authors, "individuals who have experienced trauma are often tormented by thoughts that reflect intensely negative core beliefs about themselves. These thoughts can include, as I said, I will never be able to feel normal emotions again, again, I feel like an object, not like a person, I do not know myself anymore, or I have permanently changed for the worse.
All these kinds of sentences, I'm empty inside, I'm dead inside, these kinds of sentences have been recorded by multiple clinicians.
And I refer you to Cox, Resnick, Kilpatrick, Toline, Ehlers, Osseo, and many others.
So here we begin to see, and this is me, not the authors, here we begin to see a confluence between PTSD, a disruption of the self, a sense of emptiness, the empty schizoid core, and of course, diagnosis, such as borderline personality disorder and narcissistic personality disorder, which I've been suggesting for almost 30 years, are post-traumatic conditions.
Somatically, continues the authors, "somatically recent research points increasingly towards a notion that trauma can leave a lasting physical representation, with lower back pain, general muscle aches and pains, flatulence, burping, or feeling as though your bowel movement has not finished. All these have been identified as somatic disturbances that significantly perturb the sense of self.
Here Graham and others found that two-thirds of cases of military-related post-traumatic stress disorder are missed when the PTSD checklist for the Diagnostic and Statistical Manual Edition 5 served as the only assessment tool.
What they're trying to say is that the DSM's definition of PTSD is way too narrow, and I fully agree. I think there are many post-traumatic conditions.
Judy Thurman identified CPTSD, complex trauma is one of them. I suggest that personality disorders, many of them, not only cluster B, are post-traumatic conditions as well, and that should be a convergence between PTSD, CPTSD, and personality disorders under a single umbrella of post-traumatic conditions.
My work, not the authors. Usually when we diagnose trauma, we use the PCL5, and that's what they refer to.
Anyhow, they continue, the authors continue.
Moreover, participants with PTSD report somatically based alterations in relation to self-experience, including feelings of disembodiment, depersonalization and related identity disturbances revealed by reports like "I feel dead inside. I feel as if I'm outside my body. I feel like my body does not belong to me. Or I feel like there is no boundary around my body.
All these are classical descriptors of depersonalization, and to some extent derealization. These are dissociative statements.
This is what I'm saying. This is where dissociation meets trauma.
The authors continue.
These reports underscore the vulnerability, the sense of self has in the aftermath of trauma, where both cognitive and somatic disturbances to the sense of self are thought to reflect remnants of the traumatic past among individuals with PTSD.
What about the neural underpinnings of the sense of self?
This is where the authors introduce the default mode network, the DMM.
They write, "A wide body of evidence suggests that self-referential processes as well as past and future-related autobiographical memory processing are facilitated by a large-scale intrinsic network known as the default mode network, DMM.
It was first described by the way 20 years ago.
Self-referential processes define the various self-related or social cognitive functions that allow us to gain insight and to draw inferences related to our own mental and physical conditions as well as to mentalize these alike conditions in others.
It's critical for mentalization.
This is again where post-traumatic conditions are low on empathy and the ability to create consistent, coherent, cohesive, stable theories of minds of others.
This is a problem with narcissism. The narcissist cannot perceive other people as external or separate.
Consequently, he introjects them, converts them into internal objects that has a lot to do with trauma because the damage to the DMM in the brain prevents or hampers or obstructs mentalization.
The authors continue, "Although the DMM is recruited predominantly during rest, it is also active during internally directed cognitive processes.
Collectively, these DMM-mediated processes are thought to provide the foundation for a continued experience of the self across time, occasionally referred to as "autonoetic consciousness" where self-relevant information and events associate to produce our sense of self.
The DMM is composed primarily by cortical regions located across the brain's midline including the posterior cingulate cortex, the precuneus and the medial prefrontal cortex. These DMM-related cortices contribute variously to self-related processes.
Whereas the posterior cingulate cortex and their precuneus are associated more strongly with our experience of having an embodied self that exists in space, the medial prefrontal cortex is associated more strongly with our awareness of thoughts and emotions related to the self.
Critically, the DMM displays widespread functional alterations in individuals with PTSD during rest and during trauma-related stimulus conditions. While these alterations are likely to mediate, the clinical disturbances underline self-related processes in PTSD.
This has been the missing link to these studies. By the way, dozens of studies, the bibliographies and all. This has been the missing link. This is where the brain mediates trauma and self-disturbances.
Disturbances in the formation, maintenance and access to a sense of self, to a core identity. This is where dissociation kicks in, in the form of depersonalization and derealization.
Now there is a burst of energy and an explosion of studies with regards to PTSD and these have transformed our knowledge and our perception of PTSD.
I'm going to introduce you to the latest in thinking and in knowledge, irreducion.
First of all, post-traumatic stress disorder is an anxiety, in effect an anxiety disorder. It's pathological anxiety that occurs after individuals experience or witness severe trauma, usually a single event by the way. PTSD is a single event. Complex PTSD, complex trauma
is a reaction to repeated events, many events over an extended period of time. PTSD is an anxiety reaction which is in the wake of exposure to trauma. You don't need to be traumatized yourself. You may just witness trauma and react via vicarious traumatization. We distinguish between primary trauma, experiencing the trauma yourself and witnessing trauma where what you're going through is vicarious traumatization. This constitutes a threat to the mental functioning and the sense of self of the individual. Now the trauma has to involve some kind of threat to the life or physical integrity of yourself or another person. Traumatic events may include therefore combat, automobile accidents, gun violence, mass shootings, rape, fire, other natural disasters and so on, where the physical integrity or life are threatened. This is PTSD. Complex PTSD is exposure to any stress or on a permanent regular basis or within a framework of a matrix of intermittent reinforcement. It's a bit different. The etiology is very different between PTSD and C-PTSD and flashbacks occur only in PTSD, never in C-PTSD. So the concept of emotional flashback is nonsense. Now patients with PTSD persistently re-experience and this is called revividness, re-experience the inciting events, the triggering
event in three ways. Avoidance, numbness which is externally visible via reduced effect display, emotional numbness and hyper arousal, the famous startle response. Negative thoughts and mood or feelings are often present as well in PTSD. Now PTSD is more prevalent than we think. According to the World Health Organization, they have something called the World Mental Health Survey. About 4% of the population, up to 6% of the population have PTSD and half of these report persistent symptoms.
I don't know if you grasp what I'm saying. Between 1 in 25 and 1 in 16 people have PTSD and half of them are paralyzed, debilitated by PTSD. So PTSD doesn't happen just like that. You could be exposed to the same event and you will not react with PTSD. So two people are exposed
to the same event, one of them ends up having PTSD, the other doesn't. Why? Because they are pre-existing, peri-traumatic and post-traumatic risk factors. Thefactors.
The trauma is an event, it is the perception of the trauma and the reaction of the event and the reaction to the event that creates the trauma.
Trauma is therefore a mode of reactance, a mode of reactivity. It's not the event itself.
So even somatic parameters, for example your pulse rate, your tendency to develop tachycardia, rapid heartbeat, they predispose you to PTSD.
So for example there is a heightened rate of PTSD among female patients, among people with lower intelligence, lower socioeconomic status and authority, the uneducated, ignorant people, people who experienced dissociation at the time of a traumatic event are actually more prone to PTSD.
It seems dissociation is not an effective defense or protection against PTSD which is why it's very bad to insist on recalling the traumatic events.
Today we are changing the guidelines in trauma therapy. We used to ask, we used to insist, we used to pester the patient, we used to force the patient to remember, to recall the events of the trauma. This was really very bad and today the guidelines are exactly the opposite.
Sometimes it's good to not remember actually, it's therapeutic.
Anyhow, all these predispose to PTSD. Clear memories, these are called flesh bulb memories. Clear memories are often experienced by people who survive or witness traumatic events and they are normal for many people with PTSD and they are symptom but they are not a risk factor.
Again, a change in our perception. Other risk factors include childhood adversity, development of acute stress disorder, interpersonal violence, lack of social support, pre-existing mental illness, prior traumatic exposure, severity and nature of the trauma, subsequent adverse life effects or life events so trauma can suddenly erupt years after the event and other stresses such as financial problems, divorce and so on and so forth.
The diagnosis of PTSD is based on evidence of serious threat experience followed by the recognized symptoms of PTSD including an enhanced or increased startle response and other features, other clinical features.
Relevant behavior, cognitive and emotional factors and processing dysfunctions, they all confirm the diagnosis and these factors include a decreased range of positive emotions, persistent negative emotional states, amnesia for parts of the traumatic events, this is part of the diagnosis. Distorted thoughts about the cause or consequences of the trauma, distorted thoughts of self, others and the world, there's a disruption to the internal working body. Inability to engage with clinicians, avoidance or even terror or therapy, increased vigilance, hypervigilance, problems with concentration, signs of physiological arousal upon physical examination. Physiological arousal in this sense is not what you're thinking, get your mind out of the gutter. Physiological arousal means simply sweating, tremor, agitation, particularly when the trauma is discussed.
And finally of course visible things like traumatic head injuries which cause neurological impairment.
So the problem with PTSD, it is very frequently comorbid with other things, with other diagnosis. So it can present as depression or be misdiagnosed as depression. PTSD can even be misdiagnosed as narcissistic personality disorder. Anxiety symptoms are so common that PTSD is sometimes taken to be an anxiety disorder.
Substance abuse, suicidal ideation, relationship problems, that's why people with CPTSD are often misdiagnosed as borderline, with borderline personality disorder.
Now how do we treat PTSD?
I'm sorry. Today the golden therapy, the golden choice is EMDR, trauma focused eye movement desensitization and reprocessing.
The second layer is known as prolonged exposure therapy, ERP and cognitive behavior therapy.
Cognitive behavior therapy should start, all these therapies actually should be started within the latest two weeks from exposure to the traumatic events. Otherwise they are rendered ineffective.
It seems that trauma somehow crystallizes, ossifies, becomes rock-like, impenetrable and impermeable and after a few weeks there's very little you can do therapeutically.
Psychiatric comorbidities with PTSD include mood disorders and mood disorders are very common among people with PTSD, of course especially depression. And this can be treated with non-pharmacological treatment modalities, options.
You don't need necessarily to prescribe medication. Group debriefings immediately after the trauma are bad.
So if you debrief the trauma victim or the person who has witnessed the trauma in a group setting, this is seriously bad. It fixates the trauma.
Similarly if you debrief the individual alone, it's bad. It's not as bad but it's bad. This is known as flooding. You flood the victim with the trauma and the victim is overwhelmed, drowned.
In effect you generate or you create artificial transitory borderline personality disorder. De-briefing the victim, asking the victim, "Tell me what has happened, try to remember, go into details." It doesn't fail to prevent the development of PTSD and it risks re-traumatizing the victim and flooding him or her to the point that she is no longer amenable to therapy.
There was a recent nested case control study and it tried to find out whether long-term stress or anxiety are associated with out of hospital cardiac arrest. The researchers found that patients with PTSD have almost two times the risk of out of hospital cardiac arrest compared with controls. This means that the PTSD is all pervasive, omnipresent. It's all the time with you and it complicates, magnifies, amplifies totally unrelated risks like the risk of cardiac arrest. About 30% of people with PTSD recover eventually. Another 40% improve, though not completely and only with treatment. For the others PTSD is a lifelong issue and free. That includes flashbacks and really bad things.
So PTSD is a serious business because 70% of people with PTSD, you know, are not well and they're not well for life. The prognosis varies widely based on several factors including the severity of the stress or patient's resilience, level of support, secondary stresses, ongoing injury, prior traumatic experiences and other factors.
Written exposure therapy is as effective as prolonged exposure therapy. So it can be administered at home, for example, like homework, you know, and compressed approaches to exposure therapy carry the risk of flooding.
So I think there should be a transition to milder forms of ERP exposure therapy, such as homework or written forms.
What about medication?
Paroxetine and Sertraline are the only two drugs that the US Food and Drug Administration, the FDA, approves for PTSD. So paroxetine and Sertraline, they are the only two. But the others, they're known as alpha 2 receptor antagonists.
The other drugs that are prescribed a bit off the box, you know, kind of experimentally, and they include clonidine and guantrazine. And they're used with patients with PTSD, which experience to tackle agitation and startle responses and so on.
So the first line of defense is clonidine. I'm sorry, the first line of defense is the drugs that I mentioned. And the second line of defense is the alpha 2 receptor antagonists.
So paroxetine, Sertraline, then clonidine and guantrazine.
Okay.
Now what about benzodiazepine, which is very commonly used and abused among PTSD patients, not to mention other sedatives, ADHD stimulants, which are very dangerous. Benzodiazepine is actually not recommended. It should be avoided strictly in the first few weeks after the trauma because it could create flooding and fixation.
So absolutely do not take benzodiazepine, the bad for trauma.
Eramotamine, usually used with caffeine to treat migraines is also not recommended because it creates agitation. And although it is used with patients, PTSD patients, I am not sure it's a great idea to use another statement.
There's been a recent review of pharmacotherapy for PTSD and there was no evidence of benefits. Similarly, antipsychotics, risperidin and so on, they have no effect on PTSD. There's no evidence to support the usage of eragotamine, caffeine, antipsychotics and anticonvulsants. They have very dangerous side effects and zero benefit in the case of PTSD.
Now you know everything there is to know. Go find a trauma and don't treat yourself, resort to professionals.
Thank you for listening.
I hope this video hasn't been too much of a traumatic experience and you are not right now in the throes of a nascent emergent PTSD episode.