Hello. I am shocked to see so many survivors of yesterday's lecture. You are a nation of strong people. So I am happy to see you here.
Today we are going to discuss a very sensitive topic. Diagnosing someone with a mental illness is a stigma. It has social costs. It has relational costs in relationships. It has job opportunities, costs. You diagnose someone with mental illness. You are doing them often. If it is difficult enough to do with adults, imagine how difficult it is to do with children and adolescents. There is even a tendency to deny. No such thing as a mentally ill child. No such thing as an insane adolescent. It is a phase. It will pass. You don't need to impact the child's record or the adolescent's record. Close your eyes. Look away.
And yet the undisputed fact is that there are mentally ill children and mentally ill adolescents.
Today we are going to discuss a specific subset of mental illness known as personality disorders.
Most notably cluster B personality disorders. Which include borderline personality disorder. Narcissistic personality disorder. Histrionic personality disorder. And antisocial personality disorder.
Mistakenly known as psychopathy.
There are other personality disorders of course. Paranoid personality disorder. Schizoid personality disorder. So there are others. But they are very, very rarely diagnosed in children and adolescents. So there is no point to waste time on them.
Which is what I said in English.
By the way yesterday I made a four part. I did not thank this gentleman for his selfless efforts in translating. I think he deserves thanks on behalf of all of us. And he is valiantly attempting to translate the untranslatable.
Before we start it is always a good idea to define your subject matter. And the subject matter happens to be children and adolescents.
There has been a sea change. There has been a tectonic shift in how we define adolescents.
Following the studies by Twenge Campbell and others. But mainly Twenge. Following her studies we now define adolescents as up until age 25.
And the reason is that one third of people under age 35 continue to live with their parents.
All urban children under age 25, almost all of them continue into higher education.
People begin to drink alcohol two to three years later than in the 1980s. People receive driving licenses or sick driving licenses two to five years depending on the country later than in the 1980s.
To cut a long story short people refuse to grow up. And it's not a joke. They refuse to grow up. It was called in the 1970s it was called the Peter Pan syndrome. People get married of course I don't need to tell you much much later. And they begin to have children much much later.
And about one third of people never have a relationship. 31% to be precise. People refuse to grow up. And they remain eternal adolescents.
In the 1960s and 1970s in psychoanalytic literature this phenomenon was called where are eternals. It's in Latin.
So adolescents we have adolescents age 22 and 25 and 24 and 23.
Sounds counter intuitive but the classic definition of adolescents now extends into the mid 20s.
A very interesting trend happens with children.
You remember our subject matter is children and adolescents.
Until the end of the 19th century there was no such thing as a child. People who were six years old or seven years old they were called little women and little men.
If you look at the book the famous book by Louisa May Olcott. It's not called little girls. It's called little women.
There was no such thing as a child. It's a modern invention. And because it's a highly modern invention it's actually it was actually a fad, a fashion.
And now we are going back essentially to the 19th century. We are gradually eliminating childhood. Children are hyper sexualized.
For example in advertising in show business. Children engage in adult activities like modeling. About one third of high tech and high technology entrepreneurs are under the age of 10.
So we are seeing an elimination of childhood and an extension of adolescence.
This is very important. These two trends are very important.
Because they mean that mental health issues that were once the preserve of adults now appear in childhood and adolescence.
You can even say that popular culture definitely in the west encourages mental illness, certain types of mental illness. Among young people.
So for example the amount of explicit sex and violence in products consumed by children and adolescents is dramatically up. The rating of movies for example has now shifted so that movies that once were considered adult only are now PG, family consumption.
Before I get to business and we start to deal with diagnosis and so on and so forth.
There is an important observation for me.
Do you hear me there in the back?
My apologies.
So you could have children raised in the same environment by the same parents. Even identical twins. One of them becomes mentally ill, the others don't.
For example children who have been exposed to abuse. We have a questionnaire in psychology called ACE. ACE is Adverse Childhood Experiences.
Adverse Childhood Experiences.
So when we administer ACE we find that people with the same number of experiences, bad experiences, only a relatively small percentage develop mental disorders or mental illness.
This indicates very strongly that there is a genetic predisposition to mental illness. Even among identical twins, there are differences in gene expressions. The expression of genes, not the genes, the genes are identical, but the way genes express are different among identical twins.
So what can you do about genetics? Nothing. Don't feel bad. Actually as opposed or as distinct from adult mental illness in children and adolescents, the genetic contribution is much higher.
When you're coping with children and with adolescents and with the manifestations of the mental illness, keep reminding yourself, you're not gods.
Well not all of you gods. I'm the only god here. I'm the only god here. Please let's make it clear.
And there's nothing you can do in many of these cases. They are genetically determined. Not all of them, but in a big number of cases.
The lecture is divided into two parts.
The first part I will deal with the mental health diagnosis that are specific to childhood and adolescence.
And these mental health diagnoses are related to personality disorders.
And then the second part of the lecture I will give you ten tools, ten tests, ten warning signs.
You observe these signs and if they exist or a big number of them exist, it is almost safe to say that this child or adolescent either is mentally ill or about to develop mental illness.
Okay. You broke my heart.
Listen guys, this is very tough material, very boring.
And so we need to laugh a lot.
So feel free to laugh.
There are four diagnosis that lead directly and are connected to personality disorders.
There are many diagnosis in childhood and adolescence, but only these four result in later personality disorders.
A methodological comment.
These are borrowed, taken from the Diagnostic and Statistical Manual. Addition 5, 2013.
You are much more mentally healthy than the rest of the world. Addition 5 published in 2013.
So these are borrowed from there but of course as you all know there is a major difference between the Diagnostic and Statistical Manual and the ICD, the International Classification of Diseases.
The 11th edition of the ICD will be released formally this year or next but it is already available widely and the 11th edition contradicts the DSM sometimes dramatically on many issues, disagrees with the DSM.
One example, important example. The ICD 11 does not recognize multiple personality disorders. Only one personality disorder with different emphasis.
So you would have personality disorder with narcissistic emphasis. Which is what I have been advocating since 1995. I think that is the right thing. I think they did the right thing.
But if I go according to the ICD I will not be able to make a living. I am going with the DSM. It is good for business.
There are four diagnoses in the DSM that lead to personality disorders later in life.
Reactive Attachment Disorder.
Right, L.A.D.
These are children who are unable to attach to other people most notably mother. They are withdrawn. They are emotionless. They are reticent. They refuse contact especially physical contact.
Reactive Attachment Disorder if it is left untreated in adolescence already translates into a personality disorder. If L.A.D. is not treated it becomes psychopathy.
Or more precisely antisocial personality disorder.
Time to explain the difference between psychopathy and antisocial personality disorder because it is very confusing.
Let's start with the word that is not a clinical term and should not be used by any serious professional.
Sociopathy.
It is a high. It is a media high. There is no such thing. There is no such clinical entity.
In the 19th century there was something called character disorder. In the 19th century there was something called character disorder.
And this is more or less sociopathy but it is not a diagnosis.
Antisocial personality disorder is the tendency to disregard and confront the rules of society essentially.
Extreme forms of antisocial personality disorder are known as psychopaths.
The vast majority of people with antisocial personality disorder are not psychopaths.
Similarly in narcissism we have narcissistic personality disorder and when it is taken to extreme we have malignant narcissist.
The vast majority of people with narcissistic personality disorder are not malignant narcissists.
And finally this guy, Mr. Sperry, suggested that there is something called style.
Psychopathic style. Narcissistic style. That is not exactly narcissist but has a lot of behaviours and traits of a narcissist.
No, style. It is style.
Like he has a narcissistic style. He is someone who is not a pleasant person, arrogant etc but he is not a narcissist. He is almost narcissist but not.
The clinical term for this is subclinical narcissism.
When we put the subclinical types together we get dark personality.
So when we take for example subclinical narcissist who is also subclinical psychopath and put them together we get dark triad personality.
No. You can read about it only.
How do you frame childhood delinquents?
We will come to it.
So the reactive attachment disorder becomes antisocial personality disorder.
And again the reactive child refuses to bond, refuses to get close to you, recoils if you try to touch him. Never makes eye contact. Never turns his head towards his mother.
An important test.
Mother is there. He is ignoring her like she is not there. Left untreated.
Left untreated.
This kind of child within four to six years becomes a cruel sadistic psychopath.
The next one is contact disorder.
Contact disorder is a diagnosis in the diagnostic and statistical manual.
And these are juvenile delinquents. Most of them have contact disorder.
Contact disorder is a set of behaviors which the police would appreciate. A set of behaviors which are essentially subcriminal, almost criminal.
For example, torturing animals, inflicting bodily harm on other peers. Stealing property, violent altercations or arguments. Deceit. Lying almost compulsively. Very often without reason. Extreme manipulativeness.
Early, precautious sexuality. Very early and very inappropriate sexuality. Very often directed at adults.
And of course delinquency in the extreme cases. The vast majority of children with contact disorder become diagnosable psychopaths.
So we call this psychopathy for children.
In contact disorder and in antisocial personality disorder, we don't have yet sufficient brain studies. We don't have anything, we have insufficient material in terms of brain studies.
But when it comes to psychopaths, we have a lot of brain studies. So we know, and this is a fact, that the brains of psychopaths are different to the brains of everyone else, including narcissists.
In extreme cases, dramatically different. The amount of white matter, connectivity through ganglions, everything is very very different to the psychopath.
We used to think that the psychopath is fearless, has no fear.
Because when we tested the psychopath's skin, there was no skin conductivity when there were situations that should have been frightening.
So there was no, the psychopath did not sweat when he was exposed to frightening situations. He did not sweat. The electricity in his skin remained the same.
Brain centers that should have lit up, did not light up.
So we thought, mistakenly, that psychopaths don't experience fear. They are fearless.
The last ten years we have revised our view and we understand that psychopathy usually goes hand in hand with severe anxiety disorder.
So we have to understand that psychopathy is a threat to anxiety disorder. Which connects it to a garden.
Reactive attachment disorder is a form of anxiety. The child is anxious about contact. The child has to be active. The child is anxious about contact.
Children with blood do not develop contact disorder. These are two pathways to psychopathy. They are separate. They don't lead to each other.
So these two are the psychopathic group.
And we used to think that borderline personality disorder has nothing to do with psychopathy.
Until again in the last ten years.
So the information I'm giving you now, this is the latest of the latest. That's the cutting edge. That's the absolute latest in research. It's not in textbooks. In many universities they are not teaching it yet. So it's really the latest.
So we used to think that borderline has nothing to do with psychopathy.
But now we change our mind. And following studies by Sproul.
We now know that borderline personality disorder.
When the patient is exposed to stress, for example rejection or abandonment, she actually becomes a psychopath.
A special type of psychopath because there are two types of psychopaths.
There is factor one psychopath and factor two psychopath.
Primary and secondary.
The secondary psychopath has all the traits of the factor one psychopath but also empathy and emotions.
So there are psychopaths with empathy and emotions.
As opposed to what all of us were thinking.
So the borderline, when she is exposed to extreme stress, she becomes a secondary psychopath.
Psychopath with empathy and emotions.
We are beginning to see something very interesting.
It seems to be that many of these disorders in childhood are somehow connected to psychopathy.
It seems that psychopathy is essentially a childhood problem, not an adult problem.
Great. We diagnoseproblem.
Great. We diagnose safely borderline personality disorder starting at age 11.
All the signs of borderline or symptoms of borderline personality disorder exist already in early adolescence.
Even 12-13, very common.
Emotional dysregulation, hyper sexuality, reckless behaviour, mood mobility, all these exist at age 11 and 12-13.
So borderline personality disorder can and is and should be safely diagnosed at age 11, 12 and 13.
And you will be doing the child a favour.
If you diagnose it early, the interventions are much more effective.
The cumulative life experiences cement the borderline, they make it rigid.
You catch the borderline at age 11, you still stand a chance.
Not a big chance, mind you, but a chance.
You deal with the borderline age 25, it's a serious battle.
Even the most effective therapy we have for borderline personality disorder is only 50% success.
And that's dialectical behaviour therapy.
My Romanian is not what it used to be.
Okay, last diagnosis and we get to the warning signs.
Remember, I threatened you with two parts.
Last diagnosis is ODB, oppositional Defined Disorder.
Don't you guys have Google Translate or something?
Yeah, oppositional Defined Disorder. Defined is in your face. F-U, go away.
Oppositional Defined Disorder. You can look it up online.
This is an example of oppositional Defined Disorder.
50%? Oppositionalist, provocateur.
That sounds like a communist translation.
Provocateur.
50%, 50% of children diagnosed with oppositional Defined Disorder also have ADHD, attention deficit hyperactivity disorder.
It seems there is some connection. It could be genetic. It could be brain abnormality.
I'm saying it could be because we have no idea why.
We used to define oppositional Defined Disorder. We used to define it in a wrong way.
If you have the fourth edition of the Diagnostic and Statistical Manual, including the text revision, it defines this ODD wrongly.
Do not use this definition. The only correct definition is in the DSM-5. It was corrected.
I'm not available. The ODD in the DSM-5 is defined as extreme irritability.
The correct definition is extreme irritability.
The child reacts all the time with rage attacks, temper tantrums, no impulse control, throws objects, sounds like some of your husbands.
ODD, which is coupled with ADHD, we don't know why, also leads to psychopathy.
All four major childhood diagnoses, five actually, lead ultimately to psychopathy.
Which is one of the reasons we think that psychopathy is actually genetic, is actually something in the brain.
But of course, psychopathy is only one personality disorder. There are others.
I mentioned borderline, borderline becomes a psychopath, but when she is not a psychopath, she is borderline.
There was a movie with Charlie Chaplin. He was playing Adolf Hitler. Hitler was talking like half an hour, and the secretary pushed one button, and then he said PUNKED, and the secretary typed for half an hour.
It reminds me of the same. I'm saying something short, he talked for two hours.
PUNKED, okay.
So now, borderline is the perfect Christmas gift.
You get borderline and side dish of psychopath.
So it's a perfect Christmas gift.
Nice, no? Okay.
This was the first part of the lecture.
Now, let's get to the interesting part of the lecture.
The 10 signs, I'm going to describe to you 10 warning signs, 10 red flags.
If you work with young people, if you work with children, with adolescents, you should monitor for these 10 signs.
These are not exactly symptoms. They are not signs in the clinical sense.
They are like observations. You should be alert, you should be observed.
Children who have the majority of these signs, let's call them signs, okay.
Children who have the majority of these signs, let's say, six, four, five, six, they are in elevated risk of developing lifelong personality disorders.
We start with attachment disorders.
Again, we have attachment styles.
You heard of attachment styles, so we have attachment style.
And we have secure attachment style and insecure attachment styles, multiple. And insecure attachment styles.
I never met someone with secure attachment style, but I heard they exist together with unicorns somewhere. With unicorns somewhere.
But we all came across many people with insecure attachment styles.
Now, you can't really diagnose insecure attachment style, but you can see insecure attachment behaviors.
There are two big groups.
Clinging and neediness.
These are children who pick up adults as replacement parents, parent substitutes.
So these children can pick up a teacher, counselor, and they cling to that substitute parental figure. They become extremely anxious when this substitute parental figure is absent or paying attention to someone else. They are very possessive and jealous, almost romantically jealous, if you wish. They are very needy.
So they will, on purpose, they will pretend that they are helpless or incompetent, and they will ask the adult to do something for them.
You didn't catch this?
Excellent. Let's go on.
These children, they have something called learned netlessness.
Learned netlessness.
So they, on purpose, the child will pretend that she is helpless or that she is incompetent. She doesn't know how to do something. These are, they seek attention all the time.
But not like messages. They don't want to be the center of attention. They just want to be seen, to be noticed.
Okay, so this is one group of attachment disorders.
Attachment disorder behavior, I'm sorry.
These are the children who reject any attempt to get close to them. These are children, if you show them any interest, attention, compassion, love, they become aggressive. Or they withdraw and avoid. They can become even the kind of pseudo catatonic. They can suddenly freeze and not react. They may run away physically.
So we have these two types of attachment disorder behaviors.
Attachment disorder behaviors are indications of disrupted separation individuation.
You remember yesterday, those of you who were awake, separation individuation problems.
The mother, usually it's the mother. I'm sorry, but it's the mother.
Before you ask me, what about the father? Father is totally irrelevant. It's the mother.
So the mother does not allow the child to separate properly and to become an individual. So the child reacts in one of two ways.
Either the child merges with the mother.
Clinging behavior.
Or the child feels aggression, is very angry and he runs away from mother.
So these are the two behaviors.
If you see such behaviors, there is a serious problem with the mother.
You can safely assume this. And you need to interview the mother. And to try to observe a family dynamic.
In clinical setting.
Okay.
Can I have coffee? My kingdom for coffee, I can't have a kingdom. You're kind, thank you. She has a husband and she's still kind. Not into miracles. Okay.
Okay guys, don't relax. You're still in the lecture. I will fail anyone who doesn't pay attention. Okay.
Next.
Coffee is difficult. What's this? I'm trying to convince the coffee.
This is direct transmission from Ukraine.
The next lecture is about mental illness in coffee machines.
Okay.
Guys, let's proceed. I'm only one. I'm only one. I cannot fight all of you. You want coffee, Bray? You want to make coffee? Ihope we are safe here. When it explodes, I hope you're safe.
The next sign, the next sign is when the child's emotions overwhelm the child's emotions.
Or the adolescent, doesn't matter, adolescent child.
The first sign is when the child's emotions overwhelm the child's emotions.
Okay.
And so we have dysregulation, emotional dysregulation.
Thank you, I appreciate it.
Similarly, when the child has mood-lability, when the child's moods go up and down.
When you witness dysregulation of emotions, when the child, for example, suddenly starts to cry. Or when the child is very, very depressed, sleeps, falls asleep on the table, very, very depressed.
And then the next day very, very happy or elated.
This is one of the most powerful signs, one of the most powerful warnings that the child is developing borderline personality disorder.
This is called, this is a problem in self-regulation.
Essentially, borderline personality disorder is a problem in self-regulation.
Indeed, we're going to change the name of the disorder in the DSM-6 and it's going to be called emotional dysregulation disorder.
A child who starts to cry suddenly for no reason definitely suffers from depression.
But be very careful. We often use diagnostic labels which apply to adults. And we use them with children and with adolescents.
It's wrong. The mental landscape and the brain structures of children and adolescents are not the same like adults.
So when we say that a child is depressed, it is not the same like saying that I am depressed.
It is not the same phenomenon. It is not experienced in a similar way.
The etiology is totally different. We must be very careful with that.
But it does mean that the child is unable to regulate his moods and his emotions internally.
The loss of internal regulation is a severe mental health pathology.
Severe mental health pathology.
Equivalent to cancer. This is really a serious issue because self-regulation is the foundation for all mental health.
If you can't regulate from inside, you have two choices. Regulate from outside.
So you become dependent on other people. Or not regulate.
And then your life falls apart. And you become a politician.
I did not hear this. I did not say this. It's not me.
Now a methodical break in which I am going to show you a cartoon with Tom and Jerry.
Before we proceed into the other eight signs.
So you remember two signs already. Two signs. Problems in separation and individuation. Attachment. Lack of self-regulation. These are two signs already.
There are eight more. So don't be optimistic.
But before we go, guys I really cannot compete with you.
If you talk among yourselves, I will begin to cry, I will become dysregulated and you will have to treat me.
I spoke for two minutes. It took you 27 minutes to translate.
Why?
Before we go into the other eight signs, there is something very important.
Which many, many professionals, even scholars, fail and make a mistake.
There are three elements of adolescence, of puberty.
There are three elements. There are many elements.
Puberty is a total transformation.
So in puberty we have peer interactions. We have parental interaction.
I mean there are many, many. Puberty is an earthquake. It's a tectonic shift.
But there are three elements in puberty that can be easily confused with personality disorders.
And they are not. They are not a personality disorder.
There are typical elements of healthy, healthy puberty.
We have two phases of separation and individuation.
The first one when we are 18 months old to 24 months old.
And the second phase is in adolescence.
The adolescent goes through separation from the parental figures, this time for good.
And the finishing touches on individuation. He becomes finally an individual.
But separation and individuation is an infantile process.
So the adolescent regresses to infancy. He has strong emphasized infantile elements.
Any mother of an adolescent will confirm this.
And sometimes adolescents are very infantile.
And this is healthy.
They need to regress to infancy to complete the separation and individuation.
This is a healthy process.
Now you remember from yesterday that separation and individuation involves grandiosity.
For the baby to live, money and to take on the world, the baby needs to feel godlike.
Jung called it narcissistic introversion. Everyone has a name.
But it's a fact. But it's a fact. The baby separates from mommy because the baby has a misperception of itself as godlike.
It's like the baby is saying, I don't need you anymore, mommy. I can take on the world all by myself.
Which is a sentence we often hear in divorce proceedings.
So the same happens to the adolescent.
As the adolescent separates and individuates, he infantilizes. He becomes an infant and he becomes grandiose.
And exactly like the baby, the grandiosity is compensatory.
The baby is insecure when he lives mommy. He's terrified. So he says, I'm gone. It's compensatory.
Same with the adolescent. Exactly the same with the adolescent.
He feels insecure, but he pretends to be godlike.
This is easily confused with narcissistic personality disorder. It's not. It's healthy.
Therefore, narcissistic personality disorder cannot be diagnosed safely before the age of 21.
Any diagnosis of narcissistic personality disorder before age 21 is suspect.
Is suspect.
Second thing in puberty that is easily confused with personality disorder.
So this is confusion with narcissism.
Second one is what we call negative identity formation.
The adolescent defines herself in opposition, in contradistinction to her parents and actually to adults, not only her parents.
So the unspoken monologue is I'm going to be different. I'm not going to be the same like.
Even when the adolescent says I'm going to be like my father, a famous doctor and so on and so forth, that is not the internal monologue.
This is usually instrumentalizing. The parents forced the child to realize their fantasies and dreams.
Negative identity formation is a crucial phase of adolescence.
The adolescent defines herself as unique. It's known as idiosyncrasy.
So this is easily confused with borderline personality disorder or with antisocial personality disorder.
It is not. It is healthy. You must be very careful with this. You must investigate thoroughly.
There's a huge difference between this type of grandiosity, which is a positive grandiosity, healthy narcissism, I'm going to take on the world. I'm going to do things. I'm going to accomplish.
And grandiosity, which is a falsification of reality and of who you are, finallyin adolescence, we have something called reactance.
Reactance has four elements.
Lack of impulse control or reduced impulse control. Adolescence has reduced impulse control.
Defiance in your face. I'm not going to do it. Try to define recklessness and contumaciousness or control aversion.
Dandjang. Hatred of authority. It's called control aversion.
These four together are called reactance.
In adolescence, in puberty, reactance is healthy. In adulthood, reactance is a major sign of psychopathy.
You could say, if you want to be funny, that adolescents are part narcissists and part psychopaths.
In a healthy way. But you need to be very careful, because the question you need to ask, does this promote an agenda of growth?
Does this promote self-development? Do these lead to adulthood?
And if the answer is yes, the child is healthy or the adolescent is healthy.
It's not easy. You need to be very attuned. The differences are minute. These are nuances.
It's extremely difficult to diagnose personality disorders in adolescence because of this, because they have many elements of personality disorders.
We continue to the next signs.
The next sign is the need to control and externalize aggression.
This sounds easy, but it's not.
We start with aggression.
Aggression can be internalized or externalized. Aggression that is all the time externalized is a sign of developing personality disorder.
So if you see a child that sometimes internalizes aggression, becomes, for example, very self-critical or even depressed. And then has a fight at school with another kid.
This is normal. It means that the aggression is both internalized and externalized.
But if you see a child that only externalizes aggression, only beats up other students and his teachers and destroys property, only externalizes, never internalizes, only externalizes.
Then it's a warning sign. It's a problem.
Similar with the need to control.
Self-control is healthy. And the need to control other people is healthy, actually.
Because we need to create an environment that is safe for us. And within this environment, we need to control the behavior of other people to some extent.
However, exclusive focus on control.
Without any goal, it's not like the child or the adolescent is trying to control someone else in order to achieve something. Or even he's trying to control people, other students, for example, who are much weaker than him and do not constitute a threat.
When the control has no goal, it's actually not manipulative. It's just obsession with control. It's a sign of emerging personality disorder.
And within this family, we have two additional behaviors, hyper-vigilance.
Hyper-vigilance is when the adolescent or child is all the time scanning. It's like a scanning machine. All the time scanning, expecting threats, expecting something bad to happen, expecting to be translated, expecting the worst.
So this is hyper-vigilance, this constant scanning. You can see it on specific children and adolescents.
And the other member of this family is what we call external locus of control.
It's the belief, the child's belief or the adolescent's belief, that he is not in control of his life. Someone else is in control of his life. Everything that happens to him is not his fault, not his responsibility. Nothing to do with him. It came from outside. Everything comes from outside. Everything bad that happens, every defeat, every failure, everything is never his fault. This is called alloplastic defense.
So children with alloplastic defenses, children who have external locus of control, are probably in the process of developing a personality disorder much later in life, including narcissistic personalities.
Next, identity disturbance.
We must make an important distinction again. All teenagers, all teenagers, myself included, we have identity diffusion. Identity diffusion is not identity disturbance, although it looks identical. Identity diffusion is a healthy process in adolescence.
Where the adolescent is experimenting with different identities, including sexual identities.
So identity diffusion is a healthy process.
Identity disturbance is something completely different. It's when the values and beliefs of the adolescent change dramatically, sometimes overnight. And that includes emotional statements. So the adolescent can say, I love my parents a lot, and the next day he can say I hate my parents completely. I believe that I should have sex only after marriage, or I believe in promiscuity.
So it's not experimentation with different identities.
It's something happening to the identity, to the content of the identity, that is unexplainable. That is like several people are there, not one.
Identity disturbance is a major sign of borderline personality disorder.
And we can observe it in behaviors, pervasive ambivalence, that means holding two emotions and two beliefs that contradict each other.
So when we have, in other words, dissonance, there is no attempt to resolve the dissonance.
The dissonance exists, and the child is accepted.
Identity diffusion, which is a healthy process, is about resolving dissonance.
The adolescent says, I don't feel comfortable with this. Let me try something else.
It's trying to resolve the dissonance.
Identity disturbance is when the child accepts the dissonance, and doesn't see anything wrong with it.
It doesn't feel uncomfortable.
It's very reminiscent of multiple personalities. It's very shocking to observe.
The next sign is disrupted or disturbed object relations.
Especially with peers.
Now here is a nasty surprise for all of you who are parents.
Peers are much more important to adolescents than mothers and fathers.
Children, adolescents, derive well over 80% of their decision-making processes from peers.
They derive almost all sexual education from peers, etc. Peers are critical.
Here, if you see abnormal object relations with peers, it's a really disturbing sign.
But what is abnormal? What is abnormal relationship with peers?
The refugees have arrived. What is abnormal relationship with peers, for example, if the adolescent ignores peers?
Another example of abnormality is when the child prefers the company of adults to the company of peers.
Another example is what we call precautious sexuality.
It's when the adolescent prefers to have general sexual relations with much older people.
These are all abnormalities in peer interactions and harbingers of personality disorders.
Next, reality testing and ego boundary functions.
I don't need to use these words. I'm using these words to torture you.
When the child or the adolescent prefers fantasy to reality, when the fantasy defense mechanism goes awry, when the child or adolescent's perception of reality is evidently manifestly wrong, for example, if the child confuses causation, he says it's not that A causes B, B causes A.
If the child has long-term protracted transitional objects, if he is attached to an imaginary friend or even a physical object, if the child dissociates massively in reaction to any type of stress, however minimal, if the child refers to other people, including his peers, but not only his peers, in order to regulate himself.
I didn't define it correctly. In order to regulate his sense of self and sense of self-worth.
In all these cases, we are beginning to witness the emergence of what we call dramatic or erratic personality disorders, for example narcissism.
I personally am heartbroken. I love histrionics, but you can't have everything in life.
It's a poor world without histrionics.
Next, if you see an imbalance between libido and destudo.
It's not alone.
Libido is not the sex drive. That's Eros. Libido is the force of life. Eros is part of libido.
And then there's the opposite force. It's the Thanatos force, and you have destudo as the object of that force.
So destudo is opposite of libido.
No one had a conversation with destudo and no one had lunch with libido.
So these are, of course, metaphors. Just words to describe the life force and the death force.
There are children and adolescents who are morbid, who are obsessed with death, with weapons, with blood, with artistic expressions and manifestations of these.
Children who are depressed and glamorize, idealize their depression.
Now this is called passive-aggressive personality disorder.
No, it's okay. Good to break from time to time. From time to time. Good to break.
Can we get on?
Oh my God. You're an angel. I feel so privileged.
When a child, let's go back to seriously sick adolescents. I know it's your favorite topic.
When an adolescent is morbid, obsessed with death, with blood, when the adolescent glamorizes his depression.
We have destudio. We have destudio in control. That is seriously bad news.
You heard of all the kids that should hold schools and so on? In literally all these cases, we have a history of obsession with death, obsession with weapons.
This is a serious warning song. Never ignore this.
Next.
Cognitive distortions.
When you come across a child or an adolescent, these things are more rare in childhood. They're more common in adolescence.
When you come across a child or adolescent whose perception of reality or of himself is constricted, like this, limited, tunnel vision.
We call this constriction. The clinical term is constriction.
How do you say constriction? What did I tell you? It's English. You could have life constriction. For example, people who are very anxious with anxiety disorders, they limit the possible triggers and their life becomes very narrow.
The same with depression. People who are depressed. Constriction is a typical reaction in many, many mental health disorders.
When you have cognitive distortions, which is a form of cognitive constriction, it is usually an indication of emerging narcissistic disorders, some kind of narcissistic disorder.
What do I mean when I say constriction? I have no idea. What I mean is when you confront the child or the adolescent with facts that negate his perception, he will ignore the facts. He will reject them.
This is known as confirmation bias, so children and adolescents who reject feedback or input from reality, in this way, they constrict themselves. They are not open to any change. They are not open to transformation. They never grow up. They never evolve.
So if you sit with such an adolescent and the adolescent says, I don't know, I'm ugly.
Now, like in cognitive behavioral therapy, this is a negative automatic thought. Normally what you would say, if you are so ugly, how come so many girls are interested in you?
In a relatively healthy adolescent after two sessions, he can modify his self-perception.
If the adolescent reacts aggressively to what you are saying, what are you talking about? This is confirmation bias.
This is strong indication of pathology, which leads me to the next sign, self-perception.
All adolescents have a mix of negative and positive self-perception.
The positive side is a bit grandiose and the negative side is a bit morbid. This mix is okay because it motivates the adolescent to experiment.
But if you come across an adolescent whose self-perception is 100% negative, there is a big literature on, for example, effects of trauma and abuse in early childhood and how they change negative bias in self-perception. 100% negative self-perception is a pathology, not typical adolescent.
And the last sign is self-efficacy.
If the adolescent perceives himself or herself as unable to secure favorable outcomes, it is an indication of an emerging pathology. It always fails and will not be open to try and to experiment.
And that's a sign of pathology as well.
When there is no self-efficacy, these are the 10 signs that you should be looking for.
They are all alarm bells. They all lead to lifelong pathologies.
Now, as a last paragraph, what can you do about it once you have spotted all this?
If the intervention is relatively early, and when I say relatively early, it's before age 12 in women and before age 14 in men.
I think men are two years behind women, as anything in general.
So if intervention is prior to these ages, research studies show that the interventions could be relatively effective.
For example, cognitive behavior therapy administered before the age of 12 to girls with emerging borderline personality disorder. It's about five times more effective than after age 12.
So the age is critical.
All these signs emerge already after age 6.
Generally speaking, the formative years are six months to six years.
Psychologically, we are relatively determined by age 6.
So why do we continue to change?
Because our brain continues to change.
The brain continues to change for those people who have brains.
The brains continue to change until age 25.
And only at age 25 there is termination of the process of brain growth.
So for example, risk assessment in adolescents is literally non-existent.
The problem is that we have to change this formative system.
But the foundations, the fundamentals, are finished by age 6.
You can begin to apply this list already at age 6.
You catch this at age 6, the chances are excellent.
You catch it at age 9, a little less. You catch it at age 12.
So you catch it at age 17, largely it's hopeless.
And remember, this lecture is about personality disorders.
Personality disorders are intractable and they are all pervasive.
In other words, they metastasize. They are like cancer.
Beyond a certain stage, it's phase 4. It's cancer stage 4.
The metastasizing is total and the person becomes the disorder.
It is your obligation, moral and professional, to monitor these signs and to intervene as early as you can.
Ironically, your biggest enemies would be the parents.
Because they would perceive any intervention as criticism of their own parent.
They are perfect parents. Why would anyone need to intervene?
What's wrong with my child? You are crazy. The counselor is crazy.
There is huge resistance from parents.
And this is something you will have to overcome with politics and diplomacy, if you can.
What do you think about the politics of politics and politics?
In most countries in the world, regrettably, parents have too much legal power over their children.
What do you think about the fact that parents can't stop them?
I don't know how it is in Romania, but in most countries in the world, the parents can't stop them from intervening, even when you see a clear need for intervention.
Even if your child is suicidal.
I have a question for you.
What do you think about the process of intervention?
What do you think about the process of intervention?
Do you think that the process of intervention can be achieved?
Between ages 12 and 18, a girl with borderline personality disorder will...
There is a 40% chance she will self-harm.
What do you think about the process of intervention?
The process of intervention is usually cut or burned.
What do you think about the process of intervention?
In a minute, if you want to explain the psychology of this.
There is a 40% chance of this.
There is a shocking 20% chance she will attend suicide.
And there is way over 50% chance that she will have inappropriate sex and reckless sex.
What do you think about the process of intervention?
Digitally or in real life?
In digital life.
Which is a form of self-homing with men?
It is a form of self-homing with men.
So it is cutting and burning, but with men?
It is a form of self-homing with men.
This is not about... it is about cosmetics.
It is not about, you know, you should use this eyeliner.
This is about life. It is life and death.
It is not a joke.
It is life and death.
11% of these children will die of suicide.
Because you did not intervene.
In such circumstances.
The size of their school, your counselor, psychology, you don't intervene.
There is one intention this child will commit suicide.
There is a much higher chance that this child will mutilate herself catastrophically.
So are you willing to have this on your conscience?
It is a huge responsibility to work with young people.
You are your partners in the process, exactly like the parents are.
Just one comment about self-homing, because it is a fascinating topic.
It is not going to do this lecture, but it is fascinating and I don't care if you are interested.
I am going to say it here.
Self-homing is a very interesting behavior in borderline.
It has two, apparently, contradictory roles.
Contradictory ideologies. Contradictory in psychological reasons.
Is there a way to make the body feel alive?
Such mutilation, on the one hand, makes the borderline feel alive.
It is like she is in a lethargic state, like she is a zombie, and she cuts her centrifugal body.
It is a one- function.
There is another function for cutting, burning, the very creative.
The physical pain takes away their minds from the emotional pain.
When they are physically in pain, they can't think for a minute about their inner turmoil, their inner turmoil, the mess inside, the chaos.
Self-homing, therefore, has an anxiolytic effect.
It reduces anxiety.
On the other hand, it makes the borderline feel very good.
There is no clinical connection between self-mutivation and self-homing and suicide.
It is not that suicide is extreme self-homing.
In the majority of cases, suicide happens after the borderline stops self-homing, because it doesn't work anymore.
And of course, all these disorders are diagnosed with other disorders, like substance abuse.
These children and adolescents start to abuse substances such as alcohol and drugs earlier than their peers.
And also more egregiously, in a worse way.
Everything is around self-harm in effect.
They are self-harm with cigarettes, they are self-harm with substances, they are self-harm with men.
It is all about self-harm, feeling alive and drowning the mess inside.
These children and adolescents are in extreme distress.
And they are signaling to you.
They are signaling to any adult to listen, and some adults are predatory and take advantage of them.
This has been today's lecture.
Tomorrow I think, I'm not sure, I think it's high school students or something.
Tomorrow I'm giving a lecture on what is normal and what is abnormal.
What is the line dividing normal from abnormal, which is actually a more sophisticated question than anything we dealt with.
So I hope the high school students will get it.
If any of you has any question, don't ask because you will make the other people very angry.
What can psychotherapy do then for the doses?
Depends.
Borderline personality disorder actually has very good prognosis.
First of all, by age 45, 81% of people with borderline personality disorder lose the diagnosis spontaneously.