Esteemed colleagues, dear organizers, thank you for inviting me to speak in the 33rd edition of the International Conference on Psychiatry and Mental Health.
Today I would like to explore, in brief, subject to my time constraints, I would like to explore a conundrum, an enigma, and mental health.
We know that all Cluster B personality disorders, narcissistic personality disorder, borderline personality disorder, antisocial personality disorder, and even its malignant form, psychopathy, and histrionic personality disorder, we know that all of them remit. All of them vanish or get ameliorated or mitigated with age.
Most patients, for example, vast majority of patients diagnosed with borderline personality disorder, lose their diagnosis spontaneously or with the help of dialectical behavior therapy. Even without DBT, without therapy, within 20 or 30 years by age 40, 45, these individuals, 81% of them, no longer qualify as patients with borderline personality disorder. And yet, they retain the dysfunctional behaviors associated with borderline personality disorder. Same goes for narcissistic personality disorder.
The grandiose overt narcissist spontaneously heals, if you wish, loses his or her narcissism as they age, as they grow older, which is not the case, by the way, for covert narcissists.
Covert narcissists do not change over the lifespan. They remain the same. They have the same psychodynamics, same dysfunctional behaviors, nothing changes.
But covert narcissists today are perceived as compensatory, and therefore, they are the real narcissists. Overt grandiose narcissists are increasingly perceived as psychopaths.
So in the nexus of psychopathy and narcissism, we see people with dark triad personalities, and these people change as they age in the fourth decade of life, in the fifth decade of life, in the sixth decade of life, they become different people. They lose the diagnosis. They can no longer be diagnosed using our common structured interviews, diagnostic procedures, and psychological tests. They lose the diagnosis, but they continue to behave the same way.
And this, of course, raises two questions.
Number one, what is the meaning of healing when the dysfunctional behaviors persevere? If someone continues to behave the same way, how do we know? How can we tell that that person had changed, that there was a process of healing or cure in place? Can there be healing without behavior modification? If I continue, if a narcissist continues to behave abrasively, if a psychopath continue to act anti-socially, defiantly and recklessly, can we say that these people are no longer narcissists and psychopaths?
What's the connection between behaviors and the core, the core of the pathology?
That's question number one. And of course, a much more important question, or interesting question at least.
Why this disconnect? Why this disparity? Why this break between internal pathological or pathologized moods and behaviors? Why can we cure, heal, treat, change the internal world, the internal moods, the psychology? Why does the psychology ameliorate, the psychodynamics ameliorate over time with age, and yet the behaviors remain the same?
I will attempt to answer these two fraught difficult conundrums. These two difficult questions.
Let's first define healing.
Healing is a permanent alteration in the clinical profile of the patient and in her psychodynamics.
So both elements must exist. The clinical profile must change so that using standardized psychological tests and using structured interviews and using diagnostic procedure in clinical settings, we can no longer diagnose the personality disorder in the client or in the patient.
So the clinical profile changes dramatically from a pathologized pathological profile to a relatively healthy and functional profile.
And the second element in healing is a change in psychodynamics, a change in moods, in affects, in emotions, and in cognitions within shammas, a change that is easily observable in clinical settings.
The processes, the internal processes, which give rise to emotions, cognitions, and moods change. And consequently, the emotions, cognitions, and moods are no longer the same.
If we have these two elements together, a change in clinical profile and a change in psychodynamics, we can safely say the client or the patient is healed.
In healthier clients, such changes induce behavior modifications. In other words, if we change the profile, the personality profile of a healthy person, the behavior of that healthy person will change accordingly. If we change the psychodynamics of a healthy person, for example, in cognitive behavioral therapy, if we get rid of negative automatic thoughts, which is a change in psychodynamics, if we do this, the behaviors change. The behaviors of that healthy client also change.
In healthy people, A leads to B. Change the clinical profile, you change the behavior, change the psychodynamic, you change behavior, change cognitions, change emotions, you change behavior.
Behavior in healthy people is the mirror, is the reflection, or if you wish, is the symptom of what's happening inside. There's no divorce between inside and observable outside.
But this is not the case in personality disorders, all personality disorders.
I'm going to focus on Cluster B, but whatever I say applies to Cluster C, for example, schizoid personality disorder, applies to paranoid personality disorder, avoidant personality disorder, all of them.
But I'm going to focus on Cluster C, because that's my field of study.
In Cluster B, we have a situation of either or. It's a proposition of either or.
Either behavior modification or healing. Either behavior modification or healing.
We cannot accomplish both.
If we modify behaviors, there is no mirror image. There is no reciprocal change in the internal landscape. It's like the behavior is imitated, emulated, but it has no impact on the internal world of the patient.
Similarly, if we modify, if we change, if we improve, if we cohere, if we integrate the internal world of the Cluster B patient, for example, in borderline, this will have no effect on behavior. The behaviors will remain the same.
If the borderline is promiscuous, she will continue to be promiscuous. If she's reckless, she continues to be reckless. If she's violent and aggressive, she will continue to be violent and aggressive, regardless of the fact that clinically she had lost her borderline personality disorder diagnosis.
Why this disconnect? How does this happen?
Several very important reasons.
Cluster B personality disorders can be easily conceived or reconceived as post-traumatic conditions, with the exception, perhaps, of psychopathy.
All other Cluster B personality disorders are the outcomes of early childhood trauma and abuse. Abuse is any situation where the child's boundaries are breached, where the child is not allowed to separate from the parent and to individuate.
The self in the child is not constellated and not integrated. It's fragmented and broken.
And this is the outcome of abuse and trauma. As I said, abuse is any situation where boundaries are disrespected.
So instrumentalizing the child, parentifying the child, spoiling the child, the destilizing, idolizing the child is a form of abuse because it doesn't allow the child to get in touch with reality, establish clear boundaries, and through the friction of reality, develop a functioning self later with object relations.
So these people with Cluster B personality disorder, having gone through, having suffered through early childhood abuse and trauma, they develop dissociative self-states. They develop the rough equivalent of multiple personalities, but they are not full-fledged personalities. They are aspects of the personality.
Each aspect is a self-state and each aspect is separated from the other aspect via a dissociative partition or a dissociative wall involving, for example, amnesia or depersonalization or derealization.
These sub-personalities, these pseudo-identities come to the fore, emerge, take over the patient when the patient is exposed to stressors, to stress, to abandonment, to rejection, to humiliation, in the case of mortification, in narcissism.
So dissociative self-states are the first reason why behavior and clinical settings, behavior and clinical profile do not match.
When we interfere or when we intervene therapeutically in borderline personality disorder, when we administer therapy, for example, we may change the internal composition of the various self-states and the way they interact. We may even accomplish integration of the self-states into a single cohesive self.
Even this is doable, but the dissociation will remain and will not allow this internal change to filter through to external behaviors.
It's very reminiscent of switching in multiple personalities in dissociative identity disorder.
So the internal world of the borderline does not inform her behaviors. Her behaviors are exogenously determined. They are reactive. They are not proactive. They are not imminent. They don't come from inside her.
And so when we change the inside, we don't change the outside. We don't change the behaviors.
Similarly with narcissists, narcissists interact with internal objects only. Narcissists do not interact with external objects, for example, other people. What they do, they internalize external objects and then they continue the interaction with internal objects, with the interjects, with self-states, but never with the outside.
So when we change the inside of the narcissist, which is extremely difficult to do, almost impossible, but when the narcissist changes, the grandiose overt narcissist, the psychopathic narcissist changes with time, with age, the inside changes, the interrelationship between self-states, the dialogue between internal objects and interjects changes, becomes perhaps more socially acceptable, less abrasive, less antisocial. The narcissist becomes an easier, a much better person.
But that is an internal state. Internally, everything is smoothed out, shored up, shored off. Everything is organized now. Everything is integrated. Everything is coherent. There is ego congruence. The narcissist is a much better place as far as his internal environment, but it has zero impact on his behaviors. It has zero impact on his behavior because he's dissociative.
The internal states, the internal objects, the interjects are cut off from his behaviors. They do not inform his behaviors. It's very difficult to comprehend because the question arises, what determines the behaviors? And the answer is the outside.
In borderline personality disorder, in narcissistic personality disorder, and so on, there is an external locus of control. There is an outsourcing of ego functions to other people.
The outside, mainly other people, determine the behaviors of the narcissist, borderline, the psychopath, the histrionic, because they don't have an internal regulatory system. They don't regulate their internal world.
In the psychopath's case, he has no access to his internal world. In the narcissist's case, the internal world is self-sufficient, self-contained, and solipsistic, so he has no interaction with the outside world.
In borderline, self-regulation is totally absent. The borderline is totally dysregulated. There's an external locus of control.
All ego functions, which are normally internalized in healthy people, they're all imported from the outside. They're all solicited from other people.
So, hence, the borderline's neediness and clinginess.
So, if you take the dissociative self-states, you add to this the external locus of control and the outsourcing of ego functions, it becomes clear why there is no bridge between internal processes and psychodynamics and observable external behaviors.
Another reason is anxiety. Anxiety and its commitment to depression, but mainly anxiety. Anxiety is intolerable, even in healthy people. Even healthy people resort to dysfunctional behaviors to reduce anxiety.
And in the case of Cluster B, this may involve substance abuse, from insecurity, there's a panopoly of possible behaviors, which are essentially anxiolytic. Anxiety ameliorating, and anxiety reducing, and anxiety mitigating.
Now, the anxiety is an internal process. It's an internal construct, and it does inform behavior. It's the only case in Cluster B where there is a connection between internal and external, and it is an unambiguous connection. A leads to B.
But anxiety also forces Cluster B personalities to develop internal defenses.
And one of the most important and prevalent internal defenses is a rich fantasy life.
The borderline has a rich fantasy life. The narcissist is his fantasies.
Narcissism is an extreme fantasy defense, to the point that fantasy had taken over and had devoured the narcissist and left nothing behind.
So a rich fantasy life is another attempt by Cluster B individuals to somehow control their anxiety.
In due time, fantasy as a strategy becomes dominant, and reality is renounced. Because reality is renounced, because reality grates upon the individual, reality is abrasive, forces the individual to cope.
And so Cluster B personalities, dysregulated and broken as they are, give up on reality and substitute fantasy for reality.
And this rich fantasy life means that the Cluster B person becomes schizoid, withdraws from life, gives up on reality, gives up on the world, and inhabits and resides in his own mind. It is there that all the important interactions take place.
But of course behavior has to do with reality. Behavior has to do with the world, behavior has to do with other people.
So there's a breach, there's a divorce, there's a schism, there's a break between fantasy life and actual realistic behaviors.
Reality testing is impaired to the point that behaviors are not only dysfunctional, but they are rendered irrelevant.
In other words, not self efficacious.
To summarize this, people with Cluster B personality disorders such as borderline or narcissist or histrionic and so on. They try to cope with reality by reducing in order to reduce anxiety, they try to behave in reality, they try to act in reality to maximize favorable outcomes and to reduce anxiety, but they keep failing.
Having failed, they retreat to a fantastic inner universe, a paracosm. And they inhabit, they wander, they're like nomads, like vagabonds in this fantastic space. And this fantastic space excludes the world and impairs reality testing.
Consequently, the borderline or the narcissist live utterly in fantasy and have no contact with reality. And when they have to behave, because they have to behave somehow, they need food, they need to go to work, they get married, they have children, they need somehow to function.
So when they behave, their behaviors look very odd, very out of place, very incomprehensible, because they are not linked to the inside. They are utterly provoked by the outside. Their scripts are wrong, because the scripts of the borderline or the narcissist or the psychopath or the Australian are not determined by anything identifiable as a psychodynamic. The scripts are determined by social mores and dictates, by expectations, by imitation and emulation, and above all, by feedback from the outside. It's a self-reinforcing feedback loop that is external to the individual, external locus of control.
Of course, the main problem of people with Cluster B personality disorders is identity disturbance. They don't have a core identity. They have a shape-shifting, wannabe, kaleidoscopic thing, entity, landscape that tries to substitute for a core identity, but is hampered, fails because of dissociation. Identity is crucially dependent on continuous memories. If memories are disrupted to the extent that they are in Cluster B personality disorders, there is no way for identity to form. There's no identity formation.
And there is identity disturbance. There's autobiographical amnesia. There's a shifting between values and beliefs. There's instability and unpredictability and inconsistency, both object inconsistency and self inconsistency. The self is not constellated or integrated. There's no self, in effect. There's a schizoid empty core where a person should have been.
Of course, if there's no person, if there's nobody there, there's nobody who can determine external behavior. There is a flow from identity to behavior. Behaviors are determined within the identity space.
In the absence of identity, behaviors are essentially random and they're dictated by imitation or by feedback. If the feedback is wrong, the behavior is wrong. If the cluster B personality disorder person imitates the wrong role model or the wrong movie or the wrong book or the wrong guidance from parents, gurus, role models, she's likely to misbehave.
And so gradually over time, most patients with cluster B develop reactants.
Reactants can wear many forms. In the case of the psychopath, reactants is, of course, in your face defines consummation. In the narcissist, reactants has to do with deficient narcissistic supply. In the borderline, reactants has to do with abandonment anxiety, anticipated abandonment and rejection and humiliation.
But reactants becomes a core feature.
Gradually, via reactants, the patient rejects the world. He rejects other people. He rejects situations. He rejects circumstances. He rejects jobs. He rejects his own family. He rejects his children or her children. He rejects everything.
And of course, when you reject everything, you become very inefficient. It leads to low personal autonomy and low self-efficacy. You can't reject the world and act in the world efficiently. To act in the world self-efficaciously, you need to be integrated in the world. You need to be a part of the world. You need to know the world. You need to understand the world. You need to read the world.
How do you do that when you don't have empathy?
Like narcissists and psychopaths, you have only called empathy. You don't understand emotions. You don't do emotions. How can you understand the world?
So low self-efficacy, low personal autonomy and learned helplessness. Ironically, these people, these braggadachos and machos and go-getters and daring do's and daredevils, and they have very low self-esteem and they have learned helplessness. Because they are not efficient, they are not self-efficacious, they fail repeatedly to guarantee and to garner favorable outcomes. They fail in their careers. They fail in their relationships. They fail to regulate their internal environment. They feel bad all the time. They feel helpless. So this kind of trajectory, life trajectory, leads ultimately to schizoid withdrawal, learned helplessness, low personal autonomy, low self-efficacy, external locus of control, outsourcing of ego functions, reactance, identity disturbance, withdrawal and retreat into rich fantasy life as a substitute to reality, constant anxiety, and to put all these together, re-traumatization. This is the reason, these are the reasons why even if age or therapy change the internal psychodynamics of the cluster B patient, it will have little bearing on his behaviors and on his over-relationships.
Thank you for listening. I will now refer you to some bibliography, some literature. My name is Sam Vaknin. I'm a professor of psychology in Southern Federal University in Westorvandong in the Russian Federation and I'm a professor of psychology and a professor of finance in the Outreach Program of CEAP's Center for International Advanced and Professional Studies. And here is my recommended list of literature. I would read articles by Robert Bisking, for example, the Lifetime Course of Borderline Personality Disorder in the Canadian Journal of Psychiatry, July 2015.
Zanarini and allies, Frankenberg, Hennen, Zanarini had written a lot with her colleagues on exactly the topics that I've raised in this presentation.
So, for example, there is an article she had written, she and her colleagues had written, the McLean Study of Adult Development, MSAD, Overview and Implications of the First Six Years of Prospective Follow-up. This was published in the Journal of Personality Disorders in 2005. Other scholars which I would recommend are Skodal and Gunderson and she, each one of them separately had written about the progression and prognosis of cluster B personality disorder.
There's an article, all three of them had written together, the Collaborative Longitudinal Personality Disorder Study, CLPS, Overview and Implications in the Journal of Personality Disorders in 2005. Gunderson, together with Stout, McGlashan and others, wrote a few articles.
One of them is a 10-year course of Borderline Personality Disorder, Psychopathology and Function from the Collaborative Longitudinal Personality Disorder Study. It was published in Archives of General Psychiatry in 2011, it's a bit more recent.
I would also recommend to read Paris, it's like Frank, these are two scholars, they had collaborated and also written separately. So, for example, Paris and it's like Frank had written the article, An article titled The 27-Year Follow-up of Patients with Borderline Personality Disorder. It was published in Comparative Psychiatry in 2001.
Zanarini, Frankenberg and Reich had written the article, The Subsyndromal Phenomenology of Borderline Personality Disorder, a 10-year follow-up study, American Journal of Psychiatry 2007.
And finally, I would recommend, in my reading list, I would recommend Hopwood, Morey, Donnellan and others. One of their articles, for example, is a 10-year rank order stability of personality traits and disorders in a clinical sample in the Journal of Psychiatry 2013.
Cluster B personality disorders are by far the most intractable forms of mental problem or mental issues, not to say mental illness.
And one of the reasons is that we cannot reach in in order to change the outside and changing the outside has no inward implications.
It's like we have to deal with two spheres, the internal and the external, separately.
It's very frustrating because we can do a great job, for example, with all the main or core features of borderline personality disorder, anything from self-mutilation to dysregulation. We can do a great job with victims of complex post-traumatic stress disorders, see complex trauma, which resemble, who resemble, borderlines very much.
And yet, this great work, this change in internal landscape, this reshaping and remolding, this reframing, which is very successful, this removal of the diagnosis from the patient's life has little bearing on the patient's relationships and behaviors.
And so, we have to have a second goal, teaching the patient how to behave, how to manage her relationships, her attachment style, everything.
Same with narcissism, same with psychopaths, same with histrionics, with schizoids, with pyramids, with schizotypals, with all people with personality disorders. It's very disheartening. It's very disheartening because in other mental health issues and even illnesses, even in the extremes, let's say schizophrenia or major depression, in all these cases, we firmly believe that internal intervention in internal biomedication, via talk therapy, should manifest as behavioral change and should improve the patient's prognosis when it comes, for example, to relationship quality.
That's not the case with Cluster Bs. It's a Sisyphian effort, and it's never ending because there's an infinite number of behaviors. It's like you have to teach them one behavior at a time, one relationship at a time, and it's never ending.
Many therapists, many psychologists, many clinicians, many psychiatrists just give up on these patients, give up on these patients because it looks hopeless.
But of course, it's not hopeless. Behavior modification is possible even without getting rid of the diagnosis.
We should fight. We should strive.
In my own modest way or immodest way, I've come up with a new treatment modality called therapy, which retraumatizes the patient and exposes the patient to change on a total scale, internal and external.
But that's a risky strategy. It's a risky strategy because it could lead to severe decompensation, suicidal ideation and reckless life endangering acting out.
It seems though that retraumatization is what it takes. These patients are not permeable to intervention, however well-meaning.
Thank you for listening, and I'm now open to your questions.