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1. 00:02 Last week we discussed how the international classification of diseases 11th edition how it sees narcissism and borderline. The ICD11
2. 00:15 is distinct from the diagnostic and statistical manual. The approach is completely different much more
3. 00:21 upto-date. By the way few people know that there are other
4. 00:27 diagnostic manuals. One of the most famous of which is the psycho dynamic
5. 00:33 diagnostic manual. Um, and today we are going to discuss the
6. 00:39 PDM and how the PDM views narcissistic personalities and borderline
7. 00:45 personalities. Why so many diagnostic manuals? Because of the debates and the arguments
8. 00:52 and the unsettled questions within the field. The proliferation of diagnostic manuals reflects the fact that there are
9. 01:01 vast massive and unbridgegable disagreements between scholars in
10. 01:07 psychology and psychiatry. And these disagreements
11. 01:14 have created a fractured landscape. While the diagnostic and statistical manual is still even in its fifth edition still highly categorical
12. 01:26 bullet list bullet pointless oriented despite the alternative models
13. 01:34 the international classification of diseases is much more flexible
14. 01:40 and much more modular as I’ve explained in previous videos. And now the psychonamic diagnostic manual psychonamic diagnostic manual or
15. 01:51 PDM has undergone a pretty amazing transition. It started off as a psychoanalytic manual, a manual diagnostic manual based
16. 02:02 on essentially classical psychoanalysis. But then in the 80s it has been
17. 02:09 completely transformed and now it reflects what is known as neo cryil crippling or crippleinian approach.
18. 02:22 In other words, now it is mostly biological or neurobiological and
19. 02:28 genetic in attitude. It is a medicalized diagnostic manual to a large extent
20. 02:35 which again is in one way ironic and in another way not surprising because you do recall that Ziggman Freud
21. 02:46 was actually a neurologist not a psychologist. He was a scientist
22. 02:52 not a psychologist. But even more important than Zigman Freud when it comes to the
23. 02:58 medicalization of mental health and mental illness is Emil Wilhelm Geog
24. 03:05 Magnus Kelin. Who could remain sane with such a name?
25. 03:11 I ask you. In addition to that, he was German. Kppolin lived between in the latter half
26. 03:18 of the 19th century and the first quarter of the 20th century and he was a
27. 03:24 psychiatrist. Some scholars consider him to be the father and the founder of modern
28. 03:31 scientific psychiatry, psychop psychopharmacology and psychiatric genetics together with V
29. 03:39 who had a laboratory and studied human subjects in his laboratory.
30. 03:45 Crepelene believed that the origin of psychiatric disease is biological. It’s
31. 03:52 it’s a genetic malfunction and in this sense is back in fashion nowadays.
32. 03:59 That’s why we say that modern psychology and modern psychiatry are neo cryinian.
33. 04:06 The theories of Creeplin dominated dominated psychiatry at the beginning of the 20th century and only with the
34. 04:14 advent of psychoanalysis and psychonamic influences did his contributions fade
35. 04:22 from public memory waned and disappeared only to reappear at the end of the 20th century and the beginning of the 21st century. So what about the psychonamic diagnostic
36. 04:34 manual, the PDM for short? The PDM originally was compiled by a
37. 04:41 collaborative task force members of the American Psychoanalytic Association, the International Psychoanalytical Association, the division of psychoanalysis division used to be known
38. 04:52 as division 39 of the American Psychological Association, the American Academy of Psychoanalysis and Dynamic
39. 04:58 Psychiatry and the National Membership Committee on Psychoanalysis in Clinical
40. 05:04 Social Work. in short psychoanalysts. But when the DSM3 was published in 1980,
41. 05:13 it appropriated a lot of this material. I don’t know how many of you know that
42. 05:19 the original editions of the diagnostic and statistical manual starting in 1952 and culminating in the seinal third
43. 05:26 third edition in 1980. These the original DSMs were based on
44. 05:32 psychoanalysis. And so the manual the PDM switched from
45. 05:38 being influenced by psychoanalysis being psychoanalytically dimensional to a
46. 05:45 neoclinian descriptive symptom symptom focused model based on present or absent symptoms very reminiscent of classical
47. 05:57 medicine. The PDM provided a return to a psycho psychonamic model for the nosological evaluation of symptom clusters, personality dimensions and so on. So in
48. 06:10 the PDM we have three dimensions and a few axes. The three dimensions are
49. 06:16 dimension one personality patterns and disorders, dimension two mental
50. 06:22 functioning and dimension three manifest symptoms and concerns.
51. 06:28 And like um the previous edition of the PDM because PDM right now is in its second edition like the the first edition. The PDM still classifies patients along three axis. The first
52. 06:41 axis axis is known as P axis personality syndromes. The M axis profiles of mental
53. 06:50 functioning and the S axis symptom patterns the subjective experience.
54. 06:57 The P axis is a kind of map of personality. It’s not it’s these are not
55. 07:03 lists. There’s not there not listings of diagnostic criteria like in the DSM5.
56. 07:10 They are not not even trait domains like in the ICD. Um
57. 07:16 but the the PDM defines different terms as part of the P axis including
58. 07:22 personality, character, temperament, traits, type, style, and defense. The S
59. 07:29 axis is very similar to the DSM and the ICD because it includes predominantly
60. 07:35 psychotic disorders, mood disorders, disorders related primarily to anxiety,
61. 07:41 event and stressor related disorders. somatic symptom disorders and addiction disorders. Okay, this is a general overview of the PDM. It’s a fascinating
62. 07:52 read. In many ways, it’s an integration of the ICD11
63. 07:58 with a DSM5 text revision. It’s a kind of bridge bridge between them. So those
64. 08:04 of you who are clinicians or scholars or even professors of psychology may benefit from reading this book and gain new insights and it’s very thoughtprovoking. What does it have to say about narcissistic personalities?
65. 08:21 Individuals with problematic narcissistic preoccupations, says the manual, exist along a continuum of
66. 08:28 severity from the neurotic through the psychotic level of organization. So
67. 08:34 exactly like the ICD11, the PDM recognizes that there are levels
68. 08:40 of severity of disorders. In the DSM, it’s low, mild, moderate, and severe. In
69. 08:46 the PDM there’s a similar uh severity organization. Now mind you in the ICD11
70. 08:54 what is known as the severe personality disorder is the equivalent of narcissistic personality disorder in the
71. 09:00 DSM. Okay. The PDM continues to to discuss
72. 09:06 narcissistic personality by saying that toward the neurotic end of the spectrum, narcissistic individuals may be socially
73. 09:13 appropriate, personally successful, charming, and although somewhat deficient in the capacity for intimacy,
74. 09:21 reasonably well adapted to their family circumstances, work, and interests. In
75. 09:27 contrast, people with narcissistic personalities at the more pathological levels, whether or not they are
76. 09:34 personally successful, suffer from identity diffusion, often concealed by a
77. 09:40 grandio self-presentation. They lack an inner directed morality and
78. 09:46 may behave in ways which are highly destructive and toxic to other people. Kenburgg in 1984
79. 09:53 characterizes the most problematic type of narcissistic individuals as suffused
80. 09:59 with malignant narcissism. So narcissism blended with sadistic aggression.
81. 10:06 Karnbeck said that this is a condition that he placed on a continuum with the frankly psychopathic personality and there have been studies
82. 10:17 or elaborations of this um earlier by Meltzer in 1973, Rosenfeld in 1987.
83. 10:27 Um and so malignant narcissism is a kind of
84. 10:33 the bridge between neurotic and psychotic narcissism. Whereas in
85. 10:39 psychotic narcissism there’s already a confluence with sadism and grandiosity
86. 10:45 which masks extreme identity diffusion. Continue to quote from the manual. The
87. 10:51 characteristic subjective experience of narcissistic individuals is a sense of inner emptiness.
88. 10:58 That’s very surprising because this is act this in psychoanalysis in classic
89. 11:04 psychoanalysis and psychonamic theories this kind of emptiness this empty schizoid core was initially identified
90. 11:11 with a borderline and only in the work of some scholars such as gantrip the empty gantry and and
91. 11:19 Seinfeld the empty schizoid core came to be identified with narcissism and this view has been adopted by the pdm. It’s an object relations view. Essentially,
92. 11:30 the PDM sense says that in narcissistic individuals, there’s a sense of inner emptiness and meaninglessness that
93. 11:37 requires recurrent infusions of external affirmation. Narcissistic supply
94. 11:43 affirmation of their importance and value. Narcissistic individuals who succeed in extracting such affirmation
95. 11:50 in the form of status, admiration, wealth or success may feel an internal
96. 11:56 elation. This is known as narcissistic elation. They behave in a grandio and arrogant arrogant manner against a sense
97. 12:04 of entitlement and they treat other people especially those perceived as of lower status with contempt. When the
98. 12:12 environment fails to provide such evidence that is known as narcissistic collapse, narcissistic individuals may
99. 12:19 feel depressed, ashamed and envious of those who succeed in attaining the status that they lack. And this is of
100. 12:27 course the core clinical feature of covert narcissism. The PDM says that these people often
101. 12:34 these people who have were undergoing narcissistic collapse, these people who fail to secure an uninterrupted flow of
102. 12:42 narcissistic supply. These people often fantasize about unlimited success, beauty, glory, and power. And their lack of real pleasure in either work or love
103. 12:53 can be painful to witness. This applies equally to successful narcissists. By the way, given these considerations,
104. 13:01 these narcissistic personalities would belong on the introjective end of blas
105. 13:07 blat blat continuum because their patterns reflect
106. 13:13 attempts to establish and maintain a sense of self and their preoccupations with issues of autonomy, control,
107. 13:20 self-worth, and identity add to this. The DSM’s narcissistic personality
108. 13:26 disorder describes the more grandiose or arrogant version of narcissistic personality first described by Reich in Villan in 1933
109. 13:38 as the phallic narcissistic character. Reich was obsessed with sexuality as some of you may recall. And in the DSM, the PDM is highly
110. 13:49 critical of the DSM. He says that it omits from consideration the many persons who come to therapist, feeling
111. 13:56 shy and ashamed, avoiding relationships and looking diffident. This is the
112. 14:02 covert narcissist or the covert phase. In narcissism, every narcissist cycles
113. 14:08 through overt and covert phases. But narcissists present to therapy only in
114. 14:14 the covert phase which creates the imp the wrong impression that there are two types of narcissists overt and covert
115. 14:21 when actually it’s the same narcissist experiencing collapse. Although the PDM says although often
116. 14:29 less successful than arrogant individuals with this psychology, the covert narcissists are internally
117. 14:35 preoccupied with grandiose fantasies. And that’s what I’ve been telling you all along. both overt and covert
118. 14:42 narcissists. Both in the overt phase and in the covert phase there is grandiosity.
119. 14:48 So it’s wrong to call narcissists grandios and distinguish them from covert narcissist because all
120. 14:54 narcissists are grandios. Rosenfeld in 1987 distinguished between the
121. 15:00 thickskinned and thin skinned narcissist. Actar in 1989
122. 15:06 distinguished between the covert, the overt and the covert. shy patient. Gabbard uh G- A BB B A E A R D Gabard in
123. 15:17 1989 distinguished the oblivious from the hypervigilant type. Masterson in
124. 15:23 1993 between the exhibitionistic and closet types and Pinkas and colleagues
125. 15:30 Pinkas Kain right by the way. Pickers and colleagues distinguish the grandiose
126. 15:36 and the vulnerable types. And I am dead set against this distinction because it
127. 15:42 misrepresents the fact that all narcissists are grandios. Russ Shedler, Bradley, and Weston in
128. 15:49 2008 identified three subtypes of narcissistic patients labeled grandios,
129. 15:55 malignant, fragile, and high functioning exhibitionistic. They describe the last subtype as
130. 16:03 notable for grandiosity, attention-seeking, and seductive or provocative attitudes, but also for
131. 16:09 significant psychological strengths. Patients with narcissistic concerns or
132. 16:15 who are not in a position to act arrogantly may demand that the therapist teach them
133. 16:22 how to be normal or popular, complaining that they want what more fortunate people have. In other words, they want to be better narcissists or more accomplished narcissists or more
134. 16:33 self-efficacious narcissist. Narcissistic individuals, says the PDM,
135. 16:39 frequently have hypochondriac hypochondriacal preoccupations. They preoccupied with hypochondrical
136. 16:47 um manifestations and somatic complaints. Recently, attachment and mentalizations
137. 16:54 mentalization in patients with comorbid narcissistic and borderline personality disorders have been extensively
138. 17:01 addressed by Diamond and colleagues. Was not so recently. It was in 2013 and 2014. This literature suggests that narcissistic people have insecure
139. 17:12 attachment styles, both attachment anxiety and attachment avoidance, very reminiscent of the twin anxieties of the borderline. The borderline has abandonment anxiety, separation,
140. 17:24 insecurity coupled with engulfment anxiety. The PDM says that this may
141. 17:30 result from early relationships with others that were confusing, unpredictable, and full of hidden
142. 17:36 agendas. So I refer you to studies by Diamond,
143. 17:42 Fati, Finey, Pinkas, Boroni, Mafay, Keely, uh, Joyce, Steinberg, Piper,
144. 17:49 Miller and many others. The PDM continues to say under these circumstances, under such circumstances,
145. 17:56 when the child is exposed to confusing, unpredictable, mixed signals, hidden agendas by the
146. 18:03 parent and so on. Under such circumstances, children may respond by divesting themselves of meaningful emotional investment in others and by becoming preoccupied instead with
147. 18:16 theirelves and their bodily integrity. Individuals with narcissistic personalities spend considerable energy evaluating their status relative to that
148. 18:27 of others. They tend to defend their wounded self-esteem through a combination of idealizing and devaluing
149. 18:35 others. There are studies by Bradley Heim Weston by the way um about 1015
150. 18:42 years ago about regarding all these topics. So the PDM says when they idealize
151. 18:48 someone they feel more special or important by virtue of their association with that person. This is what I call co idealization. When they devalue someone, they feel
152. 18:59 superior. Therapists who work with such individuals tend to feel unreasonably
153. 19:05 idealized, unreasonably devalued, or simply disregarded. Effects on therapists may include
154. 19:11 boredom, detachment, distraction, daydreaming, inability to focus attention or to track the therapeutic
155. 19:18 dialogue, mild irritation, impatience, and the feeling that they are invisible.
156. 19:24 Collie in 2014 by the way described it in a brilliant article.
157. 19:30 Um this kind of this therapist exposed to a narcissistic patient may also especially
158. 19:37 if the wounds to these patients self-esteem are apparent may also develop parental feelings. Gazio in 2015
159. 19:46 and Gordon in 2016 wrote about this. Gabbard in 2009 noted
160. 19:52 that a narcissistic patient, especially one of the grandios and overt types, can
161. 19:58 be experienced as speaking at rather than speaking to the therapist, leaving
162. 20:04 the therapist unable to emotionally invest in the therapy in the therapeutic relationship and to be a real
163. 20:10 participant observer. So the clinical literature on narcissistic personality disorder includes diverse speculations about ethology, the causation of pathological
164. 20:22 narcissism. And because the there’s a disagreement about the ethology, there’s
165. 20:28 also a lot of disagreement about treatment recommendations and treatment options. Kovalt in 1971 and 1977
166. 20:37 emphasized empathic attunement and exploration of the therapist’s inevitable empathic failures. Koh described periods in treatment when the patient idealizes the analyst treating the analyst as a perfect and all powerful parental figure and he
167. 20:54 called co called it idealizing transference. Coart felt that during these times the
168. 21:01 primary challenge for the therapist is to resist the temptation to confront this pattern too quickly.
169. 21:08 Kberg in 1975 and a decade later in 1984 he disagreed. He recommended the tactful
170. 21:16 but systematic exposure of defenses against shame, envy, and normal
171. 21:22 dependency. Contemporary practitioners are more likely to adopt an integrated approach to working with narcissistic individuals, confronting defenses when they are salient and empathically
172. 21:35 attuning to underlying hurt and vulnerability when those feelings are accessible.
173. 21:41 Narcissistic envy can create a subtle fear of progress in therapy because improvement would reveal that there was originally something to improve. In other words, the narcissist self-defeats, self-sabotages, and self-destructs
174. 21:57 in order to not improve. Because if the narcissist were to admit that something is improving, that there is some dynamic of of improvement, he would have been forced to admit that he had been
175. 22:08 imperfect to start with. And also this would create an envy, internal envy. The
176. 22:15 narcissist would envy the improved good object. It’s completely sick. It was
177. 22:22 Melanie Klein who first proposed that the dynamic of envy in narcissism is self-directed as well as other directed.
178. 22:30 The narcissist envies the good object inside himself. So the idealization of the therapist puts pressure on the therapist to be
179. 22:42 brilliant but not to be so brilliant as to challenge or threaten the patient’s
180. 22:48 intelligence. By comparison, of course, progress may thus be slow, but any
181. 22:54 improvement for a patient with nar with a narcissistic psychology is valuable for both the patient and for those who
182. 23:01 relate to him or her. Like persons whose character structure is more psychopathic. Narcissistic people may be
183. 23:08 easier to help in therapy in midlife or later when their investments in beauty, fame, wealth, and power have been exhausted and disappointed and when they have run into realistic limits of their
184. 23:19 grandiosity. In short, when they’ve hit rock bottom. So, let me quote from the
185. 23:25 PDM regarding the key features of narcissistic personalities. contributing constitutional maturational patterns. No clear death data.
186. 23:37 Central tension and preoccupation inflation versus deflation of self-esteem. That’s the discrepancy
187. 23:44 between implicit and explicit self-esteem. Central effects shame, humiliation,
188. 23:51 contempt, envy. Characteristic pathogenic belief about self. I need to be perfect
189. 23:59 in order to feel okay. Not only okay in general but okay with myself.
190. 24:05 Characteristic pathogenic belief about others. Others enjoy riches, beauty, power and fame. The more of those I have, the better I will feel.
191. 24:16 And finally, central ways of defending against all these emotions, against the shame and the envy and so on. Central
192. 24:22 ways of defending idealization and devaluation. This is what the PDM has to say about narcissistic personalities.
193. 24:29 And what about borderline personalities? In the first edition of the PDM, the
194. 24:35 term borderline was used to refer only to a clinically inferred level of personality organization. In other words, the PDM incorporated Kernberg’s insight into the borderline personality
195. 24:48 organization. However, since the publication of the first edition, the concept of a specific
196. 24:54 borderline type of personality disorder defined by DSM criteria has become very
197. 25:00 pervasive. So now um what the PDM the second edition of
198. 25:06 the PDM what they do they try to somehow strike a compromise between Kernburg and
199. 25:13 the DSM regrettably because I think the right way to deal with borderline pathologies
200. 25:20 is the ICD the way of the ICD11 actually. Uh but what the PDM does it uh
201. 25:31 discriminates it follows the solution offered by Kenberg. It discriminates between borderline personality
202. 25:37 organization and borderline personality disorder. Additionally, Shedler in 2015 and
203. 25:44 Western and and colleagues in 2012, they found that clinicians identify a
204. 25:50 construct of borderline disregulated personality disorder that overlaps with the DSM’s diagnostic construct of borderline personality disorder and with Kernber concept of borderline
205. 26:02 organization. What Shedler and Western have proposed in effect is that emotion
206. 26:08 dysregulation is the core of the borderline pathology. Today this is no longer accepted. We
207. 26:16 used to think this way until recently. This is no longer accepted. And if you want a far more updated view of the borderline pathology or the borderline personality, I advise you to read the
208. 26:29 ICD11 and to pretty much ignore both the DSM
209. 26:35 and the PDM. However, Kernburgg’s
210. 26:41 um construct the borderline personality organization which he proposed amazingly in 1967
211. 26:48 is a very valid point and the borderline pattern in the ICD11
212. 26:54 is actually an amalgamation or an assimilation of Kernburg’s BO together
213. 27:01 with clinical features of what the DSM calls the disorder.
214. 27:07 In attachment research says the the PDM scholars have identified a relevant
215. 27:13 disorganized disoriented or type D insecure attachment and that is a work by Fonagi target Gurgi Leotti Pasquini May Solomon and many others.
216. 27:25 I’m a bit critical of this approach. I have a video dedicated to this. Anyhow, this pattern is characterized by chronic
217. 27:32 long-term difficulties in tolerating and regulating effect and involves regarding attachment figures such as therapies as
218. 27:39 both objects of safety and objects of fear. causing um the patient or causing the
219. 27:47 intimate partner, the borderline causing the borderline to treat people with a ve
220. 27:54 very confusing combination of desperate clinging, hostile attack and dissociative like states of detachment. Neuroscientific research ferten
221. 28:09 Stanley Vander Kolk and many others. So there was neuroscientific research of the borderline condition and it indicated that early trauma can damage the capacity for capacities for
222. 28:20 executive control and for effective regulation. However, as I mentioned in another
223. 28:27 video, we now realize that not all types of trauma lead to a borderline condition.
224. 28:35 In the arology of of borderline personalities, there’s only one type of trauma actually. The trauma of neglect,
225. 28:43 the trauma of early childhood abandonment by the parent, the trauma of emotional or physical absentism. In
226. 28:50 other words, what Andre Green called in 1978 the dead mother.
227. 28:56 Efforts. The PDM says that efforts to understand the psychologies of people with borderline personalities span
228. 29:02 decades and have been undertaken from many from many perspectives. The concept has always been seen as complex and multifaceted and I would add disputed.
229. 29:13 Scholars have viewed borderline personality in terms of reliance on splitting, projective identification and
230. 29:19 other highly costly defenses, primitive infantile defenses. And that is exactly what Kberg said in the famous article in
231. 29:26 1967 when he proposed the borderline personality organization and emphasized it later in his seinal work in 1984.
232. 29:34 So borderline involves these primitive infantile defenses
233. 29:40 and this creates problems in psychiatric management. Gunderson wrote about it, Singer, Maine, Scodel, uh Silver many others. The disorganized attachment first described by Faji and others um is a is a facet of borderline
234. 29:59 personality disorder. But I have my reservations because I think it is defined in a way that it
235. 30:06 actually describes borderline personality disorder not attachment problem. I have a video dedicated to
236. 30:12 this. And so what do we have when when we when we say a borderline personality
237. 30:18 what do we have? We have primitive defenses. We have problems in psychiatric management. We have
238. 30:24 disorganized attachment. We have inability to mentalize, inability to recognize internal states
239. 30:31 in oneself and in others that underly behavior that regulate effect.
240. 30:38 And that is a work by Fagi and Geli and jurist and target. An inability to
241. 30:44 experience the continuity of self and the continuity of others. work by Bronberg heets mess
242. 30:52 regarding the ideology of borderline personality disorder. There is evidence for a genetic vulnerability evidence
243. 30:59 that is lacking in the case of narcissistic personality disorder. Kamburg and Caligor, Paris, Siver,
244. 31:07 Davis, Stone, Togerson, they all um kind of reviewed the the discoveries in
245. 31:14 genetics and hereditary the hereditary dimension or component or determinant in
246. 31:21 borderline. Um the origin uh of borderline is therefore somehow
247. 31:28 influenced by genes. However, later studies have demonstrated that even if
248. 31:34 we were to agree with this, the impact on the variability of the disorder would
249. 31:40 be limited to about 5%. So, what are the other confounding factors? What are the other factors
250. 31:46 contributing to the emergence of the disorder? Well, we have an early attachment
251. 31:52 disorder. Gano Leote wrote about this. the bed or dead
252. 32:00 parenting, the dead mother. Yes. Um and this leads to developmental arrest
253. 32:06 described by Baitman and Fonachi and Masterson and many others.
254. 32:12 And this developmental arrest uh fits into a severe relational trauma
255. 32:20 best described by Mir 2012. But what we don’t know, we know that all
256. 32:27 these factors contribute to the emergence of a borderline pathology even as early as age 12. But what we don’t
257. 32:35 know is the relative weight of each of these factors. It seems that each person presents with
258. 32:42 a different waiting of these factors in the in theology. Individuals with borderline personality
259. 32:48 disorder are notoriously difficult patients because they may challenge ordinary therapeutic limits. They breach
260. 32:56 boundaries. They evoke intense counter transference reactions in therapies and they require modification of the treatment models in which many therapists are trained. They’re highly
261. 33:07 critical. Borderline patients are highly critical. At the same time, they’re highly flirtatious and seductive. The histrionic aspect is very pronounced. end when they’re disappointed or when they feel engulfed or then they become a
262. 33:21 secondary psychopathic. Patients with borderline personality disorder feel emotions that easily
263. 33:27 spiral out of control, easily overwhelm them. They drown in emotions and they reach extremes of intensity.
264. 33:34 They could even become aggressive, externalize aggression and even become violent. And this compromises the
265. 33:42 patient’s capacity for adaptive functioning. The borderline patient tends to
266. 33:49 catastrophize. They frequently require the presence of another person to help
267. 33:55 them to regulate their effect and to be soothed. They self soo and self-medicate with other people. I call it external
268. 34:01 regulation. When the relationship with this other person, this intimate partner
269. 34:07 or this special person or this favorite person, when the relationship with this other person, the rock in the
270. 34:13 borderline’s life to which to whom she outsources her internal psychological
271. 34:19 presc. So when the presence uh and when the relationship with this kind of person becomes closer, however, the borderline feels easily controlled, engulfed.
272. 34:31 She wants to flee the intimacy that only days before she craved and she was
273. 34:38 seeking. I’m saying she half of all border lines are men. At the same time, the borderline patient feels a deep fear
274. 34:46 of being rejected and abandoned. And this conflict, this internal dissolence between the two anxieties is, I think,
275. 34:53 the engine of emotion dysregulation. This inner turmoil disposes the borderline to misunderstand the
276. 35:00 attitudes and behaviors of other people as signs of present or anticipated rejection and abandonment. Such patients for example in therapy they tend to have difficulties in connecting their own actions and feelings with what they think and with
277. 35:15 what is happening. It’s as if they inhabit three parallel universes, three
278. 35:21 parallel scenarios. And this is the dissociative walls. These are the dissociative walls that the borderline has to cope with constantly
279. 35:32 to a large extent. This is the phen phenomenology of pathological narcissism as well. These people have trouble
280. 35:39 understanding other people’s behaviors, intentions, desires and emotions. There’s a failure, catastrophic failure
281. 35:46 in mentalization which is not very far off from low functioning autism.
282. 35:52 And the borderline patients and to a large extent narcissists often
283. 35:58 misrepresent their internal processes and the external environment
284. 36:04 by deploying infantile primitive defenses such as projection or by taking it for granted that others feel and think. exactly as they do. They have
285. 36:15 difficulties in putting themselves in other people’s shoes and taking perspective. They have empathy deficits
286. 36:21 and empathy failures. As a consequence, yes, border lines as well have empathy
287. 36:27 deficits. The text in the DSM has been amended to reflect this. As a
288. 36:33 consequence, these people tend to see other people in a binary uh splitting egocentric way. good for
289. 36:41 me, bad for me, or all good and all bad. They may be naive with a tendency to
290. 36:47 develop stereotypical explanations of their own and other people’s behaviors, intentions, and desires. This renders
291. 36:53 them to a large extent gullible. They’re often victimized.
292. 36:59 And when you’re victimized time and again or when you perceive what has happened to
293. 37:05 you as having been victimized time and again, you become suspicious, unduly suspicious, paranoid ideiation. These people develop interpretations of these experiences that are so convoluted and
294. 37:18 conspiratorial that they lose connection with the experiences themselves. They
295. 37:24 impair these individuals reality testing. Additionally, these people have difficulties in feeling a sense of continuity in their own experience.
296. 37:36 They’re disjointed. They’re broken. They’re like a kaleidoscope. They’re in shards. They may shift from one effect to another, from one self-representation or self state to another, from um and
297. 37:49 they don’t notice these inconsistencies between these different effects, different representations, different
298. 37:55 states. They they convince themselves that they’re the same, that there is
299. 38:01 continuity when there’s none. As a consequence, they may feel disoriented by their own behavior. And
300. 38:08 this disorients people who are around them and are interacting with them. They
301. 38:14 tend to steer up in other people emotions similar to those that they are experiencing or emotions that they have
302. 38:20 disavowed in themselves. In other words, when you are with a borderline and to some to a logic with a
303. 38:28 narcissist, you’re experiencing their state of mind states of mind, not yours.
304. 38:36 Border lines tend to feel an inner void and they may enter into dissociated
305. 38:42 translike states of consciousness. They may use selfmutilating behavior to soothe themselves. Often
306. 38:49 border lines report that these selfharming acts make them feel alive, allow them to reconnect with their
307. 38:56 bodies, drown the internal noise or dissonance or bad feelings.
308. 39:05 When this becomes too much, border lines tend to make suicide threats or gestures. For this reason exactly the inner turmoil, the inner tumal
309. 39:17 and some of them attract other people’s attention or try to manipulate them. Of
310. 39:23 course, a lot of suicidal behavior, a lot of suicide attempts are
311. 39:30 actually call for calls for help or attempts to garner attention or to manipulate people.
312. 39:38 Most border lines, but not all, but most border lines behave sexually or aggressively when their attachment needs are stirred up. They may often, but not
313. 39:49 always, be impulsive and they tend to have um troublemaking and uh uh
314. 39:56 they they are they tend to be crazy making and other people may perceive them as
315. 40:02 troublemakers. They can’t make or maintain longlasting gratifying close relationships and and they can’t hold stable
316. 40:13 satisfying jobs. Their work lives look exactly like their personal lives. The general recommendations especially in the PDM in this psychonamic diagnost diagnostic manual
317. 40:26 the general recommendations is to work with the individuals in the borderline range of severity.
318. 40:32 uh in the following way. First of all, to try to diagnose borderline
319. 40:38 personality disorder and even if there’s a failure but a clear pattern borderline pattern or borderline personality organization to treat it as if it is borderline
320. 40:49 personality disorder. Um there’s a need to emphasize the centrality of the working alliance
321. 41:00 and the importance of repairing the alliance when it is damaged. Now this is
322. 41:06 literally impossible to do with a narcissist with someone with narcissistic personality disorder let alone the psychopath. But it is possible to do this with a borderline. The pro prognosis in borderline is much better.
323. 41:19 Borderline remits spontaneously after age 35. And border lines have access to positive
324. 41:26 emotions and to a lot more empathy, effective empathy than narcissists. So there’s hope there. The treatment of a
325. 41:33 treatment of a borderline, there’s hope and there is good reason to negotiate an alliance with the borderline, a pact, a
326. 41:41 therapeutic pact. And so the first thing to be done in in the therapy of border lines it is is to set boundaries and to educate the borderline
327. 41:53 as to the critical role of boundaries and to make the boundaries very clear.
328. 41:59 Therapists must absolutely elucidate what’s the limit of his willingness to
329. 42:06 tolerate the patient’s rage and hurt and how to maintain the boundaries. The discouragement of regression, the expectation of intensity, the inevitability of either or dilemmas, the
330. 42:18 importance of the patients sense of the therapist as an effectively genuine
331. 42:24 person, and the development of capacities for self-reflection, mentalization, or mindfulness.
332. 42:32 there’s a need for ongoing clinical supervision of the therapist uh because it’s a harrowing experience
333. 42:39 working with a borderline or with a narcissist. There were many psychoanalytic theorists
334. 42:46 who have written about the treatment of borderline personality disorder and they all emphasize how their treatments
335. 42:52 deviate from standard psychoanalytic treatments. Those of you who want to learn more, you can read work by
336. 42:58 Baitman, Fagi, Clarkin, Kernburgg himself, Mastersonson, and so on so
337. 43:04 forth. Cognitive behavior therapists emphasize how their treatments deviate from standard cognitive behavior
338. 43:10 therapy. Liner is a prime example, but also Young Clauskco,
339. 43:16 Weisahar. It seems that run-of-the-mill ordinary mundane therapies don’t work with border lines. You have to adapt the therapy. not the patient the therapy.
340. 43:27 Okay. So what does the PDM says are the key features of borderline
341. 43:33 personality disorder? Start with contributing constitutional maturational patterns, congenital difficulties with
342. 43:41 effect regulation, intensity, aggression, and the capacity to be soothed and comforted.
343. 43:48 The central tension and preoccupation in borderline self-cohation
344. 43:54 engulfing attachment versus abandonment despair. What about the personality syndrome? The
345. 44:00 P axis you remember central effects intense effects generally especially
346. 44:06 rage shame and fear characteristic pathogenic belief about the self. I don’t know who I am. I
347. 44:13 inhabit dissociative self states rather than having a sense of continuity. What are the characteristic pathogenic
348. 44:20 beliefs about others? Others are one-dimensional and defined by their effects on me rather but rather than by
349. 44:28 a sense of their own complex individual psychology. In other words, the borderline reduces other people to two-dimensional cardboard cutouts and judges them by their effects on her. They are equivalent of service providers.
350. 44:45 And the central way of defending in borderline is splitting, projective identification, denial, dissociation,
351. 44:52 acting out, and a monopoly of other primitive defenses. That’s the view of the PDM when it comes to narcissism and borderline. I hope you had as much fun
352. 45:04 as I did.