Addiction Recovery and Cluster B Disorders Through an Attachment Based Trauma Informed Lens

Hey there everybody. And welcome to today's presentation of addiction and cluster B disorders through an attachment based trauma informed lens. I'm your host, Dr. Donnellice Snipes. In this presentation we're going to review the characteristics of cluster B personality disorders, addictions and ptsd. And using an attachment based trauma informed lens, we we're going to explore the function of the symptoms of these disorders. Finally, we'll identify treatment targets to help the person develop a sense of safety and empowerment and more effectively manage emotions and relationships. So let's start out with what is a personality disorder in general? A personality disorder is an enduring pattern of behaviors and ways of thinking and feeling a about self and others that deviate markedly from cultural expectations. That's important. It's pervasive. That means it's not just at work or at home. It's in multiple areas of the person's life. It's inflexible. This is the way they behave. They don't have alternate responses and it's stable over time with an onset during adolescence or early adulthood. Personality disorders can't be diagnosed prior to adolescence or early adulthood. So of course that's when the onset is likely going to occur. But the important point here is that personality disorders aren't going to suddenly be diagnosed in late life. It's something that starts out very early on. How might personality disorders have developed as a result of disrupted attachment? And we're going to talk about attachment in a minute and why it is so important to the individual. But in what way could having insecure attachment impact the way a person thinks and feels about themselves and others? How could these behaviors be caused by other trauma? Not everybody who has a personality disorder diagnosis has disrupted attachment or insecure attachment. A lot of them do, but not everybody. So we want to look at what else. And trauma is a big issue because both disrupted or insecure attachment and trauma strip the person of a sense of safety and personal empowerment. Now, I mentioned earlier that the behaviors need to deviate markedly from cultural exploitation expectations. What does that mean? Well, that means in general, where you live, the people that you spend time with, is this person behaving significantly differently than them. And that gets a little bit dicey right now because according to statistics, nearly one half of Americans report having a mental health issue in any given year. This is likely an under report. There are a lot of people who probably have characteristics or have meet the criteria for depression or anxiety or intermittent explosive disorder and they don't recognize that as abnormal or a mental health issue. So they don't report it as such in 2019. Now mind you, this is pre pandemic data. We're looking at approximately 1/4 of US children experienced adverse childhood experiences. Now, adverse childhood experiences are trauma inducing experiences and can roughly be categorized into three neglect, abuse and abandonment. So nearly one quarter of U.S. children are experiencing trauma at an early age. We've defined personality disorders, but I do want you to recognize that personality disordered behavior is behavior that we'll see in just about anybody but on a more significant severe scale. Do you sometimes have difficulty controlling your anger or overreact to situations you know think about? Maybe when you're overtired or you're got 17 things going on and you're overwhelmed, do you tend to get more snippy or react more strongly to situations than you would if you were fully recharged? Have you ever manipulated someone or a situation for your personal gain, like to get a promotion or to get accepted by a group or onto a team? Do you ever have a sense of entitlement even if somebody else has done the work? Maybe you've worked at a company for 10 years and you think you deserve this promotion even though somebody else who's applying for it has more training, more education and has done worked in the field for 20 years. But you feel like since you've been at the company for 10 years you're entitled to that promotion. Have you ever had intense or unstable relationships? And I think a lot of us, especially if we look back to our first relationships, may characterize them as intense and unstable. That love at first sight, head over heels, can't stand to live without you intensity. And then when you feel like the other person may be losing interest or not doing what you want, there's extreme anger. And I have two children who are getting out of their teenage years and I've seen this in their relationships. And part of adolescence is characterized by tumultuous relationships. Do you sometimes have feelings of emptiness? A lot of people do. Are you sometimes impulsive? Do you sometimes have stress related paranoid ideation? And I know that sounds really bad, but what this means is sometimes when you're really stressed, do you see other people as more of a threat than they really are? Do you see other people as trying to take advantage of you more than they actually are? Many of these behaviors represent your reactions during a time of vulnerability. You may have been exhausted, overwhelmed and or felt unsafe. In those cases you do things in order to protect yourself, to try to survive excessive or uncontrollable anger. You may have Been at the brim. You may have been at the top of the mountain, and it didn't take much to trigger you at that point. And the anger is the fight or flee response. It's saying, I can't take one more thing. You need to go away right now. Intense relationships. Sometimes when we feel exhausted and overwhelmed, we may cling to relationships or be more intense in our relationships because of a desire to have somebody there to help us navigate this stuff. Feelings of emptiness are very common when people are exhausted and overwhelmed. They're like, what's the point? What's the use? I don't get it. And then, as I mentioned before, paranoid ideation. When you are exhausted, overwhelmed, and feel unsafe, your brain is in this fight or flight mode. So it perceives the negative, it perceives the glass as half empty. It perceives people, people's motivations as not necessarily the kindest in the world. Why does it do that? In order to protect you. It's preemptively saying, there might be a threat here, so you need to watch out. Now, one thing that. Well, there's a lot of things that are interesting, but people without a significant unresolved trauma often only occasionally experience these symptoms, if you will. And I'm emphasizing unresolved because when we have go through a trauma, if we're able to resolve that and integrate it so it's not stuck in our amygdala, our fear processing area, so to speak, then our brain doesn't constantly have to process it. And it's not constantly hearing or being informed by that trauma. It's been taken care of and put away. For people with unresolved trauma, those traumas are hanging around. So there's constantly activity and energy devoted to trying to figure out how does this trauma fit based on what we've learned from this trauma, how can we keep ourselves safe? And the amygdala is our fear processing area, among others, is in overdrive, so it can get exhausting. People with significant unresolved trauma may experience these symptoms most of the time. The trauma that is unresolved is constantly weighing them down. Think about trauma, unresolved trauma, as bricks or boulders in a backpack. And if you're carrying around either one really big boulder or, or 15 bricks all day, every day, that is going to drain your energy. You're not going to have a lot of energy left for other stuff. And it may make you feel vulnerable because you know you don't have energy left for other stuff. So I want you to really conceptualize unresolved Trauma as something that drains a person's energy, helps them or causes them to feel disempowered and unsafe, and that shades the way they look at and interpret the world. Our personality disorder behaviors, feelings and thinking styles maintained because that's just how people are wired or because based on prior learning experiences, they experience the world differently than non traumatized individuals. They experience the world as more threatening, more unsafe. So they have alternate safety or compensatory strategies. Now, I said at the beginning that this is a look at personality disorders and addiction from an attachment based trauma informed lens. So we've kind of defined personality disorders. Now what does attachment have to do with it? Secure attachment is essential for our development and our ongoing mental health. It's not just something we do as children and then we're done. Secure attachment impacts how we interact with others, how safe we feel, and it's characterized by consistency, responsiveness, attention, validation, encouragement and safety. We have these relationships, secure attachments, ideally with our caregivers as we get older, with our friends, with our loved ones and with ourself. The initial secure attachment helps children move through Erik Erikson's stages to develop things like trust. When they're infants, they learn that they can trust others to meet their needs, to feed them when they're hungry, to give them drink, when they're thirsty, to comfort them when they're scared. When they get a little older and they get into that toddler age and they're starting to toilet train, they're starting to develop a sense of autonomy. I can do it. And the consistent, responsive caregiver is going to be there and help them along the way, provide scaffolding to help them be successful at whatever they're trying to learn how to do. For example, tying their shoes or toilet training. The next stage is initiative. And during this stage, the child is a little bit older, preschool, you know, maybe kindergarten. And they're starting to try new things. They're wanting to pick out their own clothes, they're wanting to do things, and caregivers guide the child so they're able to take initiative without making huge mistakes. So for example, if they want to start dressing themselves instead of leaving all the clothes in the closet during the winter, only the winter clothes are in the closet. So the child's not going to walk out with a swimsuit on and say, hey, I want to wear this to school. So the caregiver makes sure that there are appropriate choices, but then allows and empowers the child to make their own choices. And then industry takes it a Little bit further. And this is when a child starts learning what they're good at, which means they've got to step out of their safety zone, their comfort zone, and, and try new things. And school kind of forces this when they force you to go to different types of classes like gym class and English class and industrial arts and home ec. I don't know if you still even have those in schools, but in my day, we did. But we explored and experienced a variety of things. Some of them we were good at, some of them not so much. And in a consistent, secure relationship, even if the child fails at something, they can come back to their secure home base and they're loved for who they are. And the caregiver is able to help them deal with distress and failure as well as when they do succeed, celebrate their successes. Secure attachment supports children as they move from egocentric, dichotomous, or what Piaget called concrete thinking to empathetic, scaled, quote, formal, operational thinking. Young children think that whatever their perception of the world is, is how it really is. They can't take other people's perspectives when they're young, which makes it more difficult. If they think something is their fault, then they assume that everybody else thinks something is their fault. And at this age, children are also thinking dichotomously. All or nothing. You love me or you hate me. I'm good or I'm bad. And in a secure attachment, the caregiver is there to respond and present alternate points of view to educate the child. I hear, Sammy, that you feel like this is your fault. There could be other explanations, and the caregiver can present those things. The caregiver can help the child learn what is their responsibility and what is not their responsibility. The caregiver can help the child start learning that there is more than just all or nothing. There are sometimes, there's the sometimes. Secure attachment helps children develop emotional intelligence, which is the ability to identify, communicate, and regulate their emotions as well as the emotions of others. We are not built with this. We are not born with this. It's something that consistent, responsive caregivers teach. In a secure relationship, the caregiver will notice how the child is feeling and will consistently be there and help the child identify. What is this called? That you're feeling right now? Will help the child, through practice, learn skills to tolerate the distress, like breathing or going on a walk. Maybe if they start getting frustrated at the playground, the caregiver will help them identify that they're feeling frustrated right now or feeling overwhelmed. And let's go on A walk so you can, you know, get, get your emotions in check and then we can talk about what to do with them. So this is really important during the child's development that the caregiver consistently is there, consistently responds to the child. They don't just notice, well, Jimmy's upset right now, they notice that Jimmy's upset now, what do I need to do to help Jimmy identify it, communicate what's going on with him and regulate it. Secure attachment teaches children mindfulness, distress tolerance, emotion regulation and coping skills, which again, were not born with. So if children don't have this, then we can't expect them as adults to just spontaneously have developed them. When children don't have mindfulness, distress tolerance, emotion regulation and coping skills, they develop strategies, whatever they can, whatever strategies they can to try to survive. And often those strategies become what we later start calling personality disordered behaviors. Secure attachment helps children develop a sense of self and self esteem because the caregiver is giving proactive attention, saying, hey, I want to spend time with you, you're a person of value. And helping the child start differentiating between unacceptable behaviors versus themselves as being acceptable human beings. They are acceptable. Their behaviors and their choices might not be. And that's where the responsiveness and validation comes in. The caregiver, through validation helps the child identify their emotions and cope with them and helps the child develop a sense of mastery or control over those things that we call emotions that can feel so incredibly overwhelming. And that also contributes to a sense of self esteem. And finally, secure attachment teaches children about healthy boundaries, physical boundaries, what is okay to allow people to do? How do you set physical boundaries to keep people from invading your space and making you feel uncomfortable? Affective or emotional boundaries and cognitive boundaries kind of go together. And that is when somebody says, this is how I feel or this is what I'm thinking, you don't have to agree with me. My feelings and thoughts are equally as valid as yours. Environmental boundaries, you know, my stuff. How can I set boundaries with my stuff so I feel safe in my environment, that you're not going to read my diary or steal my sweaters or whatever. And then relationship boundaries are the way I characterize them are boundaries where the child learns to say this person, I'm going to be friends with them. You can't tell me who to be friends with. And we see in school a lot of times, especially where certain groups are, are trying to discourage people from being friends with people in certain other groups. And it just gets, there's so much drama and healthy Relationship boundaries the child. The person is able to say, I want this person to be my friend. You guys don't have to be friends, but I'm going to be friends with them. A trauma is an event that causes a sense of terror, overwhelms a person's ability to cope, and disrupts their sense of safety and personal power. Now you may say terror. Well, what does, you know, insecure attachment have to do with that? Well, when somebody is 2 years old, 5 years old, 8 years old, they can't function on their own if they can't depend on their caregivers. That great big world that we as adults sometimes get overwhelmed by, it just seems terrifying. So yes, attachment disruption is traumatic trauma alters schema, or the way we anticipate and perceive the world and people's default mode network or their autopilot. When we experience something, we kind of write a little report about what we experienced and we file that away. So the next time we experience something similar, we know what to expect, we know what to anticipate, and so we can do it almost on autopilot, like going to the doctor. The first time you did it, you may not have known what to expect. Now that you've done it several times, you know what to expect. So you can kind of do it on autopilot and you don't think about, well, what do I need to wear, what's going to happen, what do I need to bring, blah, blah, blah, you know what to expect. And that's your default mode network. Unfortunately, when people experience trauma and they write down that report of this traumatic situation, then whenever they experience similar situations, they expect trauma. If a sense of safety and empowerment is not restored, the brain continues to perceive the threat as ongoing and, and the HPA axis or the person's fight or flight threat response system begins to become dysregulated. It just keeps it's going 247 and you know, just can't keep up. Eventually it starts to react to protect the person, the HPA access goes, we can't run, be this excited, be this stressed, run this hot, whatever you want to call it, this much, this long. So you know what, I'm just going to dial down the sensitivity. So it's going to take a lot more to get me to kick off. In that situation, the person starts feeling kind of flat, maybe numb in some. In some instances, however, when they do get triggered, they go from numb or flat to extremely upset in no time flat. So I call it the flat and the Furious. They go from being Kind of flat to either being terrified or enraged at the drop of a hat. This is a physiological reaction. This is a physiological change that happens in the brain where it goes from not much in the way of stress hormones to a tsunami of stress hormones. It's not just a person willfully, quote, overreacting as a result of ongoing anxiety or threat. The nervous system perceives the world through a trauma informed lens. The nervous system starts just seeing the world, you know, whenever the person is stressed, which is all the time, seeing the world as malicious, seeing the world as threatening, as dangerous, as overwhelming, which causes them to expect the worst. Now, the reason our brain does this is to protect us. If we don't notice a bunny, no harm, no foul. If we don't notice a cottonmouth, it could kill us. So our brain actually puts more weight, puts more what they call emotional salience on threatening stimuli. It notices, it's more aware of threatening stimuli in the environment than it is of benign or even pleasant stimuli. So think of it. If you're looking at the world through this veil of, of threat, where everything seems, you know, scary, how might this impact your perception of safety, your emotions, the way you think about yourself and others and whether they're safe or you're safe? And how might it impact your relationships if you're, you know, if your emotions are, you know, negative or dysregulated, if you feel unsafe, if you don't trust other people? And how do you think that's going to impact your relationships? How is disrupted or insecure attachment traumatic? Well, we kind of talked about that earlier. A child cannot thrive on their own. When children aren't getting their needs met, it is very traumatic to them. Even as older children, adolescents, when attachment is disrupted, when something happens that's so severe that somebody believes that there's nobody I can trust, then it starts to impact the way they perceive everybody. How might a lack of emotional intelligence, mindfulness, distress tolerance and coping skills, a sense of being a valuable person or self esteem, and the ability to set and maintain healthy boundaries contribute to repeated or ongoing trauma? So we have children, young people, who are exposed to trauma, who may not have secure attachments to help them navigate this scary world and the traumas that they're experiencing and they start developing, you know, alternate coping skills. But when they're not, if they don't develop mindfulness, for example, then they may never effectively identify what triggers them. If they don't have emotional intelligence, then they may not be able to effectively identify and regulate their emotions or which could cause Problems at work, in other relationships with their self esteem, which is, again, those problems lead them to feel even less empowered or even more unsafe, which creates or compounds the trauma. Many people in active addiction display personality disordered behaviors. Yet in recovery, those behaviors have often dissipated. Now, remember at the beginning I said most of the behaviors that we qualify or we use to define personality disorders occur occasionally in people without personality disorders. It is the intensity and the pervasiveness of those behaviors that makes them diagnosable. Addiction may represent the person's only secure attachment. Now, stick with me here. A lot of times in addiction recovery, with addiction recovery, we talk about the addiction as the person's best friend. Why is that? Well, it is consistent and responsive to the person. When they are in pain. That addiction usually numbs it or makes it go away for a period. It provides safety through the temporary relief of either emotional or physical pain. The person's like, oh my gosh, I can breathe for a second. And it does not invalidate the person's feelings and thoughts and tell them that they're overreacting or they're thinking about it wrong. The addiction just shows up and does its job and comforts the person. Now, is it a healthy relationship? Obviously not. But if you look at it from that perspective and you recognize that with a lot of people with addictions, they may not have another secure attachment. Maybe they've never had another secure attachment. So that is sort of their surrogate. When people with addictions cannot access their addiction, they may get overwhelmed by their emotions, negative self talk, chronic feelings of emptiness, and an unstable self image, which causes frantic efforts to survive that can manifest as anger, emotional dysregulation, intense relationships, impulsivity, etc. Again, going back to what is the function of these behaviors and in what way might they be helping the person survive? As we discuss personality disorders, think about how addiction may have been used to numb or medicate prior trauma. And without it, the person feels too much or feels unsafe and may result, resort to other behaviors to try to numb that pain. Are people who met the criteria for personality disorders persistently mentally ill? Or are they people who've experienced extreme and or ongoing trauma who are trying to survive in a world where they never feel safe or empowered? And I know I asked you a question that was very similar to that a little while ago, But I wanted to put that trauma spin on it so you can start seeing the bigger picture. PTSD and, and cptsd. PTSD typically is one significant event. CPTSD often represents ongoing traumatic events and they can be ongoing significant ones or ongoing moderate ones. No trauma is ever insignificant. With PTSD and CPTSD we see efforts to avoid distressing memories. And these can be memories, for example, of abandonment in the past. And that would be something you might see in somebody with borderline histrionic or antisocial personality disorders or rejection, which you might see in somebody with narcissistic personality disorder. Dissociation is another common symptom of PTSD and cptsd. Checking out because the pain or the memories are just too overwhelming. So they check out from that experience. And addiction provides a way of, for some people, of checking out or numbing their feelings. And personality disorders sometimes involve a certain amount of dissociation. Emotional dysregulation, when perceiving a threat to self or self concept, and the emotional dysregulation being getting very angry or extremely depressed. That flat to furious is very common in people with PTSD or CPTSD because they've experienced those brain changes. And when there's a threat to themselves, it triggers that tsunami of stress hormones in people with narcissistic personality disorder. Sometimes we see it when there's a threat to their self concept because they put up this wall, this facade of grandiosity. And if there's any indication that there might be cracks in that wall if extremely terrifying. Now, people with narcissistic personality disorder, some do have a grandiose sense of self esteem. And when they're faced with any contradiction, it's. They can't conceptualize it, they can't understand it, and it makes them very angry. On the other side, there are also people who have narcissistic personality characteristics who have a very low self esteem. So they put up this facade, this fake wall of bluster and say, I'm all this, you know, don't look behind the curtain. But this is what I want you to see. People with PTSD have persistent and exaggerated negative beliefs and expectations about themselves, others and the world. Does that sound familiar? Again, because of their traumatic experience, they are now perceiving the world through a trauma informed lens, through a trauma informed veil. They may have persistent distorted cognitions about the causes or consequences of the trauma. They may blame themselves or they may blame others. Either way, they don't feel safe. Either I can't trust me or I can't trust you. Either way, I ain't safe. Feelings of estrangement from others. I don't feel like I can connect with anybody. Either my feelings are too overwhelming or people wouldn't understand where I'M coming from. And a lot of people with personality disorders, because of their history of trauma and inability to articulate and cope with the trauma as well as, you know, future life, a lot of times they feel like nobody understands them. And quite honestly, unfortunately, that may be true a lot of times because there's been so much stigmatization of people with personality disorders, irritable behavior and angry outbursts. Again, that's another one of those characteristics we already talked about in with personality disorders. People with PTSD are already stressed out, feeling unsafe. So they may get angry. You know, that tsunami of stress hormones kicks in and they are saying, I can't take one more thing or I can't, I don't trust you. You're not safe, go away. Reckless or self destructive behavior can be seen sometimes to numb the feelings that are going on. And this is akin to what we'll see in personality disorders with impulsivity and hypervigilance. Hypervigilance means constantly scanning, constantly screening, constantly looking for threats in the environment, never being able to relax because you don't feel, feel safe. So let's start with borderline personality disorder. Five criteria. There are nine. Only five need to be met to qualify for a diagnosis. I want you to think about how these may be present in people who are recovering or who have addictions, as well as people who have experienced trauma. Frantic efforts to avoid real or imagined abandonment. Well, if the initial attachment, the primary secure attachment, never happened or was insecure, then that person, until they address that, is likely going to feel threatened, feel afraid of abandonment. So it's important to recognize that disrupted attachment in childhood can cause later life abandonment anxiety. People with addictions may react frantically to avoid abandonment from others, but a lot of times that hasn't worked. And so then they glom on to their addiction, which, remember, serves as a surrogate. Secure attachment. And they frantically try to avoid being abandoned by that, having that taken away. So they may lie, they may manipulate, they may justify, they may deny use in order to protect that relationship with their addiction. Unstable and intense interpersonal relationships. Love you, hate you. In people who've experienced trauma, they don't know who to love, who to trust, who they can count on. So a lot of times they get into these relationships because they desperately want to be loved. They desperately want to feel safe and secure. But at the moment it seems like they are not safe or secure. They may kind of Jekyll Hyde and turn to the I hate you. And that goes back to what I said about children thinking egocentrically and dichotomously, if the person feels threatened, feels like the other, they're getting ready to be abandoned. They may figure that that's, you know, they're either in a relationship or they're out. And the only safe thing is to push that person away first. When dysfunctional thought patterns, or when childhood thought patterns like concrete thought are not fully developed into formal operational thought, when children experience trauma at a young age, they often continue to think egocentrically and dichotomously. So in treatment, one of the things, one of the challenges is to help people look at what are some other explanations. Because cognitively, as adults, they're able to do that now. They just never had someone there to help them bridge that transition. They may also have a persistently unstable self image. They go back and forth between I love me or I hate me. And for the same reason, they get up in the morning. One morning they look in the mirror and they say, okay, it's going to be a good day today. Things are going, okay, I love me. And then something goes wrong and they just turn and they start telling themselves that they are horrible people and they hate themselves. And because of a lack of secure attachment, because of a guide, so to speak, to help them navigate intense emotions when they were younger, they never developed the ability to tolerate distress, to unhook from unpleasant emotions, and then to explore triggers. Impulsivity is another thing that we see in people with addictions. They may impulsively begin using, they may impulsively act out in order to protect their addiction or in order to numb pain. People with borderline may act impulsively in other ways. Getting into. Impulsively getting into relationships, impulsively doing other things to try to numb their pain, to. To numb their sense of emptiness, to give them something to focus on. They may have recurrent self injurious behavior or suicidal ideation. And many times, self injurious behavior is not designed to actually kill the person. It's designed to help the person actually feel a sense of control. Their internal state is so overwhelming and so overpowering and so intolerable and that they resort to modifying their external environment through self injurious behavior. And they can control that. It takes 100% of their focus. One example of an alternative to self injurious behavior is putting your hands in a bucket of ice water. And if you do that, I can almost guarantee you, you're not going to be thinking about how you feel or what you're going to eat for lunch or what somebody did wrong at the office today, it's painful enough having your hands in a bucket of ice that you're focused on that and tolerating that distress in the moment. Chronic feelings of emptiness, emotional dysregulation. A lot of people with addictions, probably because of prior trauma, experience emotional dysregulation and feelings of emptiness. They don't know who they are, they don't know what they stand for. If they were raised in an addicted family, they were often taught, don't talk, don't trust, don't feel. So they don't know what their thoughts are, they don't know who to trust, and they don't know what they feel because that was always dictated by the person with the addiction. Well, when you don't feel safe, when you're afraid of abandonment, when you have difficulty controlling your impulsivity, when you feel overwhelmed, it makes sense that you may be a little bit more irritable. And people with borderline personality disorder, because of the trauma, the ongoing trauma, and the brain changes, they often will go from feeling okay to furious, you know, that flat to furious. Emotional dysregulation or difficulty controlling anger, whatever you want to call it, we really want to look at it as a function not only of the person's survival, but also recognizing that it represents brain changes and that occur as a result of trauma. People with narcissistic personality disorder have a grandiose sense of self importance. They exaggerate their achievements and expect to be recognized as superior sometimes. This is because when they were growing up, that's what they were taught. They were taught that they were the most important and that they were supposed to exaggerate their achievements and that other people were always supposed to recognize them as superior. In other cases, the person, as I mentioned earlier, may put on this facade of self importance and exaggerating their achievements because they feel like the only way that they can be loved is for what they do. And in order to avoid abandonment, they have got to make themselves, quote, worthy of love through what they do. Person with narcissistic personality disorder is often preoccupied with fantasies of success, power, brilliance, beauty, or perfect love. A lot of times they're thinking, if I can only get power, then I will be happy and safe. If I can only get this perfect relationship, or when I'm in this perfect relationship, then I will be happy and safe. They may believe that they're special and can only associate with other special people. And by doing this, they may be creating an artificial zone of safety where they feel like they're accepted they may require excessive admiration. A lot of people with attachment issues have difficulty with, with self validation. They have low self esteem, so they can't look in the mirror and say, I'm a person of high value, I am worthwhile, I am worthy of love. So they require. The only way they get validation is external. They require other people to give it to them. Which for people with narcissistic personality disorder comes in the form of requiring other people to admire them. I need you to feed my ego. I need you to tell me how good I am. Sometimes again, it's to keep this self fulfilling prophecy going on. And other times it's because they can't. They don't feel good enough themselves so they need someone else to fill up their esteem bucket, so to speak. They have a sense of entitlement and may be exploitive and take advantage of others to achieve their own ends. Now this is a very unpleasant behavior. But if they grew up in an environment in which that's what other people did to them, what do you think they learned? If they take advantage of others to achieve their own ends, then they are sometimes demonstrating power and, and may feel like that keeps them safe. If they can manipulate others, if they can control the situation, then not only can they get something they want, but it assures them or reassures them that they're safe. Lacks empathy and is unwilling to identify with the needs of others. Now we really want to look whether the person actually lacks empathy, lacks the ability to, to understand what somebody else is experiencing or if they're unwilling to do that. There's a difference. If you're unwilling to do that, it could mean that I'm too afraid that if they feel something different or they think something different than me, I might be wrong, which may shatter my very fragile self esteem or put a little crack in that facade of grandiosity that I have. They may be unwilling to empathize because they're overwhelmed. They can't deal with their own stuff, let alone deal with somebody else's stuff. So they're focused on me. They're focused on survival of me in the moment. They may be envious of others and believe that others are envious of them and show arrogant, haughty behaviors and attitudes. Aggression pushes people away. Arrogant, haughty behaviors also pushes people away. If you go around acting like you're better than everybody else, a lot of times people won't really want to be around you. So that could be a protective mechanism that they developed in order to feel safe, in order to try to Prove to others that, that they are worthy of love, but keep them at arm's length so they can't get too close and look too closely. For antisocial personality, again, five criteria must be met. And there's a whole lot of criteria. They have a disregard for right and wrong. They're going to do what they want when they want to do it, because they want to do it. And think about a five year old. A lot of times five year olds will do what they want when they want because they want to do it, especially if they don't think they're going to get in trouble. So if trauma occurred when a child was very young, they may not have developed their moral compass quite the same way. Persistent lying or deceit to exploit others. A lot of times my experience has been people with antisocial personality characteristics often have been exploited by others and they don't trust others, they don't like other people. So they don't have any qualms about lying or manipulating them because they don't see them as worthy, lovable, trustworthy human beings. Which takes us to callous, cynical and disrespectful and manipulating others for personal gain or personal pleasure. Arrogance and being extremely opinionated is another characteristic. And this one overlaps obviously with narcissistic personality disorder, but antisocial personality disorder. If you want to look at the different types of insecure attachment, antisocial is more the avoidant Insecure attachment. The person with antisocial personality disorder really doesn't have a use for engaging in intimate relationships with others. For the person who's antisocial, they often see others as a pawn in the great chess game of life. They may repeatedly violate the rights of others through intimidation and dishonesty. Again, often a learned behavior from their prior traumatic experiences, impulsiveness or failure to plan. So we see impulsivity a lot. And impulsivity is often that reaction to a threat. I need to do something to make it stop, or I need to do something in order to keep myself safe. Hostility, irritability and aggression. You know, when people are persistently feeling this way, they're not happy. You know, you can't be hostile, irritable and aggressive and happy at the same time. So we want to ask ourselves, you know, what is going on with this person that is making them feel threatened? Because irritability, hostility and aggression are all emotions that represent anger, that represent part of that fight or flight response. So where's the threat coming from? Lack of empathy or remorse. A lot of times people with Antisocial personality have given up, if you will, on other human beings. So they don't even try to empathize with others. Unnecessary risk taking, with no regard for the self or safety of others. A lot of times people with anti social personality really care that much about themselves either. They just care about surviving the moment. So they may engage in high risk, high reward behaviors in order to either feel something or because they just don't care. Poor or abusive relationships. Well, obviously if you're cynical, disrespectful and manipulative, you're not going to have good relationships. Failure to consider or learn from negative consequences and consistent irresponsibility. A lot of these characteristics sound like a very immature, unhappy, scared child. So from that perspective, if we're thinking about personality disordered behavior, we want to say in what ways did this child, when they experienced a trauma, develop these behaviors in order to survive? And then those behaviors and those schema have just to date gone unchecked and histrionic. Five criteria they're uncomfortable when not the center of attention and they're constantly seeking reassurance or approval. And this is very common again in people with low self esteem. They feel like they need others to give them to fill up their esteem bucket because they can't do it for themselves. They may do this through inappropriately seductive behavior. They may be overly concerned with their physical appearance or use physical appearance to draw attention to them. You know, it's like, hey, over here, I need my, my esteem bucket filled up. Their opinions may be easily influenced by other people, but difficult to back up with details. So they have very weak boundaries because they are going to change their opinion to coincide with whoever's approval they're trying to get. They may be dramatic with exaggerated displays of emotion. A lot of times these behaviors were rewarded for that young person in order to get them some sort of response from their caregivers and a tendency to believe that relationships are more intimate than they actually are. And the person with histrionic personality disorder often so craves love and attention that they look for any way to rationalize that this relationship is super intimate and that this person is going to be there for them. Treatment now obviously treatment for personality disorders is extremely complex. But some of the treatment targets are designed to create safety and empowerment. Help the person identify historical causes and present triggers of unsafeness. Explore and adjust core beliefs related to those experiences and their triggers. Explore the pros and cons of current behaviors and feelings towards self and others. Enhance emotional intelligence and distress tolerance skills. Developed mindful Awareness of self. What are my thoughts, wants, needs, and feelings? My triggers and vulnerabilities? What are the functions of my behaviors and what are alternate ways that would be effective to help me meet those needs, learn about healthy boundaries and develop a plan to begin to developing, setting, and maintaining those healthy boundaries. People with personality disorder behavior may have experienced significant trauma which influences their perceptions, thoughts, feelings, and behaviors. People with addictions often demonstrate similar behaviors as a result of their sense of unsafeness and powerlessness over their life, as well as their addiction. When superficial symptoms are treated without addressing the underlying cause of the behavior, I.e. the trauma or attachment disruption trauma, and without providing viable alternatives, the person is most likely going to relapse, which is why we see such a high relapse rate, because too often we deal with the presenting symptoms instead of saying, all right, what is the underlying thing that is triggering this, that is maintaining this behavior? People with personality disorders need to learn how to safely deal with intense feelings. Specific issues which may trigger intense feelings include poorly developed or unstable self image, which is often associated with excessive self criticism and feelings of inadequacy. Interpersonal hypersensitivity, where they're prone to feel slighted or insulted. And remember I said hyper vigilance is very common in people who've experienced trauma as well as in people with personality disorders. And intense, unstable, and conflicted close relationships marked by mistrust, neediness, fear of abandonment, and difficulty trusting people due to alterations between feeling appreciated and condemned. So there's a lot of potential treatment targets here. We don't want to oversimplify what somebody is going through.