Grief Trauma and Personality Disorders: Trauma Informed Care

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome you to today's presentation. I'm Dr. Donnelly Snipes and we're going to be talking about trauma, grief and personality disordered symptoms. Now we are going to kind of break it down a little bit by personality disorder towards the end, but what I want you to think about is personality disordered symptoms in general and how they might actually represent a creative, albeit unhelpful way of coping that a child developed. You know, it was helpful for the child, but it may not be helpful for the adult in in later life. We'll explore the similarities between grief traumatic reactions and personality disordered symptoms. We'll explore the possible etiology of symptoms. I already gave you a hint there. And we'll try to start encouraging people to change the language from why is this person doing this? To how does this make sense? What happened to this person that would have prompted the development of this behavior? As we go through this presentation, continually ask yourself how could this behavior be an adaptive reaction? And remember, personality disordered symptoms often begin or we can start seeing them in anywhere from adolescence to early adulthood. A lot of us well, I'm jumping ahead of myself. Persistent complex bereavement disorder is actually listed as a condition for further study in the DSM 5. It's page 789 through 792 and it talks about bereavement that really doesn't get resolved. And we started touching on this a little bit on Tuesday when we were talking about the grief and trauma associated with the loss or lack of a primary attachment figure. We're all hopefully familiar with the symptoms of ptsd, so we're going to look at those a little bit in depth. And then personality disorders, like I said, I wanted you to think of them sort of globally at first. They are pervasive, long standing ways of being. It's not just at work, it's not just with friends. But these behaviors permeate people's lives. Their ways of perceiving and interpreting the self, others and events is affected and impacted by their behaviors. They have a varying range, intensity and appropriateness of emotional response. They have challenges in interpersonal functioning, especially as it regards empathy, trust and sometimes just simply the desire for relationships. Sometimes the person, as in dependent personality disorder, really wants a relationship and other times, as in avoidant, they're no that's just more than they can wrap their head around. And generally we'll see some difficulty in impulse control. So let's look at some of the symptoms again in general, as we're talking on the left side of my screen. I hope it's the left side of your screen. You'll see the symptoms of trauma and grief. Now, the ones that are specific to grief are not italicized. The ones that are common to trauma and grief are italicized. And guess what? You're going to notice that pretty much everything in the left hand column is italicized. When somebody is grieving. When they experience a loss, whether it's a complicated grief or simple grief, it is or can be traumatic. And if the person is experiencing traumatic grief, they're going to have shock, denial, disbelief about what's going on. This is very true. Now this is one category or one symptom that you don't really see a lot in personality disorders because it doesn't come from out of the blue. It's not representative necessarily of a loss that we can really identify clearly. There's guilt, shame and self blame involved in trauma and grief. A lot of times when there's a loss, there can be some of this coming up. It doesn't have to happen. You know, just like any disorder in the DSM, you have 12 characteristics and you only need four in order to meet diagnostic criteria. But in a lot of people, we do see some guilt, shame and self and or self blame. Interestingly, here's our first parallel. In personality disorders, a lot of times we can see guilt, shame and self blame. Let's think about that. You know, how could or why would somebody develop guilt, shame and self blame as a result of trauma and grief? And how would it continue to be functional as a reactive method, if you will, in adulthood? How is it that this may have developed from trauma and grief and the person may still be holding onto it? And sometimes it's just that simple. It's not some convoluted reaction. They experienced a significant trauma in their childhood. They have significant guilt, shame, self blame. And they've held on to that. They haven't worked through that. So they're still holding on to that stuff, which ends up resulting in some of the behaviors that we really focus on in personality disorders. In trauma and grief, people feel sad or hopeless. Alrighty, again, you look over here at personality disorders, sadness and hopelessness. Now how many of you have worked with people with personality disorders who have in for the most part, there's always those exceptions. For the most part who have no history of trauma. My experience has been, and I'll watch the chat room, my experience has been that people who display personality disordered symptoms, whether they meet the criteria for a personality disorder or not, and we're going to talk about that in a few minutes, often experience pretty significant trauma of some sort in their early, early formative years. And remember, it can be, we need to see these symptoms in potentially childhood, but adolescence or early adulthood. So all the way through college, we're really looking at the time that a personality disorder can actually manifest itself. Feeling disconnected and numb. We expect to see that in trauma and grief. Feeling disconnected and numb. Think about antisocial personality disorder. Think about some of the other personality disorders where the person just isn't not feeling empathy, they're feeling totally disconnected from other people on a meaningful level. Some of your category A personality disorders are going to be in there. And yes, there is a high comorbidity of personality disorders with substance use. And I will point out that again, my experience over two decades of working in co occurring disorders, not to say that it is true all the time, but a lot of people who have substance use disorders do have a trauma history. And as they get to the point where they're embracing recovery, as they get healthier, get through that post acute withdrawal syndrome, which lasts about a year, sometimes more once they get past that. A lot of times, not all the time, but a lot of times I've seen some of these personality disorder symptoms remit, which is one of the reasons why you want to really make sure not to give a PD diagnosis until you rule out the other stuff. And it even says in the DSM 5, you want to rule out other mental health conditions or behaviors being the direct result of substance use. So you want to make sure that you rule that out before you diagnose somebody with a personality disorder. My premise here, I don't want to use the word argument, is that we really also need to rule out trauma and grief. If we resolve the trauma and grief issues, will the PD symptoms remit? And if so, did the person truly have a personality disorder or were we working with someone who had complicated grief and PTSD who was having difficulty coping with that? That's my premise. You can, you know, chew on that for a few minutes and obviously don't have to disagree or don't have to agree. But you know, that's kind of a lot of what I've seen when people start working on the underlying issues, develop the coping skills, resolve the trauma, lot of Times the personality disordered symptoms disappear. Now, there are truly people who have personality disorders, no doubt, but we'll talk about that more as we go through dysregulation. We see this in trauma and grief. When people are traumatized, especially if they start developing hypocortisolism as a result of the trauma, we're going to see more emotional dysregulation. People with personality disorders often emotionally dysregulate. If you haven't been here for that dysregulation discussion before, it's going from, you know, zero to 90 miles an hour in 1.2 seconds. You know, it's when somebody goes from being baseline to extreme in a flash, and then they have difficulty returning to to baseline, they have difficulty calming back down. It takes them longer than other people. Anxiety, we see this in trauma and grief. And especially after a loss, we may see separation anxiety. And this isn't just with itty bitty children. We may see after a trauma. Think about parents who lose a child, heaven forbid, and then they don't want to let their other child go. You know, they want to hold that other child close. They start having anxiety with separation, or the child doesn't want to leave. And then you have the opposite end where there's reactive attachment. The person didn't have a stable attachment when they were growing up, so they're trying to find anybody. And they tend to be overly familiar with people. And you'll see this again in histrionic behavior, dependent personality disorder, etc. Angry and irritable. Yeah, well, part of the phases of grief, denial, anger, bargaining, depression, and acceptance. So we expect anger, we expect irritability, because your world kind of gets turned upside down when there's a trauma of some sort, when there's a loss. And that activates our HPA axis, our fight or flight response. And guess what? Fight equates to anger, basically, and flight equates to fear, basically. So it makes sense that when people are undergoing traumatic grief that they will experience some anger and some irritability and some emotional ability. That totally makes sense. People with personality disorders, we see this a lot too. Now, you can chalk that up to dysregulation if you want to, but a lot of times, if the person with the personality disordered symptoms feels like they're out of control, you will see a lot more anger and irritability. Think borderline, think histrionic, think antisocial. There are a lot of characteristics there, okay? Both of them we see depression makes sense. And interestingly, in both of Them. We also see loneliness. We see loneliness in people who've experienced a trauma or grief. Sometimes they feel isolated, like no else would understand what they're going through. Sometimes they feel lonely because they lost someone. There's a lot of reasons for loneliness that as clinicians, we see that, we see trauma, we see grief, we're like, oh, yeah, that makes perfect sense. When we see loneliness and personality disorders, we typically don't think about it as being potentially related, but think about the person who experiences. They have a very unstable sense of self. They have a need for constant validation. They may feel like they are not good enough. Then you're gonna may see more loneliness, more social anxiety. Cognitively, in personality disorders, sometimes you see grandiosity, which is not something you typically see when somebody is grieving. So that's one of those. That's kind of off the beaten path, but I threw it in there because it is a common enough symptom. The rest of them, confusion and difficulty concentrating. Well, we expect that in traumatic grief, confusion and difficulty concentrating. In personality disorders, though. Well, let's think about it. When the person with borderline personality disorder feels like they've been rejected, they may get angry, they may get stressed out. The person with dependent personality disorder, if they feel rejected or they don't have somebody that is helping them telling them what to do, they may get very stressed out. Well, that stress, we know when people are stressed, they're going to have especially extremely stressed. They're going to have confusion and difficulty concentrating. So that makes sense. If the person's with the personality disorder symptoms are their life is not as they want it, and they don't feel like they've got total control then, or they don't feel like they're getting their needs met, which a lot of times they don't, then they may experience a lot of stress, which leads to difficulty concentrating, short attention span. They make sense. So asking yourself when we're talking to this person, and maybe they came in with a diagnosis of XYZ personality disorder and concurrent substance abuse and maybe major depressive disorder. Okay, well, grief's not anywhere in there. Grief's not actually a diagnosis, so we might overlook it. And I'm challenging you. Whenever you're working with somebody with a personality disorder diagnosis or who evidences personality disordered symptoms to really look for that grief. Now, they may not be ready to address that grief or see the connection, but it's important for us to start being a little bit aware. Difficulty making decisions. Well, that's true for anybody who's under a lot of stress. Whether you're under. Whether you've experienced a trauma, whether you're grieving or whether you're stressed because you still haven't coped with the trauma and grief from your past and you're feeling really out of sorts. Inability and trauma and grief, inability to find meaning in the events of life and life itself. Okay, well, again, another common one we see in grief, not surprising, doesn't really need an explanation. But what about impersonality disorders? How might this manifest itself in personality disorders? If people are having difficulty finding meaning in life, what types of things, what types of behaviors might they engage in that we deem, quote, disordered? Sometimes it's the antisocial type behavior where you know that the person doesn't care about anybody else or portrays that they don't care about anybody else. They have difficulty with empathy and they just want what they want when they want it. And it's not about meaning in life, it's about the next rush, sometimes physical. And in both trauma and grief and personality disorders, the physical effects often secondary to stress and anxiety. In trauma and grief, it's caused because of the trauma, because your world got turned upside down because of the loss you're experiencing. In personality disorders, it can be caused because you haven't dealt with the traumas and you're still topsy turvy, not feeling safe, that amygdala is firing, your HPA axis is elevated, and. Or it could be because you don't feel safe or you don't feel like you're getting your needs met. And a lot of that lack of a sense of safety and a lack of a sense of getting needs met can often be traced back to guess what? Trauma, fatigue, it's exhausting. It's exhausting to be stressed out all the time. Now, people with personality disorders aren't often startled easily, but we do see hyper vigilance. We do see hyper vigilance, for example, in the person with borderline personality symptoms who is constantly on guard, looking for somebody to slight them. People with paranoid personality disorder, they tend to be more hyper vigilant, watching for signs of somebody betraying them or going against them. Racing heartbeat, aches and pains, muscle tension, appetite disturbances, all these are really common with stress, with anxiety, with grief, with trauma. And we realize that there are a lot of people. We're realizing more and more now that there are a lot of people who've experienced trauma, gastrointestinal disturbances, and compromised immune response and increased illness. We know that when we're under Stress that we tend to get sick more easily. And there's a lot of co occurring physiological stuff. Interestingly, that co occurs with personality disorders socially. Sometimes you'll see isolation, detachment, withdrawal, avoidance. After somebody experiences a trauma, you know, they just, they don't trust the world. They don't want to be around it, it's too scary. Or they don't want to be hurt again because that was just too painful. So they're just going to wall themselves off and withdraw. Makes sense. We also see these same behaviors in personality disorders. So again, I ask you to challenge yourself and say, why would a person develop these behaviors? What may have happened to them prior to now that prompted the development of these behaviors as a protective mechanism. We don't do things that don't have a benefit. So at some point in this person's life, isolation, detachment, avoidance, withdrawal, those behaviors were functional. Those behaviors were protective in some sort of way. So what happened to them that may have made this happen? And on Tuesday we were talking about that primary attachment relationship. And in that primary attachment relationship, you know, zero to 18 months, obviously the child is generally not verbal until the very end of that period. But if there is not a primary attachment relationship or if it gets disrupted, especially before the age of six, a lot of times children don't learn how to emotionally regulate. They don't learn how to interact with others they may not trust. Especially, especially if that attachment figure disappeared for some reason, they died, they went to jail, whatever it was. And so they may not be willing to connect with somebody again because the pain was too strong. Withdrawal. We talked about that. Distrust and suspicion. Depending on the reason for what happened, the traumatic incident. People with traumatic stress may develop distrust and suspicion. People with personality disorders are often distrustful and suspicious because a lot of times the mainstream world doesn't fit the way they want it to be. And they are regularly experiencing invalidation. They are regularly experiencing things that they don't know how to control. So they tend to be more distrustful. Self absorption is really not that uncommon in trauma and grief. When somebody is just so overcome with their current grieving state or their current trauma that they can't focus on other people. It's all about them at the moment in trauma and grief. That usually lasts until the trauma is resolved. But what happens if the trauma doesn't resolve? And sometimes, you know, you know, I'll give you, give you that one. That when people go through a period and they need to be taken care of for some reason, maybe they experience a traumatic reaction. Some of those Self absorption behaviors may be rewarded or reinforced, so they may become stronger. So trauma is not the only reason for developing self absorption, but it is potentially one of them. Searching is not uncommon in trauma and grief. We search for the person, we search for answers, we search in personality disorders. You do see some searching, especially in your cluster B sort of personalities. Insecurity is common in both, as is a distorted self image. After people undergo a trauma, their world has been turned upside down. And if they are, or a loss, not just a trauma by definition, if you will, most losses involve trauma and most trauma involves losses. The loss of a sense of safety, the loss of hope, the loss of faith, whatever, and sometimes the loss of more tangible things. So they go hand in hand. But after that trauma, the person has to regroup and figure out, okay, who am I? Who am I Now, after this trauma has occurred, after this loss has occurred, and trying to try to figure that out, Gunner points out that it seems CBT could be effective to reduce many symptoms and maladaptive behaviors, personality disorders or personality disordered symptoms. But is it effective to reduce the personality disorder itself? Again, that depends on in large part on what's causing it. Is it an underlying trauma issue? We may have to resolve the trauma issues. Is it a cognitive issue? What happened that is prompting the person or that prompted the person to develop those behaviors? And obviously Marsha Linehan had wild success with dialectical behavior therapy. So there is a lot that can be done to help people learn how to address a lot of these behaviors. And that's where I would start with it is starting with what is the cause? What is the motivation for these behaviors? What is the function of these behaviors? If somebody is avoidant, how does that protect them? How is that rewarding to them? If somebody is aggressive, how does that protect them? How is that rewarding to them? And I'm going to get to explaining cluster B in just a second. Personality disordered Behavior in context. Now, you can click on this link and it will give you descriptions and characteristics of all the personality disorders. Didn't figure we needed to go over that in today's class, but if you want to look at it, you can. Personality disordered behavior must be traceable back to adolescence or early adulthood, not early childhood necessarily, as most of us were taught. So it doesn't have. Personality disordered behaviors don't necessarily have to begin before the age of 15. Now, you do still see that caveat for antisocial personality disorder, where you're looking for oppositional defiant type behaviors. But in large part we can look for the emergence of these behaviors anytime through early adulthood. 1% of children are victims of of reported abuse or neglect each year. And why do I say reported? Well, because those are the only ones we know about. How many cases of abuse or neglect go unreported? And again, my experience has been a lot, and it's unfortunate, but a lot. 37% of American children are reported to Child Protective services by their 18th birthday. Let that sink in for a second. That's more than one in three. 37% of American children are reported to Child Protective services by their 18th birthday. That is heartbreaking. But all of those children potentially experienced adverse childhood experiences and potentially experienced trauma in their little young lives. And there's a lot of people who experience adverse childhood experiences who don't get reported to Child Protective Services. Think about some of the adverse childhood experiences that were measured. Divorce. That doesn't get reported to Child Protective Services. Somebody in the household with a mental health issue or a substance abuse issue. A lot of times that doesn't get reported to Child Protective Services, does it? Are the parents maybe less emotionally available? Yes. Are the parents maybe more physically unavailable? Yes. Does it potentially disrupt that primary attachment relationship? Yes. But does it rise to the level of a CPS report? A lot of times? No. So 37% are only the ones that actually rose to the level that somebody said this needs to be reported. This is really bad mojo. 48% of US children, almost half. 48% of US children experience at least one serious trauma or adverse childhood experience by the age of 18. And you can find these stats on acestoohigh.com, childhelp.org or invisiblechildren.org I'm not just making these up because these are staggering, staggering numbers. That being said, those are the percentages in the general population. Think about what the percentage is in our clinical population. Our percentages in the clinical population are probably far higher. Which means that our percentages in the clinical population that are presenting with personality disordered symptoms probably, almost guaranteed, probably have some adverse childhood experiences multiple in their history. So how could it be functional? If you will, cluster A is your odd and eccentric category of personality disorders. Paranoid personality disorder. The person is suspicious, holds grudges, and tends to be jealous. How is it that those behaviors could be protective? And I'm asking, this isn't rhetorical. How is it those behaviors could be protective for a child or a young person who experiences some sort of trauma or loss? Exactly. I would agree. It protects them from danger if they're if they experience a trauma and then they start to be suspicious, they're like, okay, you know, people are dangerous, so I need to really be hyper vigilant. Makes total sense. If especially, you know, after a trauma. Sometimes that suspiciousness can get over generalized and people start to feel like others are. The majority of other people are malevolent, which can increase suspiciousness. They hold grudges to keep from getting hurt again. And sometimes jealousy can become prominent because they're afraid that the one person they trust going to leave them. So they may be extraordinarily jealous. Schizoid personality disorder. And obviously all of them aren't up here. I'm just hitting the ones that seem to most relate to trauma. Social detachment, restricted emotions and oblivious to social cues. Well, let's just hit number three right away. If you're socially detached and you avoid being around people, then you're probably not going to be as good at picking up social cues. Your emotional awareness is going to be much, much less. Why would somebody want to be socially detached? Well, sometimes that's not hard to ask. That's not even hard to answer. And somebody pointed out earlier that bullied youth sometimes just want to socially detach. It's like it's not worth trying because I've had too many bad experiences or the one experience I had was so bad I don't want to try again. People can't be trusted. People don't meet my needs. Thinking back to Maslow's hierarchy and that primary attachment relationship, if a young child doesn't get their needs met when they're younger, they may learn before they can even speak that ain't nobody going to take care of them but themselves. So it's important for them to watch out for number one and be detached from the rest of the world and really not care about them. Restricted emotions. You know, sometimes you have emotions and dysregulation. Sometimes you have very restricted emotions that can be protective. In some situations it is important to look at. Why is this person unable or unwilling to feel their emotions? It can be inborn. It may have nothing to do with trauma. It could be wiring in the brain for some people. Not again, not saying that all personality disorders are caused by trauma. That's not the case. But I do want you to consider how that behavior may have been functional, reinforced, and become part of that person's repertoire as they've been growing up. Cluster B are your antisocial, histrionic, narcissistic, borderline personality disorders. In antisocial personality disorder, there's a disregard for the right of others, aggression, poor impulse control, tendency to blame victims, and lack of empathy. Well, if I'm thinking about being a child, growing up in a family where there's domestic violence or where I'm being abused, then what is the abuser doing? Disregarding my rights, being aggressive, showing poor impulse control, blaming me for what happens, and lacking empathy. So it could be social learning, and there are a lot of other reasons. But how could. If it's not learned from the abuser, for example, how could it be protective? Another possibility again comes back to, did the person ever have anybody that met their needs? Was there some sort of emotional or physical neglect? Not necessarily rising to the level of abuse. So they grow up and they're like, you know what? Nobody took care of me. I'm out for number one, so y' all can kiss my little patootie. Histrionic personality. This is the overly dramatic, often overly sexualized personality disorder. This person is uncomfortable being alone, constantly needs to be the center of attention, tends to be easily influenced by others. They tend to be human chameleons. They need approval. They need attention. They need to be the center of attention most of the time in order to feel alive. They need. In order to feel calm, if you will. If they're the center of attention, then it's like, okay, the world is good. If they're not the center of attention, they feel like they're disappearing sometimes. How can this have developed from childhood trauma? Well, if the child was left alone a lot, then they may need. They may crave the attention. On the other side of it, if the child grew up in an environment where making himself or herself the center of attention eliminated or reduced some of the tension in the environment, then that may have been reinforced. In a lot of families where there's high conflict, and in a lot of families where there's an addiction, you see somebody who tends to be the scapegoat or the mascot or the hero. All three of these people tend to try to get attention on themselves. It's like, okay, y' all are dysfunctional out there. Look at me. This is one thing y' all can agree is good, so pay attention to me right now. Narcissism or narcissistic personality disorder, These people have a sense of entitlement, just like antisocial. They tend to disregard the rights and feelings of others and lack empathy and need to be admired. One of the common MIS beliefs about narcissism is that all people with narcissistic personality disorder have really flat Fragile self esteems. Sometimes they really don't. And newer research is showing that there are people with narcissistic personality disorder who tend to be very grandiose in their thoughts about themselves. And they, they do see themselves as far superior to everyone else. If somebody has a sense of entitlement, I deserve this. Where could that come from? I've worked with families before in which the family itself was just highly dysfunctional. But Junior always got whatever Junior wanted. That was, you know, if Junior started acting out, they would buy Junior something. And this could be, I'm saying Junior because male or female, if in order to pacify the teen or the adolescent, a lot of times they were bought things. There was no emotional availability, but parents were giving them things or constantly making sure that they had access to places where they could get awards or get into Harvard or whatever it was. People with narcissistic personality disorder, you know, often disregard the rights and feelings of others because it's all about them, they're superior. And if they realize that they're mere mortals, it is a devastating blow to their concept of the world. And notice I'm not saying self esteem in their vision of the world, a lot of times they see themselves as superior to everyone else. So it's devastating. If somebody points out that they're not perfect and they're not entitled to everything, they don't know how to handle that. This person tends to have an unstable sense of self. Dichotomous thinking, emotional dysregulation, impulsivity, which is often self destructive and difficulty interpreting the motivations of others. Most of us have worked with people who have borderline characteristics, if not full out borderline personality disorder. You know, they met the criteria, unstable sense of self. And a lot of times, let me back up. A lot of times people with BPD do have a significant history of trauma. So how could trauma lead to the development of these symptoms? An unstable sense of self. Who am I? If they grew up in a family in which they were not ever respected for who they were and they were somebody's punching bag, or they were somebody's, you know, errand boy, or they were somebody's something, they may not know who they really are. They may not know if they deserve love. How devastating is that to be wondering, do I deserve love? They tend to think dichotomously. Well, think young children's thinking is by definition dichotomous and egocentric. That's just how their mind works. Until they get up into the elementary school years and beyond, they think in all or nothing terms, you either love me or you hate me. So when somebody approaches a person with borderline characteristics and is critical in any way, instead of seeing it as okay, you're critical of my cooking or you're critical of the way I did that project, they see it as a total rejection of themselves. And that's devastating again because they feel isolated and out of control, which often leads to emotional dysregulation. When they feel out of control, they go from zero to, you know, 95, just like that. They are, they don't, they're not upset. They go from being okay to being devastated or enraged. They're really colorful words you can use. And then they have difficulty winding back down. Which is why we often see some impulsive, self destructive behaviors. Because a lot of times, not all the time, but a lot of times they're trying to cope with the emotional turmoil caused by this sense of rejection. Oh, rejection. So we're going back possibly to that initial primary attachment that never happened. Or you know, it could be other traumas in life that happened where they experienced rejection or abandonment and they didn't have enough coping skills or they never developed the coping skills to deal with this, to deal with regulating their emotions. They were always in environments. A lot of people with borderline personality disorder are naturally prone to emotional dysregulation. They tend to be your more high intensity children, if you will. Unfortunately, up until recently we didn't really realize that that was such a thing. So people who would emotionally dysregulate as children were regularly in environments that were invalidating, telling them, you're overreacting, get over it, straighten up whatever they were being told, but not giving them any tools to do that. So they constantly felt rejection and what's the word I'm looking for? Invalidation for how they were feeling and for who they were. Well, we can see whether that would be traumatic for a child or an adolescent or even an adult. They develop their own skills without somebody to help them address dichotomous thinking, to develop self esteem and to develop distress tolerance and problem solving skills. They're doing the best they can with the limited tools they have. As, you know, children, adolescents trying to deal with distress and rejection and people with borderline personality disorder have difficulty interpreting the motivations of others. When you grow up, as we've talked about before, or when you are regularly exposed to situations that are traumatic, a lot of times it will shape the way you perceive everything else. If your HPA axis is activated, then you're going to be Looking through a danger lens. If you're calm, then you're going to be potentially looking through a, you know, contentment lens, if you will. So people with borderline personality disorder symptoms, as well as other personality disorder symptoms, especially ones who've experienced trauma, are probably having difficulty not seeing the world through this malevolent danger lens, which is one of the ways that cognitive behavioral therapy can be really helpful for them as well as interpersonal skills. Cluster C is your avoidant personality disorders. People who are avoidant or have social disin, Social inhibition. They don't want to be out around others. They just. They feel inadequate and they're hypersensitive to criticism. Well, that one, you can totally see how that might manifest from a person who was in a domestically violent relationship in adolescence or who grew up in a household that was abusive in some way. And it can be just. It can be verbally abusive, not physically abusive, or even in a household where there's substance use or mental illness in which the parents are not able to appropriately or effectively communicate love, acceptance, all that kind of stuff, and they tend to be more aggressive and critical, yada, yada. Okay, well, I can see where you could potentially grow up in an environment that would prompt these kinds of behaviors. So that's. That makes sense. And that would be the result of childhood trauma. Dependent has a. This person has a strong need to be taken care of by others. So they tend to be very submissive. You know, it's like, I will do whatever you want. You just tell me you want the lights on, you want the lights off. Where do you, you know, you tell me where you want to go to dinner. They typically don't have a lot of desire to make independent decisions themselves. They want somebody else to caretake them. They also tend to be in more serial relationships. They get out of one and they get into another one. Or sometimes they get into a second relationship before they're even out of the first because they are so desperate to have someone there to comfort them and help them. And they can't function on their own without having somebody else sort of leading the reins, if you will. This also sometimes leads to them getting into serial bad relationships. You know, obviously there's a wide range in there. People with dependent personality disorder are often challenged to make decisions or begin a task or without help. I want you to think back to Erickson's stages. You know, we have trust versus mistrust. That's your zero to two. Then you have autonomy versus shame and doubt. In the toddler years and early Kindergarten, the child is learning to make decisions and begin tasks like getting dressed or brushing their teeth. If that is thwarted by a aggressive parent or not assisted, you know, because children don't know how to brush their teeth to begin with, then they may have difficulty making decisions. They may feel guilty if they try to do something for fear of making a mistake. And it an obsessive compulsive disorder. They're preoccupied with rules and order. They're devoted to work. They're perfectionistic and unable to delegate. We see this a lot in people with eating disorders. For example, they need things just so what would happen or what happened to a child or an adolescent or a young adult who is preoccupied with rules and order. They're devoted to work, perfectionistic, and unable to delegate. Well, that sounds to me like somebody who is trying to avoid getting in trouble, trying to avoid abuse, trying to acquire love that they may not be getting and afraid to trust. That makes sense to me. And why we can't diagnose personality disorders later in adulthood. That's the question for the DSM 5 people. But remembering, and you raise a good point. The frontal lobe doesn't fully finish developing until about the age of 24. And adolescence goes up to. I think adolescence actually technically goes up to 24. So we can potentially diagnose a personality disorder if we felt the need to up until 24. My guess would be that for personality disorders, the behaviors are so dysfunctional and impairing in multiple areas of life that a person with a personality disorder is probably going to show these symptoms or evidence these symptoms by that period of time. If they make it past that period of time, then the behaviors are probably not nearly as pervasive. But that would be. That would be my guess. Grief and trauma symptoms overlap considerably, almost exclusively. Most of the symptoms of personality disorders can be seen as adaptive responses after a trauma which occurred in early adulthood or before. Again, I'm not saying that every person with a personality disorder or personality disorder symptoms has had a trauma, but looking at the statistics, chances are really pretty dagum good that they did. We want to look before we start trying to fix the behavior, modify the behaviors in the present. We want to say how is this behavior protective for this person? Or how was it behavior, this behavior protective for this person at some point in their past? And how can we help them achieve that same goal, achieve that sense of safety or whatever? Now, with healthier coping skills and tools, clinicians should evaluate for a history of trauma and or symptoms of reactive attachment disorder, disinhibited social engagement disorder in childhood. You know, just check for that. Not everybody is. You know, a lot of people are not going to have that, even if they do end up developing personality disorders later. But people who have reactive attachment disorder or disinhibited social engagement disorder are much more likely to go on to develop significant problems if it didn't get addressed early on. Before diagnosing someone with a personality disorder, it's essential to rule out other issues such as persistent complicated bereavement disorder, post traumatic stress disorder, and substance abuse, which, as I said earlier and somebody else pointed out that substance abuse often masks ptsd. A lot of times people are coping with trauma and unbelievable emotional distress, emotional dysregulation with substances. It is a way of coping. Not a good way of coping, but it is a way that is has helped them to survive to that point. The longer the behaviors have been used, the more generalized and pervasive they may become. So if a child grows up in a household where there's abuse or neglect and these certain behaviors work at home, then eventually those certain behaviors may also be tried out at school, at work and other relationships. And the ones that are reinforced, the ones that tend to work for them, are going to be strengthened and maintained. The longer somebody's HPA axis is activated, the more cognitive, interpersonal, physical and behavioral symptoms that will develop. The longer they've got this distress going on, the more hyper vigilant they may be and the more compensatory behaviors like impulsivity and aggression and withdrawal potentially that we may see from people. Are there questions? You're always so enthusiastic, Lisa. I appreciate it. Alrighty everybody. Have an absolutely amazing weekend and you know, hopefully it warms up wherever you are and I will see you on Tuesday. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allce.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com Sponsor thank you.