Healing Trauma: A New Approach to Personality Disorders

I'd like to welcome everybody to today's presentation on the differential diagnosis of personality disorders from a trauma informed perspective. I'm your host, Dr. Donnelly Snipes. In this presentation, we're going to review the criteria for the personality disorders. I'm not going to go through each one in the objectives and then we'll identify eight common errors in diagnosis. And I'll give you a hint. A lot of them have to do with failing to differentially diagnose, especially considering the function of the behaviors and whether it's a result of trauma. Personality disorder diagnosis is something that in my opinion, and I say that because I haven't actually gone out and done an objective study on it, but doing clinical supervision and talking to clinicians, I personally believe that personality disorder diagnoses are given far too often. But regardless, we need to understand where these behaviors are coming from. Why did these behaviors develop and what function are they serving to help the person feel safe? Personality disorders must be, must be an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations in two or more areas. Okay, so there's two, well, three caveats here. Enduring pattern of experience. It's not just this week, this month, in the past year, it's something that's been an enduring behavior. They've acted this way for a long, long time and across situations. It, it's not just at work, it's not just with their significant other. It's in. It's pervasive throughout their life and it deviates markedly from cultural expectations. And I 10 I think we tend to forget this one too, that if we are in a culture or in an environment that promotes arrogance and haughtiness and lack of empathy, then is it really a personality disorder because it's not deviating markedly from cultural expectations. However, However, I will kind of put a little caveat out there that there are often settings in which a person's behavior may appear to be less kind, for example, and, but that's expected in that setting, business, for example. And, and there's a lot of debate back and forth and a lot of people that feel like their bosses are narcissists. And in reality their bosses may be poor leaders, their bosses may exhibit narcissistic behaviors at work. But we can't say that they're narcissists unless that pattern of behavior is long standing and pervasive throughout their life. And it need needs to deviate markedly from cultural expectations in two or more areas. Cognition, the way they think about themselves or others, affectivity, the Range, whether it's really flat or really intense. If it's, there's a lot of lability, it's all over the place and how appropriate it is if somebody is laughing at something that is graphic and inappropriate. That might be more on the what we might think of as antisocial behavior type scale. Interpersonal functioning. Do they function well with others or do they exploit others or do they get exploited by others? And impulse control? And I'll say it one more time, it has to differ markedly from cultural expectations in all or most areas of their life and have been a long standing behavior since childhood or adolescence. Okay, so what we're dealing with is something that we can look back and say, yeah, for as long as I've known Johnny or ever since Johnny was a teenager, Johnny's behaved this way. The behavior is inflexible and pervasive. So it's not going to change. Even if you talk to the person and highlight how it's problematic, they're not going to change. And part of that could be that they don't know how to change. Part of it could be they don't feel safe changing. They're going to hold on to this because it's the only armor they have to protect them against what they perceive as the danger out there, the behavior stable back to adolescence or early adulthood. And I typically say late adolescence because adolescence technically can go up to like 24. We think about when the, the brain sort of solidifies and stops forming in such a rapid fashion. But yeah, you know, your early 20s or before, not better explained by another mental disorder, medical condition or substance use. We need to rule out brain tumors. We need to rule out other medical conditions that may be contributing to it. Substance use is another big one. A lot of people, when they come into substance use treatment for, and they're in detox very, very early recovery, a lot of their behaviors may appear very antisocial. But when we get to antisocial, we'll, we'll talk about that. But I want you to think about what a person's feeling like at that point. Do they really have the energy to empathize when those cravings strike and those urges strike? They have had difficulty staying clean and sober before because they have succumbed to those cravings and urges. Therefore, it's likely that they're going to be manipulative of staff if they're in residential or in detox in order to try to get the drug or get relief from the withdrawal symptoms. So we, again, we're looking at why are they engaging in these behaviors and in what, what function are these behaviors serving for this person right now? Because most of the time it makes total sense to be diagnosed in someone under 18 years of age. Symptoms must have been present for at least one year, except antisocial personality disorder, which cannot be diagnosed with prior to 18. For paranoid personality, it's first apparent in childhood with solitari, poor peer relationships and social anxiety, underachieve, underachievement in school and hypersensitivity. So we see a lot of behaviors and I want you to think back to adverse childhood experiences and what a child may be learning when they're experiencing. When they're life experiences have been one of trauma or one of neglect or verbal abuse or physical abuse. Do you think they really want to spend time with others if they're constantly in fight or flight, not knowing where they're, when they're going to get punished or where the next meal is coming from or whatever it is they're not getting whatever needs they're not getting met. Do you think they really have the ability to develop social skills? I mean, think about Maslow's pyramid. You have physical needs here, your food, your shelter, your medical care, which sometimes these kids aren't getting in chaotic households. Then you have the safety level, which in these chaotic households, generally the child doesn't feel safe. Above that is love and belonging. So until they're getting those bottom needs of the pyramid, Maslow, Maslow's hierarchy, until they're getting the bottom levels of those that pyramid met, they are not probably going to have the energy or motivation to even try to form healthy peer relationships. And they may have a lot of social anxiety. If they, their experience up until now has been one of rejection, one of criticism, or one of just being ignored, then they may be anxious about engaging with others. Because remember, social anxiety is this fear of embarrassment or humiliation generally. I mean, look at little kids, 2, 3, 4 year olds on the playground. They're silly. They will do things because they want to. They're not worried about being humiliated. That doesn't come until much later unless their caregivers have or, or their family has already started shaming and humiliating them. So we're not born socially anxious, we're actually born quite social. And it doesn't come until later that we learn to fear ridicule from others. And in addressing paranoid personality type behaviors, we want to again examine what happened to this child that prompted the development of, of this reaction in relationships. Underachievement in school. We know there's a lot of things we know that we kind of forget. But we do know that when somebody is stressed, whether it's physically stressed because they're malnourished or haven't slept well, or cognitively stressed because they're afraid, they, because they're thinking they're unworthy because or because they don't trust other people and they feel anxious around others. So that social anxiety, they're in that fight orf flight state they are not going to achieve in school. They're not going to be able to engage that wise mind when their amygdala and the survival part of their brain is saying, you need to be hypervigilant, you need to be on guard. You're not safe here. Hello, why aren't you getting out of here? So the kids sitting in school going, I really hate this, I feel unsafe. And it's hard to focus on the teacher. Heck, for a lot of us, it's hard to focus on the teacher even when you feel safe because, you know, it's just, it's school. Algebra was never my thing, but for, for these children, it's ten times harder thinking about a soldier in a foxhole. And that's kind of the way a child who has social anxiety, who feels unsafe in, in their environment, that's kind of how they feel. You think they're going to. A soldier in a foxhole is going to be able to dissect war and peace. It's not going to happen because they're going to be, you know, 80% of their attention is going to safety and they're trying to wrangle in 20 of their attention to focus in school. Additionally, if they feel unsafe, if they feel unloved, if they feel misunderstood, then they may also have some depression or depressive symptoms when they're at home. They may not sleep well, they may not feel safe in their home environment, and they may be hypersensitive. And by that I want you to consider if you are already feeling unsafe, you're primed. It's like, all right, I'm primed. So then when something happens, you're going to react often stronger than if you weren't primed. So people who are hypersensitive may be hyper vigilant. They are overly aware of all the negative things or all the possible threats. So their stress response is already primed and ready to react to anything that might potentially maybe pose a threat. And sometimes we misperceive that as hypersensitive. These interpersonal behaviors and I guess cognitive for underachievement must be present before any psychotic symptoms emerge. There's a pervasive pattern of distrust and suspiciousness. They may, and the mnemonic here is suspect. They may suspect others of infidelity or disloyalty. Well, where would that come from? Is that something we're born with or is that something that we are, that we learn from our life experiences, from our attachment experiences? If we have been abandoned, if we have been rejected, if we have been ignored, if we, you know, if someone has been disloyal to us or lots of someones, then we tend to suspect people of being unfaithful or disloyal, unforgiving and begrudging. Now remember, the child thinks in all or nothing terms. All good or all bad, safe or unsafe. For some people, once they're moved over to that unsafe category, they ain't coming back. And that's where it can be perceived as unforgiving or unbegrudging or, or, or begrudging of, of others. A lot of times this is something people have learned either because it's happened to them, they've been put over into this rejection category or because other people have repeatedly hurt them in some way and they've learned that no matter how much somebody says they're not going to do it again, they're going to do it again. So I'm not going to forgive. The only way to stay safe is to keep you out. So it's all or nothing, always or never. And that's a target we can work on. In. In therapy is helping people evaluate situations. They're suspicious of others motives. If they grew up in a chaotic household, then they may have been manipulated. They may have been used by their parents to get away with things or to manipulate somebody else in the household. They've discovered that or experienced people being used as, as pawns, so to speak. So they're suspicious of anybody, especially kindness. It's like okay, if you're doing this for me, what, what's, what's in it for you? It's a transactional thing and that's the way it's always been for them or often been for them. So they expect that in the future they may perceive and quickly react to attacks not apparent to others. We talked before in other videos about projection. If someone has experienced criticism and verbal attacks in, in the past, they have started to learn the non verbals that are associated with it. The tone of voice that's associated with it. The and they may learn to expect well, I made a mistake so I expect that I'm going to be harshly criticized for this. So they are already expecting to be attacked. And other people may respond to them not intending to attack them, but since they're already expecting that, that's what they experience. Enemy or friend is the other e. And that kind of goes back up with unforgiving and begrudging. You're one or the other. There's no middle ground. And that's the way the child stayed safe. And they haven't learned any other way. They haven't learned how to trust people because ostensibly they were probably in an environment where there were at least some people who were untrustworthy and so they had to protect themselves. But they, as children had difficulty differentiating. Well, this person is untrustworthy, but this person is trustworthy. Children have difficulty with that. And you can go back and review Piaget's stages of cognitive development, but confiding in others is feared. Now remember that in avoidant attachment, a lot of times the child, when they admitted any pain, when they asked for help, when they admitted mistakes, they were harshly criticized. And so now they have fears of confiding in anybody else about their thoughts, their fears, their wants, their needs. Same thing is true in households where there's addiction and other chaos. Don't talk, don't trust, don't feel. It's just not safe. And that's what people learn. Threats are perceived in benign events or remarks. The person with paranoid personality and oftentimes who has an extensive history of, of trauma, has been attacked, has been neglected, has been criticized. So they've either been verbally or physically harmed by people in the past. So they're hyper vigilant to that. And it could be the way you say something that leads them to believe that you're threatening them in some way. I had one client I worked with who did not have paranoid personality but had schizophrenia. And he believed that T H e that word, T H e was someone attacking him. He believed that when someone said that, it was a direct insult to him and a threat. And they were, as he would put it, damning him to hell. And think about how hard it is to talk for even a couple of sentences without using that particular word. You know, I'm trying not to use it right now, and it's, it's difficult. So most people aren't going to think anything about that particular word. But for him, that was associated with trauma now or, or threats. Not sure exactly where that came from with him. I was a very young clinician when I was working with him, but it Certainly is interesting. Instead of saying someone's overreacting or thinking that they're misunderstanding what's going on, maybe they're misperceiving somebody's intent. But their experience is one of threat. When they've experienced something like this before, it's been one of threat. So then their guard goes up. In terms of schizoid per personality, we talk about the mnemonic. Distant, detached, indifferent to criticism or praise. Sexes of little interest. Tasks are done solitarily, Absence of close friends. Neither desires nor enjoys close relationships and takes pleasure in few activities. So let's go through those again from a trauma informed perspective. Detached or flattened affect, they seem to lack emotion and react passively to adverse circumstances. Okay, is it that we have this as part of something that is going on in their brain that is not related to trauma? Or do they have a detached or flattened affect because it hurts too much to feel? Because they've gotten their hopes up so many times and been disappointed so many times that it hurts too much to feel? And when bad things happen, it's just like, yeah, kind of expected that. So they actually don't get emotionally charged. And that can result after extended, extended trauma. When the HPA axis, the stress response system, basically gives up, it quits working. It says, you know what? We've been doing this for too long. I'm burned out. I just. I can't do it anymore. And so the person is not going to be feeling the same way. They may be indifferent to criticism or praise. If they've been criticized a lot, they may have developed a barrier to that. But they also, when somebody praises them, it may not mean much to them, partly because they don't have a lot of energy to invest in emotion right now. So when somebody praises us, it makes us feel good and makes us feel happy. But if they aren't feeling right now, then praise ain't really gonna make much difference. And criticism probably not either. Just. They're just like, yeah, you think I suck? Okay, goodbye. Sex is of little interest. Well, when dopamine is low, when motivation's low, when there is no emotional charge to go after sex, it will be of little interest. When the HPA axis is dysregulated, it alters the hpg, or the hypothalamic pituitary gonadal axis, which actually reduces sex drive in most people. So we see the body saying, hey, there's too many threats out there, not the time to procreate. So all of those hormones that would promote sex drive and libido they're not there, they're not activating those receptors. Tasks are done solitarily. Well, that sounds to me like somebody who learned that people aren't safe. They're a lot of trouble. And if you want something done right, you do it yourself. We want to explore with clients, if you like doing things by yourself, why. Why is it that you prefer to do it by yourself than with others? Did you have experiences in the past where you did things with others that you didn't go well? Did you have things in the past that you did with others that did go well? Just try to understand what that behavior is communicating about their desire to be around others and their sense of safety around others. They have an absence of close friends. A lot of this sounds like that avoidant personality that we were talking about. It sounds like avoidant attachment in many cases, absence of close friends. If people have let you down, if people have caused you stress and trauma, and you're to the point that you have this flattened affect, you have difficulty feeling happy or motivated about anything, you're probably not going to be real jazz to go out and start trying to make friends. They neither desire nor enjoy close relationships, and they take pleasure in few activities. Well, if you lack emotion, it's hard to take pleasure and stuff. You know, that's. Some of these seem a little bit redundant to me, but is what it is, there's not much that really makes them happy. They get along throughout the day. It reminds me a lot of. Of Eeyore. In terms of differential diagnosis, we want to rule out paranoid personality. Are they paranoid or avoidant personality? We want to rule out addiction, especially to depressants or opioids. When people are using especially depressants, their affect's going to be flat, and they may kind of be in. In this zone, in this haze where they don't care about much. Sometimes they may not have a lot of interest in sex because they're, you know, so chill. And they might not desire or enjoy close relationships because that may feel like a threat to their addiction. We want to rule out persistent depressive disorder, any psychotic disorders, and. And autism spectrum disorders. Schizotiple is another personality disorder that we have that involves magical thinking and experiences unusual perceptions. And this differs from schizoid personality with these are the two characteristics that make them different from skizoid. It is important to understand that magical thinking and unusual perceptions are probably not going to be the result of trauma. So there's something else going on here. If you start seeing some signs of Psychosis, but not always. Children engage in magical thinking and if they had a lot of severe trauma or when they were very, very young, you may see magical thinking in adulthood. Paranoid ideation is another thing. If you've regularly experienced trauma or unsafeness from others, then you're probably going to expect it. So it looks to others as paranoia may be that person protecting themsel based on their past experiences, eccentric behavior or odd appearances. This is another one where the ch person, child or person may sort of march to the beat of their own drummer. They may have some eccentric behaviors that aren't, you know, what you would consider totally normal or typical in your culture. But it may just be something that they've always done. It may be a way they found to self soothe in in their life. The odd appearance may be a perceptual disorder. Constricted or inappropriate affect. So you may have constricted affect. Again, the person is, has a flat affect, not really reacting the way you would expect, if at all, or sometimes inappropriate affect. They may laugh when you would expect them to cry or. Well, that's, that's generally the example we give. And, and sometimes this is a behavior that develops because it wasn't safe to cry. So they had to learn some other way to emote when they were feeling devastated or terrified. Unusual thinking or speech different than what you and I think. And we have to look back and understand it from that person's perspective. Now sometimes they may have some psychotic features where their experience of the world is very different than ours. They may see the sky and they think it's purple. It looks purple to them, it looks blue to us, but it looks purple to them. We can't argue. We don't know exactly what they're seeing, but we may think that it's different. So they may be thinking differently because they're perceiving the world differently. They make lack close friends. They may have ideas of reference and anxiety in social situations. Schizotypal is not usually the result of adverse childhood experiences and and chronic trauma. However, we can see how this could be in and of itself a traumatic experience. If you have schizotypal personality disorder, and I hate the word disorder, but if you have schizotypal personality in a neurotypical environment, you may get a lot of criticism. Parents may say, you know, you're making things up, you're lying, you are. Whatever their eccentric behavior, their understanding or experience of the world is so different from their peers. They may have an inability to, to make close friends which, and receive A lot of criticism and bullying which may lead to anxiety in social situations. So we want to again look at where did these behaviors come from. Even if trauma doesn't fully explain it, we need to see how the person may have experienced or may be experiencing trauma as a result of the diagnosis. Now we do need to rule out psychotic and developmental disorders. The avoidant personality cringes. That's the mnemonic here. Certainty of being liked before getting involved. They've experienced rejection so much that they're not putting themselves out there. Rejection preoccupies their thoughts. Intimacy is restrained due due to fear of getting shamed. They don't want to share emotionally, they don't want to share physically. They don't want to share cognitively. So they don't share their thoughts, wants, feelings, needs or person with other people because they're afraid of being shamed or criticized. And we have talked in the past about how avoidant attachment develops as the result of regular severe, harsh criticism and shaming behaviors on the part of caregivers. N stands for newly relations. New relationships are inhibited even if the person is certain they're going to be liked and they say okay, maybe I'll try to be your friend. They are often very, very slow, very very slow to warm up because they've been hurt so much in the past. They get around occupation occupational activities involving others. If they are assigned group work or if they have to go to a meeting with others, they do everything they can to get out of it. If that means calling in sick, if that means having an emergency in their department, whatever it is, they protect themselves from being around others because they're, they've got so much social anxiety and they need to avoid the danger that is other people. Embarrassment produ prevents new activity. That's a straight out of the social anxiety diagnostic grid. And they view themselves as unappealing or inferior. Have very low self esteem. Now if you grew up in an environment where you were regularly getting shamed and criticized and rejected for who you were, what you looked like, what you did, and you expect others to humiliate you and embarrass you, then you can see how a child might develop the schema of themselves as unappealing or inferior. They're like, you know, my parents said that I was, you know, a screw up and my, the people that I have been going to school with have always criticized me so I must be inferior. Unappealing. And we also need to recognize that the, the behaviors that are initially created often end up creating self fulfilling prophecies because people who have been criticized, who have, you know, developed these behaviors to protect themselves from abusive, neglectful caregivers, they may expect other people to act the way their caregivers do. So they react toward other people the way they do toward their caregivers and create that environment. Now, I don't want to victim blame here by any means, but we need to help people examine their part in relationships not working out, for example, if they wanted to. With avoidant personality, it's important. Well, with any personality disorder, it's obviously important to join the person where they are as much as you can and to figure out what is it you want from life. How do you define a rich and meaningful life? A person with avoidant personality may never want to get married and have three kids and, you know, be a CEO of a company. That's just not something they even fathom. So we want to make sure we're helping them work toward their definition of a rich and meaningful life. You do want to rule out body dysmorphic disorder, eating disorders and social anxiety. And it is really difficult to differentiate avoidant personality from social anxiety. A lot of it has to do with the, with the onset, the timing of it. In terms of dependent personality, you have the mnemonic reliance. They need reassurance for decisions. They express, have difficulty expressing disagreement, their life responsibilities are assumed by others. Initiating projects is difficult, alone is feels awful for them. They, they really need to be with somebody. They feel very much incapable of taking care of themselves. Nurturance is needed constantly. Companionship is sought urgently and exaggerated fears of being left to care for themselves predominate their thoughts. So let's go back over that again, thinking about how this could evolve from trauma, from adverse childhood experiences. If they've made wrong decisions before and it's caused a problem. If a child makes a wrong decision, does something wrong and then there are as a catastrophic event, even if the two are unrelated, like the child told his, his parent, his parent, I hate you and goes to his room and then the parent has a heart attack and dies that night. God forbid, the, the child may believe that they caused that. Because children have that kind of magical thinking, personalized, everything is my fault, whatever I do, whatever happens is my fault, or because of me, all or nothing thinking, all good or all bad. So if they've had experiences where they believe they've caused bad things to happen, then they may need reassurance for any decisions. Expressing disagreement is difficult because they fear rejection. They feel more like an 8 year old, even if they're 38, they feel, feel more like an 8 year old and they fear and feel and believe they are incapable and incompetent in taking care of themselves. Their life responsibilities are assumed by others. Now this is sometimes an enabling behavior that we see because someone who is afraid of doing things, someone who requires constant reassurance and some of these other things, they may have people in their life that jump in and take over. The codependent person who wants to be indispensable, who needs to be needed. And so a lot of times you'll see dependent personality. With someone who has history of codependency or even anxious attachment. It's like, okay, you need me, I need you, we're just going to glomp together. Initiating projects is difficult due to low self confidence. They've never had to do it. Somebody else has always done stuff for them so they don't believe that they can accomplish anything. In therapy we need to help people learn how to set goals and accomplish small goals and very, very small independent personality. Alone. The person feels helpless and discomfort when alone because they're afraid that somebody's not going to come back. Like that eight year old when it starts to get dark out and mom and dad aren't home from work yet, that 8 year old starts feeling a little, you know, squirrely. Same thing for the person with dependent personality. It's like, you know, what if that person doesn't come back and, and then their mind may go to all these places like what if they got hit by a truck or. And they never come back. Nurturance is constantly needed and the person may go to excessive lengths to obtain nurturance from, from others. They may give and give and give to someone just to get a little bit in return. You know, just for somebody to say I appreciate you. They may go way over, above and beyond in order to get that nurturance. It's like the lifeblood. Companionship or other relationships are often urgently sought. When one relationship ends, they feel very uncomfortable again being alone because they don't feel competent or capable against doing what they need to do. And the world out there, even calling and making a doctor's appointment or something is terrifying. So as soon as one caregiver leaves, they find another caregiver and they have exaggerated fears of being left to care for themselves. And we need to consider what happened in this person's life that made them believe that they were completely helpless and powerless to function as an independent person. You want to differentially diagnose it from separation and generalized Anxiety. A lot of times people with dependent personality have grown up in environments in which they were shamed for trying to express tiny independence. They, their caregivers were enmeshed with them, they weren't allowed to talk, they weren't allowed to trust, they weren't allowed to feel. You know, the same thing we talked about in households where there's an addiction or mental illness. It's just everything is determined by the lead identified patient in the family whether they have depression, anxiety or addiction. The entire family's rhythm on any given day is based on how that person is doing. So you're not supposed to think for yourself. You're not supposed to initiate anything because unless you are told to. Antisocial. Now this is one of those that I really. Well, corrupt is the mnemonic. Conformity to law is lacking, obligations are ignored, reckless disregard for safety of self or others, Remorse is lacking, underhanded or manipulative planning is insufficient, and their temper is irritable or aggressive. I want you to think of that child who's growing up in a chaotic household or a person who's experienced, you know, ongoing trauma and their HPA axis, their stress response has started to dysregulate. So when they get angry, they get really angry, but. Or they are just constantly irritable because they're constantly feeling unsafe. When you are stressed out, do you tend to be more impulsive? You know, just, I'm going to do what I want to do to make myself feel better or I want to make the pain stop or fine, okay, I'll do it. Just, just shut up and quit bothering me because I'm already overwhelmed with everything else. So we tend to be more impulsive when we're stressed. We tend to have. A lack of remorse when we engage with others. When people who are antisocial are engaging with others, they don't care how other people feel and think about the child. Growing up in this environment, nobody cared how they felt. And so they didn't learn that skill of empathy. They didn't and they didn't develop in an environment where anybody showed empathy. We learn what we live. So they may have been abused, they may have been neglected, and their caregivers had no remorse. Their siblings may have been awful to them and had no remorse because remorse wasn't something that was taught and that creates an environment where that's scary. I mean, if people around you are hurting you and have no remorse, it's like, ah, you know, who can I trust? Reckless disregard for the safety of self or others. That goes along with impulsivity. And oftentimes that disregard has to do with achieving some making the pain stop. Whether it's getting drugs or being the most important drug dealer on around. So you have infamy and you have power, whatever it is. But there's a reckless disregard for others safety and aent a lot of impulsivity in order to get what you want, which is very common in children and a very common strategy. And if it's been working for them, then they're going to keep doing it. We don't change our behavior until it doesn't work for us anymore. Conformity to law is lacking and obligations are ignored. Now these kind of overlap. When people grow up in an environment where nobody cares about them and doesn't, they don't teach them what's right and what's wrong, then they kind of develop their own moral code. And we can see that. We also see on a slightly different track people, as I mentioned earlier, people who are in early, early, early recovery are often in a lot of pain. Emotional pain because they're thinking thoughts now and they're feeling feelings now and it really sucks. But also physical pain because their endogenous opioids, their pain management system is also all screwed up. So they may ignore obligations in order to use. They may break the law in order to access their substance or behavior of choice. They may disregard their own safety in order to get that drug. They may have no remorse if they spend down their kids entire college fund on their, on their gambling habit. They may manipulate others to try to hide their addiction, to try to hide what they're using to quell their pain, what they're using to survive, Their planning may be very insufficient. And they may be very impulsive, especially if they're craving, if they're in, in early withdrawal, if they haven't gotten a hit lately. And they tend to have an irritable and aggressive temper. When we are in physical emotion or emotional pain or we're just cognitively overwhelmed, those are all registered as stressors in our brain. And it triggers that stress response which makes puts us into fight or fleet. It makes sense that people who are in active addiction and or early recovery often exhibit a lot of antisocial behaviors. However, once they get clean and address the issues that caused them to use, that they were numbing, that they were running from, a lot of these behaviors tend to dissipate. We want to have. This person must have symptoms of conduct disorder before the age of 15, which is another reason why we can't Diagnose a lot of our CL addictions clients with antisocial personality because these behaviors developed in concert with the addiction and they didn't have conduct disorder as a child. And we want to differentially diagnose from addictive disorders and as well as bipolar disorder, specifically mania or hypomania. And people who are in a manic episode can have all of these symptoms, but it is confined to a manic episode. When they're not in their manic episode, they're not experiencing that borderline personality. This is the one I mentioned earlier that is most often associated with, with trauma, traumatic childhood traumatic history. The mnemonic for this is am suicide and I don't like it. But it is what it is. When we think of people who have borderline traits, they tend to, it feels like they tend to be more likely to engage in self injurious behavior or, or suicidal ideation and behaviors. So we're going to talk about why that is. All right. Abandonment. The person with borderline personality has often experienced repeated abandonment and usually has attachment trauma. That initial secure attachment was disrupted for some reason, whether it was by aces. Well, I guess it would be aces. If the primary caregiver dies. That's one of those aces. So their primary attachment was disrupted. So they've got attachment trauma and now fear abandonment constantly because that one person that was supposed to help them survive poof, disappeared. M stands for mood instability and marked reactivity of mood or disregulation. Well, when you're constantly fearful of abandonment and your stress response is on, then you're going to start having that dysregulation as the stress response, as your HPA axis becomes more dysfunctional, dysregulated. So you're going to have more flat to furious. And I have other videos that explain how the receptors for all those stress chemicals start becoming tolerant to stimulation. Just like people become tolerant to alcohol over time they need more in order to feel the same high. Well, the same thing's true with our stress chemicals. Over time the brain starts saying yeah, that's not even enough to worry about. You know, I'm not. That's not going to activate the receptors anymore. It has to be more. And so eventually they have to have that tsunami of stress chemicals to even activate the receptors. S is for suicidal or self injurious behavior. Now why? Well, if you're fearing abandonment, if you've got mood instability, if you've got some of these other symptoms we'll get to in a minute, it can feel very hopeless. You can feel very powerless, it can feel very bleak. And for some people that may feel like it's never going to end and it's completely intolerable. And we may see some suicidality in terms of self injurious behavior. On the other hand, a lot of self injurious behavior is non suicidal. Not saying they can't take it too far and accidentally kill themselves. It very possible. But a lot of non suicidal self injurious behaviors are coping skills designed because the person can. Number one, when they do activates those endogenous opioids and helps them feel a little bit better. Number two, they can control the pain. They can make it stop. Number three, because of the pain, they're focused on something external again that they can control, not something internal like their mind and their feelings that they feel unable to control. So NSSI does non suicidal self injury again does make sense as a way of trying to at least temporarily escape from those intrusive thoughts and memories of past traumas and abandonment and rejection. U stands for unstable and intense relationships. We've talked about that. People who have had severe abandonment and have difficulty knowing who they are often cling to someone. Someone who will hopefully provide the love and acceptance and security that they haven't gotten yet. And when that person doesn't automatically just fall head over heels in love with them, they are hyper vigilant to any signs of, of potential abandonment. And that when they feel that they get angry, they feel un, they feel vulnerable, they feel uneasy. And it probably reminds them of prior rejections which intensifies the anger which can lead to arguments and disregulation and a lot of intensity in the relationship of I'm either furious with you or you're the best person on the planet. But there's no middle ground. Impulsivity in two potentially self destructive areas could be spending and alcohol use. It could be spending and non suicidal self injury. There there's a lot of things. Control of anger is difficult and this goes with that disregulation. When people whose autonomic nervous system has become miscalibrated when they get upset, their anger tends to be extreme because they're going from flat to furious. And we need to recognize that it is a neurological response. Can we help them heal their autonomic nervous system? Yes. However, it's not just something they can think away and suddenly respond emotionally the way someone without trauma responds. They often have identity disturbance. A person with borderline personality or who's experienced a lot of abandonment and rejection has often tried to Be a chameleon. I will be whatever you want me to be. Just don't leave me. So they don't even know who they are anymore. They define themselves by who or who they're with. I'm so and so's spouse, I'm so and so's daughter, I, I'm so and so's, you know, whatever. But they don't know who they are. And they don't even a lot of times know what they like. It's just I don't care if you love me. Then I'll like whatever you like. And there's dissociative or paranoid symptoms that are transient and stress related. When they start to feel stressed, when they start to fear abandonment, they may become more hyper vigilant to signs of rejection or abandonment which is perceived by others as paranoid. And they may dissociate, they may just check out because the pain is just absolutely too much. And they may have chronic feelings of emptiness. In terms of differential diagnosis we need to look at addictive disorders because people who are in active addiction may exhibit a lot of these symptoms. Fear of abandonment, they've gotten a lot of rejection, they know they've screwed up. So they may fear abandonment and rejection by others. They also may have mood instability because as the drugs ebb and flow from their system it's unstable. They may have a lot of suicidal ideation and we want to think back to what are they becoming aware of. As they come out of their substance induced intoxication they start realizing what they've done or haven't done. They may have unstable and intense relationships in order to get by. They tend to be more impulsive in order to access their access their addiction of choice or protect themselves from getting found out from having their addiction found out. They may have difficulty controlling anger when they're experiencing substances or detoxing from substances. They may have identity disturbances and the chronic feelings of emptiness because they feel like nobody understands who they are. So to differentially diagnose we want to rule out. Oops. To differentially diagnose we want to rule out addictive disorders, depression, generalized anxiety, intermittent explosive disorder, which would explain some of the self injurious behavior, impulsivity, anger, bipolar disorder, particularly mania, paranoid personality disorder, antisocial and dependent personality. Now it is very common for borderline personality symptoms to co occur with depression, anxiety, bulimia and ptsd. Now if PTSD can explain, fully explain all the symptoms and then we would not give a BPD diagnosis, that means the trauma had to happen before the Behaviors developed. According to statistics, borderline personality behaviors may be as high as 6% in primary care, 10% in mental health, and 20% in psych hospitals. If you review the diagnostic criteria for complex post traumatic stress, however, you will see that in many cases people who've been diagnosed as B with as having borderline personality actually better meet the diagnosis criteria for complex post traumatic stress. And the CPTSD diagnosis in the ICD11 fully explains all their symptoms. Nearly 50% of individuals with a borderline personality diagnosis in early adulthood do not meet criteria 10 years later, but the diagnosis travels with them. People say, oh, you were diagnosed as borderline, while nobody ever recovers from that, so you're still borderline. Well, if they're asymptomatic, that kind of flies in the face of a pervasive pattern enduring pervasive pattern of behavior. So that underscores the fact that nearly 50% of individuals with a BPD diagnosis in May have actually had some other diagnosis, particularly trauma related diagnosis that they potentially have dealt with maybe in therapy or something. So that that's a really interesting little caveat that we want to look at. Many adolescents and young adults display borderline characteristics as they develop identity, adjust to independence and resolve their existential conflicts. We need to evaluate the behaviors that we're seeing and again look and see if they are radically different from what is culturally expected or developmentally expected. Adolescents have those hormones going crazy in in their mind and in their bodies, which can prompt a lot of emotional behavior in impulsivity, anger. Remember, their prefrontal cortex is not fully developed yet. So by de developmental definition, they tend to be more impulsive. Whoops. Histrionic behavior. The mnemonic is praise me. They tend to be prod, provocative or sexually seductive. Their relationships are almost awesome. Wow. Relationships are often considered more intimate than they actually are. They need attention and they need to be the center of attention. They're influenced easily. Their style of speech is impressionistic and lacks detail. They'll say whatever you want to say, however you want them to say it. Their emotions rapidly shift and are often shallow. They'll be your best friend if that's what you want them to be, but they're not really feeling it. They're just kind of putting it out there. They're acting it, but they're not feeling it. They often present as made up or having a physical appearance designed in such a way to draw attention to themselves. They have makeup on or they're dressed from head to toe in this fancy outfit. You, you know, their shoes cost $1,400 or something. So that they are drawing attention to themselves and their emotions are often exaggerated. Now again, we want to look. Is it that they're exaggerating their emotions or are they disregulating? Are they going from flat to frantic, flat to furious? Now with histrionic the other emotions might be they may be gushing with love and seeming to overly exaggerate how they're feeling. In families where someone is experiencing adverse childhood experiences, these behaviors may have protected them from the abuser. These behaviors may have redirected attention to them from. In order to take attention away from someone else. So the histrionic behaviors may have been a way of surviving. In addiction, we talk about the different roles in the addicted family. We have the. The hero who always succeeds. We have the mascot who tends to draw attention to themselves. We have the lost child. You know, are a lot of different roles in there. But examining, as I've said like six times already, going to say it again, examining the function of the behavior, in what way does being provocative help you feel safe and empowered? When did you learn that being pro provocative would help you feel safe and empowered? And how else might might you do that? Narcissistic mnemonic is special. They believe that they're special or unique. They're preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. They have a sense of entitlement. They're conceited. They have in. They engage in interpersonal exploitation. They tend to be arrogant and lack empathy. Like any other DSM 5 TR diagnosis, none of these personality disorders require all of these symptoms. So you can have somebody who's narcissistic or has narcissistic personality disorder and they are not presenting as entitled and they do present as having empathy, but they have all the other symptoms. So just saying that someone who has narcissistic personality or antisocial personality means they don't have empathy is wrong because you can have it is possible. It's rare, but it's possible anyhow. Thinking about, and I know we're running short on time here, thinking about the function that these behaviors served the to help protect the child in a chaotic environment is important. If they grew up in an environment where they were constantly feeling criticized and rejected, then they may have had to succeed because their the love they got was based on conditions of worth. Or they may have grown up in a household where they were constantly told that they were special and unique. And if they didn't live up to that, then they were harshly punished it's like you can do better than that. You can be the valedictorian, you can go to the Olympics, you can do this or that. Preoccupied with fantasies of unlimited success. Again, this can be a reaction to experiences in someone's life where they want unlimited success to get out of where they're at. Or it can be the other way around. They may have experienced unlimited success because their caregivers or family made sure it happened and now they don't know how to deal with it. If they fail, they believe that they have to have that. That sense of entitlement is something that also can be learned or it can develop. When someone grows up in an environment where they haven't had anything and they see others having a lot of stuff, then they may start feeling, well, I'm entitled to it just as much as they are. And that grandiose sense of self importance sometimes, especially in narcissistic personality, it can develop because that's they were always taught that they were number one. They went to this school, they're from this family, they're, they're all that in a bag of chips. Or it could have developed to cover up from a low self esteem and they try to make others believe that they are super duper important. In order to avoid rejection, we want to differentially diagnose narcissistic behaviors with psychotic disorders and delusions of grandeur. Antisocial personality and again, manic or hypomanic episode. In bipolar disorder, Obsessive compulsive disorder the person often loses the point of the activity due to preoccupation with detail. And that mnemonic hears law firms, so they lose the point of the activity due to preoccupation with detail. Their ability to complete tasks is compromised by perfectionism. Worthless objects are retained, they just can't throw things away. Friendships and leisure activities are often excluded due to a preoccupation with work or perfecting whatever they're doing. Inflexibility, scrupulousness and over conscientiousness are often hallmarks of their behavior. They're often reluctant to delegate, miserly toward themselves and others, and stubborn. If the person received a lot of criticism when they didn't do something right, or if the person only received love, they were ignored unless they did something perfect. Then they may develop those perfectionistic tendencies and focus on doing that instead of engaging with friends and leisure activities that they don't feel are going to help them be more loved and worthy. The inflexible, scrupulous, over conscientiousness often results from growing up in an environment in which either they experience this and their caregivers were this way, or again, their caregivers were the opposite. So they have decided, I'm not going to be like them. And so they evaluate ethics, values, morality in a way that is super intense and super inflexible. It has to be this way. If it's not, then it's not. Right. You want to differentially diagnose obsessive compulsive personality disorder with autism spectrum disorders, social anxiety, schizoid personality, hoarding disorder and obsessive compulsive disorder. Now remember obsessive compulsive disorder as opposed to obsessive compulsive personality disorder. In OCD you have the repetitive behaviors. In OCPD you tend to have somebody who is very inflexible, follows the rules, perfectionistic, type A and then some. We need to make sure that we don't confuse problems with acculturation. Is what they're doing something that we don't like but is actually expected in the culture. We want to consider the influence of the individual's culture, including intergenerational PTSD and how that may impact them and maybe cause CPTSD in them. Shared values, beliefs and customs, a common pattern or style of communication or language that we're not used to, that seems inflexible or seems rude or unempathetic to us, but not to them or the geographic location of residence and the behaviors and beliefs that are expected in that culture. Some ethnic groups also display culturally related behaviors which should not be confused with paranoia, avoidance or dependence. We need to make sure we don't misdiagnose based on stereotypical gender roles. A lot of times females are diagnosed more often with borderline histrionic or dependent personality and males with antisocial or narcissistic because those stereotypical gender role behaviors are can be confused with a personality disorder. Personality traits are only personality disorders when inflexible, maladaptive, persistent, and cause functional impairment or subjective distress. We want to differentiate personality disorders from mood disorders with psychotic features. Paranoid, schizoid or schizotempal personality disorder must not have, include must not have occurred exclusively with within schizophrenia, bipolar or depressive disorders with psychotic features, including postpartum depression with psychosis. Personality changes may result in from PTSD, including lack of interest in social relationships, solitariness, affect, flattening, irritability, pessimism, lack of trust, hypervigilance, a need for control, and avoidance of reminders of the event in Terms of addiction, addictive disorders. About 47% of people with addictive disorders are also assigned a personality disorder diagnosis. We need to reassess that and figure out did the behaviors develop as the result of trauma or did the behaviors develop during the addiction. We want to differentiate from autism spectrum disorder in terms of social emotional reciprocity, non verbal communication, relationship skills and absence of interest in peers. Deficits in imaginative play, hypo or hyper, reactivity to stimulation, insistence on sameness and inflexible adherence to routines and highly fixated interests. You can see how some of these behaviors overlap with symptoms of many of the personality disorders. But we need to look at ASD first and give that diagnosis. If that better explains it. Neurobehavioral disorder associated with prenatal alcohol exposure used to be called FASD. People with FASDs often have impairment in mood and behavioral regulation which results in high rates of suspension and expulsion. So you may see what looks like antisocial behaviors or conduct disorder in people with FASDs. Their social communication may be overly friendly with strangers. They may have difficulty reading social cues, difficulty understanding social consequences and be easily manipulated. They can, they can look very much like they've got dependent personality disorder, or they can be manipulated to do things that may actually appear as antisocial when they're actually trying to please someone else that's manipulating them. People with FASDs are at increased risk for ADHD, depression, anxiety disorder, post traumatic stress, oppositional defiant disorder and conduct disorder diagnoses. Personality disorders represent a long standing and pervasive pattern of behavior which causes impairments in psychosocial functioning. Many people with uncontrolled mood and or psychiatric disorder psychotic disorders may display symptoms resembling personality disorders. For a PD to be diagnosed, the other conditions must be brought into remission and or the pattern of personality disorder behavior must have existed before the onset of the mood or psychotic features. So if they've got depression and personality disorder, depression with psychotic features and a personality disorder diagnosis, potentially before we can give them that personality disorder diagnosis, the depress depression with psychotic features has to be brought into remission. So we can see if those personality disorders remained. Same thing with addiction. Many treatment centers have restrictions against admission of persons with personality disorders asserting they need a higher level of care. But then when the people finish that higher level of care, they have nowhere to step down to. So we're creating a situation where there's a huge gap in services.