Triggering in NPD, BPD, Trauma, Addictions, Compulsions

Trigger Alert: My name is Sam Vaknin. I'm the author of *Malignant Self Love: Narcissism Revisited* and a professor of Clinical Psychology. Today, we're going to discuss what else triggers Capson, and Capson—not trigger. A trigger is defined in a dictionary this way: especially of something seen or heard, causing someone emotional distress, typically as a result of arousing feelings or memories associated with a particular traumatic experience. As far as it goes, that's a great definition—all-encompassing and pretty accurate. But triggering is involved not only in post-traumatic conditions.

Consider, for example, addictions. When an alcoholic comes across alcohol, the alcoholic is triggered by the alcohol. The alcohol arouses feelings, memories, and modifies behaviors. The alcohol causes the alcoholic to drink. Same with a junkie and his drugs. Same with a loved one. When—when you're infatuated or limerent and come across your loved one, you react; your physiology changes, your cognitions, your emotions, your behaviors; you utterly changed and transformed by the experience of having come across a person who is the subject and the target of your—of your infatuation or limerance. So, love is based on triggering; addictions are based on triggering; and post-traumatic conditions, or post-traumatic responses, or post-traumatic disorders are also based on triggering.

But pay attention to a fascinating difference: In addictions, the trigger is irresistibly and compulsively desired. The alcohol—the alcoholic desires the alcohol; the junkie desires his drug of choice; and you, if you're in love, desire your loved one. So triggering occurs, but the trigger is irresistible; it's positive; it's compulsive; but it's also desirable. It is, in other words, perceived to be benign and beneficial. Same dynamic, same mechanism, same progression of internal processes, and then trans—which are translated into external behaviors—all identical. But in addictions—and love is an addiction—in addictions, the trigger is perceived or misperceived as positive. Of course, alcohol and drugs are not positive, and your loved—your loved one may prove to be very, very negative in due time, but they are perceived as positive. They create an approaching behavior. When the alcoholic is faced with alcohol, he wishes to approach the alcohol. When you're faced with your loved one, you wish to approach your loved one. Your par—more in trauma, on the other hand, in the wake of trauma, the trigger is perceived as negative, menacing, frightening, and is best avoided.

So, while in addictions the trigger creates an approaching behavior, in post-traumatic conditions the trigger creates avoidance—exactly the opposite. And while in addictions the trigger is perceived as desirable, positive—the trigger is craved and wanted—in trauma and the aftermath of trauma, the trigger is perceived as a threat, something best shunned. And the person who is traumatized—the traumatized patient or the traumatized person, traumatized client—they do their best to avoid triggers. They actually reconstruct their lives so as to avoid triggers: to avoid a specific location, specific smells, specific sounds, and more, and of course, specific people. And so we're beginning to see that triggering is not always the negative thing it is made out to be. Triggering is simply a bridge between stimulus and reaction to stimulus, which could be arousing, could be frightening, could generate paranoid ideation, could generate suicidal ideation; but the linkage between the stimulus and the resulting ideation and the resulting behavior—this linkage is what we call triggering. And again, it's not—not always negative.

Compulsions can be conceived or described to perfection as addictions. The compulsive person is addicted to a ritual that usually involves objects, other people, or inanimate objects, and this ritual is repeated regularly, and it's repeated regularly in a way that is essentially, or at least resembles essentially, addiction. Indeed, many addictions involve ritualized actions. For example, junkies consume drugs in a highly ritualized manner, and these highly ritualized aspects of addiction can be described in a satisfactory manner, in a comprehensive way, as compulsions. They are many compulsions which are antisocial and dangerous. I'll mention, for example, sadism, especially sexual sadism, pedophilia, and there are other compulsions which are benign and harmless, and there are compulsions which are—could even be perceived by society as commendable. These are sublimated compulsions. Compulsion, therefore, is the behavioral outcome of constant triggering. When a person is constantly triggered, it creates a form of sensitization, desensitize—desensitization, and then the reaction is compulsive, addictive, and it bonds with the trigger. It creates a rigid structure which involves the trigger—is an—is the beginning, and the compulsion is the end point.

We're beginning to see that trauma, addictions, compulsions, and even emotions such as love, compounded emotions, all have a lot in common structurally, processually, and as far as the initiating stimulus—known as trigger. I mentioned that some triggers generate approach and some triggers generate avoidance. If you're an alcoholic, you would approach the alcohol. If you're in love, you'll approach the object of your desire. If you are—um—you have a traumatic memory, you would avoid smells and sounds and people and places who would trigger the trauma or ret—traumatize you in a way. So, approach-avoidance behavior is very common in many mental illnesses. For example, it's common in borderline personality disorder, and we could therefore reconceptualize it and say that approach-avoidant behavior is a combination of addiction—because addiction is about approaching the trigger, approaching the stimulus—so it's a combination of addiction and a reaction to acted trauma, to retraumatization, because trauma creates avoidance. So when we talk about approach-avoidance or approach-avoidant behavior or approach-avoidant cycles, we're actually talking about a combination of addiction in the approach phase and trauma or reaction to trauma in the avoidant phase. And so, revivid—also known as flashbacks—emotionalized or emotionalized, disregulated emotions which are not flashbacks—there's no such thing as emotional flashback; it's an oxymoron—but flashbacks and this kind of memories and so on so forth, they all part and parcel of the avoidant pole of approach-avoidant cycles.

So in the approach phase, there is craving, there is fantasy—often shared fantasy, but not always—there is um—the visualization of the end result, and there is a drive to approach the trigger, to approach the stimulus that is in the approach side of the equation. In the avoidant side of the equation, there is exactly the opposite: there are flashbacks, in case of post-traumatic stress disorder—PTSD—or vividness, or in case of complex trauma—CPTSD—there are memories which are highly emotional and highly disregulated. All these cause the person to avoid, to try to somehow cope with the averse stimulus—aversive stimulus—cope with a trigger by ignoring it, denying it, avoiding it, reframing it, and there's a variety of other ways. So, approach-avoidance, addiction, trauma—it would seem that in mental health disorders such as borderline personality disorder, we are talking about a cocktail, a combination of addiction and trauma, which is an interesting way to reconceptualize borderline personality disorder.

I mention compulsions and the role of triggering in compulsions. Compulsions are, of course, ritualistic attempts to fend off post-traumatic after-effects. So when you're traumatized by something—even if you haven't been traumatized actually, but you can imagine or anticipate the trauma—so when trauma is present, either because it has happened or because could happen, it has effects—after-effects—and compulsions are kind of rituals—ritualistic attempts to cope with these effects, to fend them off, to bury them, to repress them, to ignore them, to do something with them. So in compulsions there is a trigger, which is the essential—the initial stimulus. Again, it could be a memory, could be a smell, could be a scent, could be a place, could be a person; it's a stimulus; it's a trigger. So there's a trigger; the trigger evokes the trauma; and the trauma leads to a ritualistic attempt to get rid of its effects. This ritualistic attempt is known as compulsion. We can therefore introduce compulsion into the equation of approach-avoidant behaviors, for example, in borderline personality disorder, and we can say that approach-avoidant behaviors are combinations of addiction and compulsion. Does the addiction approach? For example, the borderline approaches an intimate partner, and she approaches an intimate partner as an object of desire because she conceives of the intimate partner as a secure base, as an external regulator of her emotions and moods—indispensable, the one and only. There's a lot of idealization going on. So the borderline approaches the intimate partner, and this approach behavior is essentially addictive; it's an addiction. She approaches the intimate partner the same way an alcoholic approaches alcohol and a junkie approaches drugs. But then it triggers in her trauma—ancient trauma, early childhood trauma, or whatever—engulfment and anxiety, and she becomes compulsive, and her avoidance is compulsive; her memories overwhelm her; she becomes disregulated and hyper-emotional, and she withdraws; she runs away, and she does this compulsively. So approach-avoidance both involve triggers or a process of triggering, and when you put a—when you put together the addiction involved in approach and the compulsion involved in avoidance, you can reconceive of borderline personality disorder as addiction followed by compulsion followed by addiction followed by compulsion, etc., etc., and all this founded on an underlying unitary set of triggers. And these triggers are organized in a narrative known as trauma. The underlying narrative of borderline is the trauma. The trauma is a story; the trauma is a way to make sense of events, to organize reality, to introduce meaning into life. So trauma, which is a binding narrative, includes multiple triggers. This triggers generate addiction-approach, compulsion-avoidance.

One last point before I go uh—deeper into professional academic material: There is trauma transmission via communicator triggers. Abusers, for example, they pass on their triggers onto the victims. The victims acquire the same triggers and may pass them on in their turn. So triggers are like coinage; they're like coins; like—they're like money. Abusers, narcissists, and so on, they have been triggered in their life, in their early childhood or at some point in their liv—and they pass on these triggers. They re-trigger when they reenact the trauma or try to resolve it with a new—new partner, a new person. They also uh—reactivate the triggers, and so they pass on the triggers. Triggers are contagious; they are a vector of contagion. It is via triggers that we pass on behavioral injunctions, organized largely along addiction and compulsion, approach and avoidance. And triggering is not—not only the mechanism that triggers addiction and compulsion; it's the mechanism that makes sense of addiction and compulsion, and the mechanisms which allows—allows addiction and compulsion to be—to be um—passed on, to be transmitted to new recipients. Transmissibility is based on triggering. Victims become infected with the underlying trauma. This creates a—of course, for example, intergenerational trauma, but there's also inter-dioic trauma. Trauma is communicable, and the language of—of trauma is communicable, and the basic alphabet—the letters with which we au—or trauma—write it and pass it on—these letters, this alphabet is the set of triggers associated with the trauma. Of course, each trauma has its own highly specific set of stimuli—triggers—because each trauma has its own highly idiosyncratic set of memories and emotions—attendant emotions—and so on and so forth.

I would like to clarify a few concepts I have—have been—have used in this video: Approach-avoidance conflict. It's a situation that involves a single goal or option that has both desirable and undesirable aspects or consequences. The closer an individual comes to the goal, the greater the anxiety because of the undesirable aspects, but withdraw from the goal increases the desire. So this is the problem with addiction. When the alcoholic tries to go sober, when the sad—try to not hurt any—any anyone, when the p—pedophile keeps his distance from children—in all these situations there is an inner conflict, an approach-avoidance conflict, because the desirability of the alcohol, or the desirability—desirability of the victims of sadism, or the victims of pedophiles—the desirability is overwhelming; it's irresistible; and yet a moral code, fear of punishment, whatever the motivation may be, causes compulsive people, addicts, causes them to behave themselves, to impose on themselves inhibitions, to go sober, to avoid children, to not hurt people. So, and this creates a lot of conflict because the self-imposed limits and boundaries and rules of conduct are perceived as undesirable, unpleasant, dis—comforting, hateful, while the trigger, the stimulus, the pot of gold at the end of the rainbow, is always, of course, desirable. The trigger, therefore, is a stimulus that elicits reaction. An event could be a trigger for a memory of a past experience and an accompanying state of emotional arousal. But not only an event—a place, specific location, um—a date, a person, a smell, a drink, a taste—uh—anything—anything could be a trigger. There something you need—you need to understand: absolutely anything and everything can be a trigger and can act as a trigger. Trigger leads to a set—a chain reaction—a set of developments and a progression of events that is unstoppable, essentially. There's this triggering cause, which is a stimulus or a phenomenon that initiates the immediate onset of a behavioral problem. Um, it's also known as a precipitating cause—cause. Now, there's a difference between precipitating cause and predisposing cause. The precipitating cause is a particular factor—sometimes a traumatic or stressful exper—expence—that is the immediate cause of a mental or physical disorder. A single precipitating event may turn a latent condition into a manifest form of the disorder, and it's not the same as a predisposing cause. Predisposing cause is a factor that increases the probability that a mental or physical disorder or hereditary characteristic will develop, but the predisposing cause is not the immediate cause. Whatever behavioral changes, whatever behavioral choices occur, whatever happens is not caused by the predisposing cause, but by the precipitating cause and the triggering cause. So we have the—all these kinds of causes. I mentioned compulsion. Compulsion is a type of behavior or a mental act um—that people engage in. Some people wash hands all the time, check the door if they've locked the door 100 times, count in their mind, pray um—without stopping, etc. So these are all kinds of activities—mental or physical—and they're—they're anxiolytic; they're intended to reduce anxiety, distress, tension, stress. The individual feels driven or comp—to perform the compulsion in order to reduce the distress associated with an obsession. An intrusive thought is one form of obsession—H—and the obsession usually is pseudo-psychotic; it involves catastrophizing. Intrusive thoughts or other forms of obsession have to do with an impending doom and gloom; something horrible is going to—is going to happen—an event, a situation, a set of c—circumstances, and there's no limit to the imagination. And so there's a lot of catastrophizing going on here, and the compul—and this creates anxiety, and compulsion—compulsion is intended to ritually diminish the anxiety. Individuals with—with an obsession about, for example, contamination—germaphobes—these kind of people wash their hands repetitively; the skin is cracked, parched, bleeding, and they continue to wash their hands. There's not pleasure here; it's not about gratification of any kind; uh—it's about relief—relief—a reduction in anxiety. When you engage in the activity as a compulsive person, you're somehow fending off the inevitable, somehow changing the structure and order of the universe or God's mind or whatever, and buying insurance against the horrible things that are about to unfold. And that's why people pray. Religion is a form of compulsion—r large. It's a combination of delusion and compulsion. Um—the—there's no proportion between the fear and the methods used to mitigate or neutralize the fear. The fear is huge—usually someone is going to die, the world is going to go to pieces, I'm going to—I'm going to u—suffer a horrible ill—deforming illness. So the fear, the anxiety, are—they're catastrophizing; they're usually—they're usually enormous; and the compulsive rituals and methods intended to reduce the anxiety—these are usually trivial or frivolous—very small types of actions—and they're also not relevant. You can't demonstrate any connectivity or correlation between the compulsive ritual and the fear. So if you—if you're afraid of diseases and you wash your hands, there is some relevance here, but in the vast majority of cases compulsions are irrelevant to the feared situation. They neutralize the fear situation not by logically and rationally doing something that has to do with a fear or with the expected adverse outcome. No—compulsion is totally independent. It is, therefore, symbolic—exactly like in a dream where we have symbols that represent internal processes, whichever they may be. Compulsion is a set of symbols that represent expiation, repentance, redemption, absolution, getting on good terms with the universe, with God, whatever it is that you believe in. And one of the most famous forms of compulsion is known as repetition compulsion in psychoanalytic theory. Repetition compulsion is the unconscious need to reenact early traumas in the attempt to overcome them—and to them—by guaranteeing a different outcome. You know the famous saying that insanity is doing the same thing expecting a different result—that's repetition compulsion—doing the same thing again and again and again expecting a different outcome. And the traumas that are connected with repetition compulsion—because usually it's a reenactment or a replay of early childhood traumas—so the traumas are repeated in a new situation, symbolic of the repressed prototype. So again, there's a lot of symbolism involved. Repetition compulsion acts as a resistance to um—any change, because any meaningful change, for example, in the wake of therapy, is about not having to repeat yourself; it's about facing the trauma head on, conquering it, so to speak. And repetition compulsion is a reenactment of the trauma, but in highly fantastic and symbolic settings—a little like a dream again. The shared fantasy is very dreamlike. The narcissist shared fantasy—so it doesn't—it has no therapeutic value; it doesn't induce any insight or any meaningful dynamic—healing dynamic. Uh—compulsion is sick and cannot lead to healing. Compulsion to repeat is just one example. Many compulsions create counter-compulsions. Counter-compulsions are also compulsions. There's a lot of nonsense online about this. Counter-compulsions are also compulsions. These are compulsions that develop in order to resist the original compulsion. So there's a sequence here: there's an original anxiety or fear—a result of catastrophizing and a reflection of internal processes in the wake of trauma—so there is this fear—ambient fear—diffuse anxiety—and then the way to cope with it is to create a ritual, and this becomes the primary uh—compulsion. But then the primary compulsion becomes a problem on its own; it becomes problematic; it is disruptive—disruptive to life; it constricts life; it renders the individual dysfunctional. And so the individual—the compulsive individual—copes with his or his or her compulsion by developing a secondary counterveiling com—compulsion—counter-compulsion. So the counter-compulsion is a new compulsion that replaces the original comp—compulsion. In order to continue the compulsive behavior, is deep inside the individual perceives the compulsive behavior as the only reliable defense against the world that is minacious, hostile, and how to get him or her—a trauma trigger.

I made a distinction at the beginning of this video between a trauma trigger and an addictive trigger. While—whilst a trauma trigger is perceived always as negative, the trigger of addiction is often perceived as positive. It is sick—it is sick to perceive any trigger as positive. An addiction is sickness, but while inside the addiction, while in the throws of the addiction, while under the control of the addiction, the addict perceives the trigger as highly positive, craved, desired, and wonderful. Again, think about the relationship between alcoholism—an alcoholic and alcohol—or between you and your loved one in a love relationship which is essentially a form of addiction, and so on. So a trauma trigger is not the same as an addiction trigger, although, as I said, structurally and operationally the mechanism is the same, but the trauma trigger is a psychological stimulus, and it's involuntary. Trauma trigger usually generates memory recall, and the memory or recall of the previously traumatic experience is invol—involuntary; it's uncontrollable. The stimulus doesn't have to be frightening or traumatic, or it doesn't have to be directly associated with the original trauma. Um, it could be indirect; it could be superficially reminiscent of some earlier traumatic incident. As I said, it could be a scent, could be a piece of clothing, it could be a color, it could be a date. It's—the triggers are very, very indirect in this sense; they're very reminiscent of the language of dreams; they're highly disguised and symbolic in order to somehow pass—pass master—pass the censorship, to use Freud's delectable metaphor. And so triggers can be subtle, individual, and difficult to predict. And triggers are so idiosyncratic, so individualistic, that sometimes they cannot be communicated to others. And it's a very invalidating experience to try to explain to others why a bottle of mineral water triggered you, or why were you triggered when you smelt cookies—which is how the famous book by Martel PR starts. So the trauma stimulus, the trauma stressor, or the trauma reminder—these are different—different terms used to describe the trauma trigger—is very, very unique to the traumatized person and renders a traumatized person a prisoner, a hostage of his own internal, highly symbolic landscape. The process of connecting a traumatic experience to a specific trigger is known as traumatic coupling. When a trauma is triggered, there's—as I said—an involuntary resp—response, which is usually uh—about memory; there's some kind of recall of memory—memory—but then there's emotions as well, and there—there's initially a feeling of extreme discomfort and maybe a feeling of impending doom or anxiety, but—and gradually, if—if it's not tackled somehow, it could become overwhelming and lead to uncontrollable behaviors such as panic attacks or, in case of post-traumatic stress disorder, a flashback or a strong impulse to do something, for example, to run away to a safe place. So it's very important to avoid trauma triggers um—because they provoke disproportionately extreme reactions—in many cases—not in all cases, but in many cases—the potential for inappropriate behavior which could have adverse consequences and outcomes for the individual—this potentially pretty high. Um—so there's a need to—to map—map the triggers, to get acquainted with what triggers the individual—the patient, for example—and then design strategies of avoiding these triggers. Long-term avoidance of triggers increases the likelihood uh—that—that PTSD would become permanent. This is something we—when we treat post-traumatic stress disorders—we commit an inordinate number of mistakes, and I'm talking now about clinicians, for example. We force the trauma victim to describe the trauma immediately in the wake of the trauma. This is called debriefing; this is very bad—very bad practice—debunked in many, many studies. Another thing we do: we teach the trauma victim to avoid triggers as a permanent behavior. This should never be done. Avoiding triggers is very important in the initial phase of treating trauma—to allow us to somehow get the patient acquainted with the trauma and get on with it—move on—but at some point the patient would need to confront the triggers. This is exposure therapy. At some point the patient would need to be—retraumatization—to avoid triggers all the time, the trauma deepens. If you expose the patient to the trauma and ret—traumatize the patient and trigger the patient on purpose, structurally, of course, the trauma disappears. Identifying and addressing trauma triggers is an important part of PTSD precisely because at some point we need to expose the patient to the triggers. I refer you to works—work by Foa, Noa, many others. And so the trigger can be anything that provokes fear or distressing memories in the affected person. And we don't have to agree with the affected person; we don't have to enter the affected person—the traumatized person's mind; we don't have to say, ah, we understand how you're triggered. No—it's up to the—to the traumatized person; it's up to the triggered person to tell us which stimuli cause triggering—entirely the decision of the traumatized patient. Just as trauma is not merely some unpleasant common experience, trauma trigger is not merely something that causes discomfort or offense—something that destabilizes profoundly. So this is the picture of triggering, as you can see—it's a common mechanism in a variety of mental health pathologies—trauma being only one of them—same with addictions, same with compulsions. Of course, this leads us back to borderline personality disorder and narcissistic personality disorder, where triggering plays crucial roles in the economy and the management of the internal mental apparatus of these two disorders. These two disorders are based essentially on patterns of triggering—trauma or retraumatization or—r trauma—a reaction to r trauma via fantasy, and then the cycle starts again. Approach-avoidance is built as a compulsive strategy to cope with the addiction involved in the trigger in some triggers and the terror associated with other triggers. The borderline and narcissist are torn between desire and terror—desire and terror—they flee—they flee the terror into the desire, and then they flee the desire back to the terror. And this pendula movement—this pendulum between terror and desire—is a great description of—of the shared fantasies of the both the narcissist and the borderline, although the shared fantasy of the narcissist, the shared fantasy of the borderline have different theologies, different causation, and different reasons. They share this feature of the pendulum—the approach-avoidance, the compulsion and the addiction, or the addiction and the compulsion, and the desire and the terror. Some might even say that these people—the narcissist—narcissists and borderlines—desire the terror and are terrified of their own desire.