Transcription
When narcissists experience stress, anxiety, when they go through a state of crisis, when they experience abandonment, collapse, narcissistic injury, narcissistic mortification, in short, when narcissists fall apart, when they decompensate, when their defenses are down, they evince, they exhibit what could be easily mistaken for a borderline personality organization. They become emotionally disregulated, and some of them develop suicidal ideation.
Grosstein suggested that pathological narcissism is an advanced stage of borderline personality, that the borderline is a failed narcissist. Similarly, Kernberg suggested that narcissistic defenses are aimed at an underlying borderline vulnerability or borderline structure. That narcissism is a defense against borderline. I'm mentioning all this because decompensation plays a major role in the transition from borderline personality disorder or organization to a psychopathic or antisocial state.
Switching is very common in borderline personalities. Some borderlines switch imperceptibly, gradually, incrementally. They maintain continuity, memory, and a semblance of identity across various self-states. This kind of borderline resembles OSDD, other specified dissociative disorder, a form of attenuated DID with preserved memory function.
Other borderlines switch suddenly, abruptly, violently. They shock their environment. Both borderlines and narcissists are prone to switching owing to splitting and self-splitting defenses. The previous self-state, it was, is now perceived as all bad, while the new self-state is all good. There's a lack of core identity. There's identity diffusion or disturbance, and there's no constellated or integrated self-ego state. There's an emptiness, an empty schizoid core.
I'm leading somewhere. I'm leading to the question of whether borderline is actually another name for psychopathy, or whether there is a comorbidity occurrence. These types of disorders are in constant flux. When confronted with situations which involve uncertainty, could be positive uncertainty, a promise, or a threat, real, imaginary, anticipated, or recalled. When they are confronted with such situations, they essentially fall apart.
Their switching is responsive to real or anticipated environmental cues. Stress, anxieties, substance abuse, holidays, important events, life crises or traumas, new people, crowds, mortification, medication, even sensory input. Remember Marcel P in his book? The whole book is triggered by a smell. And so switching is preceded by emotion dysregulation. Emotional switching, uh, Hoben called it.
Switching could be consensual, could be forced, or could be triggered. And there are signs of switching. There's a prodromal phase. There's a rigid body posture, pseudo-fainting. There's the calm before the storm. Atypical behaviors or traits, um, could be positive traits like kindness, reasonableness, submissiveness, conflict aversion, which are not typical to the individual involved. There's changes in body self-image, a dramatic alteration in identity, behaviors, preferences, values, beliefs, emotionality, cognitive style. They all, they all transform dramatically, cataclysmically, mysteriously. The stockativity, hyperverbalizing, hyperreflexivity, pseudopsychosis, and hyperactivity followed by a period of subdued, slow-motion, hesitant reactivity. And throughout all this, there's a lot of impulsivity and a lot of dissociation.
And this leads us to the topic of today's video. When the borderline switches, she often switches to a secondary psychopathic state. And that raises the question, is the borderline actually a failed psychopath? Is the borderline personality organization a defense against an underlying antisocial structure? The same kind of relationship that exists between borderline and narcissism. Is there a similar relationship between borderline and psychopathy? Is psychopathy, is borderline, I'm sorry, psychopathy for for women? Is it a female version of psychopathy? Should we attribute any of this to gender differences? Biological innate sex differences? And so this is the topic of today's video.
My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited, and I'm a professor of psychology. Before we proceed, let's get rid of some misunderstandings. There's no such thing as sociopath. Sociopath is just another word for psychopath. Psychopath is not the same as antisocial. Psychopathy is not the same as antisocial personality disorder. Presumably, psychopathy is an extreme form, an exaggerated malignant form of antisocial personality disorder. And we also make a distinction, following Robert Hare's work and the PCL-R. We make a distinction between primary and secondary psychopathy. The latter being more impulsive than the former. The former concerned more with dominance, grandiosity, power.
Let us begin to discuss the co-occurrence or comorbidity between antisocial personality disorder and borderline personality disorder. It's pretty impressive. Anywhere between 5.6% and 27% of community samples of people with borderline personality disorders have the comorbidity. In other words, it's safe to say that one in five borderlines could also, or can also, be diagnosed with antisocial personality disorder. In clinical and forensic settings, this figure skyrockets. 57% of people in clinical and forensic settings diagnosed with borderline personality disorder also have antisocial personality disorder.
The prevalence of both disorders is similar: 1 to 3% in the community, 10 to 30% in clinical settings. The prevalence of antisocial personality disorder among relatives of someone with borderline personality disorder is 7% versus 3% in the general population. That is a strong indicator of a genetic component in both disorders. So it would be safe to say that borderline personality disorder and antisocial personality disorder share some kind of genetic etiology and what is known as non-shared environmental influences.
We know, for example, that in the personal histories of people with borderline personality disorder and of psychopaths, there is childhood trauma, maladaptive parenting, stressful life events, and adverse childhood experiences. That is not to imply necessary causation. We know, for example, in psychopathy, that there are substantial brain abnormalities involved and physiological abnormalities. We also know that both these disorders, borderline and antisocial, are hereditarily communicated. There's a hereditary component. There are many shared features. Emotion dysregulation is common in secondary psychopathy and in borderline. There's a weak inhibitory control. There's a preoccupied anxious attachment. There's social cognition deficits.
The attachment issue is very interesting. Anxious preoccupied attachment is an insecure attachment style. It is characterized by a deep fear of abandonment, separation, insecurity, by low self-worth, and a constant need for validation and closeness in a relationship. People with this style often view themselves negatively, but I, but they idealize others, and consequently, they become highly dependent on their partners for emotional security. Now, normally, people would not associate this with psychopathy, but the studies are unequivocal. Anxious preoccupied attachment is very common among psychopaths and among borderlines. In this sense, people with borderline personality disorder resemble psychopaths in the sense that they are terrified of abandonment. They cling on to their partners, and they tend to idealize them.
Now, both these types, borderlines and antisocials, are able to predict someone else's behavior based on their belief state and mentalization. This is not unique to borderlines, but it is unique to borderlines and antisocial personality disorders. So these people have what I call cold, cold empathy. The ability to scan other people and to construct immediately a theory of mind about what makes other people tick, and then the ability to leverage this theory of mind in order to manipulate other people, to induce behavior modification in other people.
Both disorders, borderline and antisocial, they share a similar developmental course. There's a steep increase in adolescence and a decrease or plateau in young adulthood, and then there's a burning out of the pathologies by late middle age. According to the ICD, it starts with borderlines. It starts at age 35. And by age 45, 81% of people who have been diagnosed with borderline personality disorder no longer meet the diagnosis. They become either subclinical or nonclinical. The same happens with psychopaths or people with antisocial personality disorder. At least the antisocial, abrasive, antagonistic traits and behaviors tend to vanish with time. When the individual, the psychopathic individual, antisocial individual, reaches the mid-40s, early 50s, these aspects of the personality are gone.
In the majority of cases, of course, affective instability, identity diffusion, difficulties in interpersonal relationships, idealization-devaluation cycles, and so on and so forth, are much more common in borderline personality disorder than in psychopathy. Borderline is much more emotionally unstable than the psychopath. The identity of the borderline is much more diffused and fragmented and kaleidoscopic. The psychopath has a much more rigid, bounded, strongly well-defined core identity than the borderline. There are difficulties in interpersonal relationships in both cases, but the intensity is different. Borderline relationships are very intense, very tumultuous, very stormy. Whereas in psychopathy, the relationship is on an even keel, although it can end, and does end frequently abruptly. Borderlines idealize their intimate partners and then devalue them. Not only intimate partners, but people in their circle, and then devalue them. These cycles are not common among psychopaths and people with antisocial personality disorder. They do not. They rarely idealize other people and then devalue them.
The borderline has a false self. Exactly like the narcissist. The psychopath doesn't. The borderline has difficulties to tell apart reality from fantasy in certain situations. The psychopath is well-grounded in reality. The borderline requires external regulation. She uses other people, especially an intimate partner or a special friend, special person. They use, she uses other people in order to stabilize her labile moods and to regulate her disregulated, overwhelming emotions. That's not the case with the psychopath. The preoccupied attachment that we mentioned earlier is common in both disorders, but it's much more pronounced in borderline personality disorder.
And so there are differences, but to a large degree, these are differences of extent or differences of degree. These are differences of intensity. These are not substantial differences. These are not meaningful structural functional differences. It appears to be that the psychopath is a more well-regulated borderline, or that the borderline is a more disruptive, chaotic psychopath. The similarities are overwhelming. Disinhibition, for example. Both these types are impulsive. And again, in the borderline, certain aspects of impulsivity are emphasized, whereas in the antisocial, other aspects. Impulsivity is comprised of urgency, perseverance, premeditation, and sensation seeking or thrill-seeking. Urgency and lack of perseverance were uniquely related to borderline personality disorder. Whereas a lack of premeditation and excitement seeking were uniquely related to antisocial personality disorder. But the outcome, the behavioral outcome, is the same. They're both, both impulsive. They have problems with impulse control.
And all this raises the question of sex or gender. Does it have anything to do with the female, with female biology or with male biology? We know that 2/3 to 3/4 of all borderline personality diagnoses are females, as as late as 10 years ago. We know that in contrast, three times ASPD, antisocial personality disorder, is three times more common in men than in women. Again, the figures are 10 years old. We also know that there's a problem with this. There may be gender bias. It may be that the criteria are defined in a way that is culture-bound. That criteria reflect some mores and beliefs about gender roles. So the criteria is defined. It may be that we have been studying samples which were non-representative. For example, we've been studying mostly females when it comes to borderline. And we've been studying prisoners in prison, most of whom were males when it comes to psychopathy.
Borderline and antisocial personality disorder have so much in common. And borderlines default to a psychopathic state so often, that it raises the possibility that the gender attribution of these disorders is somehow very wrong, and that what has happened is that we were witnessing the same disorder in different phases, in different populations. So that women express psychopathy differently to men, and we got the impression that these are two distinct, disparate disorders, and we gender-attribute them.
Borderline and histrionic personality disorders may be manifestations in females, in women, of secondary type psychopathy, as measured by factor two of the PCL-R test. In other words, borderline and histrionic women may actually be psychopaths. A growing body of recent studies supports this startling conclusion. Survivors of complex trauma, CPTSD, also manifest psychopathic and narcissistic behaviors. That's the overlay.
Intimate partners won't be surprised by any of this. Intimate partners of people with borderline personality disorder would tell you that they're highly impulsive. They're defiant. They're grandiose, antisocial. There's interpersonal aggression which often devolves into violence. There's manipulativeness. There's disregulated negative emotionality. There's a lack of object constancy, object impermanence. There are attachment dysfunctions. There's hostility. The splitting, dichotomous, dichotomous thinking, the high levels of distress, anxiety, depression, and substance abuse. So all these are typical and common among borderlines, but they also perfectly capture the behavioral profile of psychopaths, actually, especially secondary psychopaths.
These women with borderline personality disorder also usually defy gender roles and behavioral stereotypes and norms. They act more masculine. They're more masculine. But this is where sex may play a part. Whereas psychopathy in men is culturally channeled, societally defined, society informs men how to express their psychopathy, how to express their antisocial tendencies. Society similarly dictates to women what is and not, and is not permissible or acceptable in social settings. So even people with psychopathy, and even people with borderline, express their disorders in ways which would not incur high social costs.
Borderline adds a twist to this cocktail: dissociation. Whenever stress levels and inner dissonance become intolerable, the borderline hands over control to her inner psychopath. She depersonalizes. She derealizes, and she develops amnesia. And in this way, she kind of legitimizes the emergence of a psychopathic protector self-state. She becomes a psychopath.
When a borderline life partner is another, another proud member of the cluster B tribe, another borderline, another psychopath, another narcissist, he reacts with equal measures of abuse to her frequent misconduct. It creates a cycle of abuse which is described by both parties as reactive. The relationship ineluctably devolves into a vicious power play and warping, cruel mind games, exacerbating traumatic mental health outcomes for everyone involved.
Dissociative depersonalization and derealization are common reactions in borderline personality disorder, in dissociative identity disorder, formerly known as multiple personality disorder, and in patients with post-traumatic stress disorder, PTSD, and CPTSD. And so, what is the inner experience of the borderline when she transitions or when she switches to a psychopathic state? An equally good question would be, what is the inner experience of a psychopath when he or she becomes a borderline, when there is a transition to an emotionally disregulated state, a borderline state? Um, we know that in both these switching conditions, both these switching situations, there's a sense of loss of self, a sense of loss of identity, disorientation, estrangement, alienation, and the feeling that none of this is real, and it's not me. The experience is variously described as being on autopilot, sliding into anesthesia, or reverting to the status of an empathic or sad observer.
I repeat: in the same individual, borderline and psychopathic self-states are triggered or provoked by some kind of intolerable dissonance. The dissonance could be external. Something is happening in the environment which the individual finds stressful, intolerable, unbearable, threatening. Or the dissonance could be internal, endogenous, generated from the inside. For example, when you, when the individual cheats on the partner, when the individual is having self-trashing sex, when the individual is breaking the law or breaching some deeply held mores and values. And in all these situations, switching is a definite possibility.
I was asked by many of you, what is this comorbidity of antisocial and borderline? How does it look? How does it operate? What I'm trying to explain to you in this video is that this, this distinction is spurious, is wrong. This distinction does not reflect clinical reality. In clinical reality, borderline and psychopathy are intertwined. They're two faces of the same coin. They are transitory states within the same individual. They're self-states.
And so a patient with borderline personality disorder who finds herself in an intolerable situation which challenges her self-concept, undermines her perception of reality, grasp on reality. This kind of patient distances herself from the events, from her pain, and from anticipated abandonment and rejection via the mechanisms of estrangement and alienation. This kind of patient says, "This is not happening to me. This is just a nightmare. This is not real." Substance abuse and ambient distractions tend to exacerbate these reactive patterns, and the patient often misattributes to alcohol or drugs or bar hopping or video games the behaviors wrought by her alters, or the subsequent amnesia.
Having said all this, the conditions are exclusive. When the borderline switches from a borderline state to a psychopathic state, she's a full-fledged psychopath. When the psychopathic state terminates, and usually it doesn't last because in, in the comorbidity, the borderline, the borderline disorder is the dominant disorder. So when the psychopathic state ends, the, there's a transition to a borderline self-state, and that borderline self-state is again dominant, with no trace of psychopathy. So they are mutually exclusive. You can't have both simultaneously.
Patients describe the inner lived experience of switching. They can tell you, "I turn myself off. I'm becoming cold. I'm becoming detached. I no longer care. I lose my emotions and my empathy. I can do anything. I'm uninhibited. I'm remorseless. I'm cruel. I'm goal-oriented. I'm focused." Patients describe this. It is when the borderline disappears and the psychopath makes an entrance and takes over.
Similarly, when the dominant state in the comorbidity, the dominant disorder in the co-occurrence, which is the borderline disorder, reassumes control, the psychopath disappears, leaving behind traces of shame and guilt. Some of these traces are erased by dissociation. Some of them remain. And a borderline patient would typically tell you, "I can't believe I did this. It's not me. I feel so ashamed, so guilty. I don't know what to do with myself. I don't know where to bury myself. So horrible. Can't believe I've done that." This is the borderline speaking, observing, as it were, the actions of the psychopath.
So not only are these two self-states mutually exclusive, they are a bit dissonant. The borderline and the psychopath don't like each other within the same individual. There's dissonance between them and dissonant tension between them. The borderline disapproves of the psychopath's choices, decisions, and actions. The psychopath disapproves of the borderline's perceived weakness, her emotion dysregulation, her submissiveness, her reliance on external regulation, her dependency. The, the psychopath finds all these abhorrent and, and abominable, contemptible. Psychopath holds the borderline in contempt. Borderline holds the psychopathic state in horror.
And yet, the borderline does feel safe with the psychopath. Does feel secure. The psychopath is a protector self-state. It emerges when, when the borderline perceives some kind of threat or danger or risk. The borderline may consider the psychopath's actions reckless. She may consider the psychopath to be a bit stupid. She may consider the psychopath to have endangered her. All this is true. But when the psychopath takes over, the feeling of the borderline, the experience of the borderline is that of reassuming mastery, regaining control, empowerment, being in charge, um, invulnerability, immunity, impermeability, untouchability. The psychopath imbues the borderline with a kind of defiance and consummateness, rejection of authority that the borderline associates with safety. It is this addiction to safety that pushes the borderline to maintain the psychopathic self-state in reserve as an option, as an insurance policy.
I would like to refer to a study or two, starting with, um, an article published in, uh, 2017 in the, um, Journal of Abnormal Psychology. The article is titled, "A Psychometric Investigation of Gender Differences and Common Processes Across Borderline and Antisocial Personality Disorders." And I would like to read to you an excerpt or two. "Our results," say the authors, "suggest common underlying vulnerability." Sorry. "Our results," say the authors, "suggest that that common underlying vulnerability accounts for both the comorbidity between borderline personality organization and antisocial adult behaviors across sex. And this common vulnerability drives the association with other psychopathology and maladaptive behavior. This, in turn, has implications for diagnostic classification systems and treatment."
What the authors are saying is that there's a common factor. There's a personality factor which is very reminiscent of the Dark Factor, the D factor. And this personality factor underlies both borderline personality disorder and antisocial personality disorder. They are both manifestations or emanations from this single underlying factor. This single underlying factor has facets, according to the authors. So I'm continuing to read: "The borderline personality disorder-specific factor incrementally predicted lifetime major depressive disorder and lifetime history of psychiatric treatment. Whereas the antisocial adult behavior factor predicted lifetime number of days in jail." While these results intuitively make sense and are consistent with previous work, mainly Zanagavini, it is unclear how a factor representing emptiness and cognitive distortions interacts with the liabilities representing the general factor to produce depression and psychiatric treatment history. Likewise, the association between the antisocial adult behavior specific factor and incarceration is not surprising. The highest factor loading on the AAB, antisocial adult behavior specifier, the highest factor loading on the AAB specific factor, is an indicator reading "failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest." The association of this factor with incarceration may simply reflect the same construct. More notable are the associations of the AAB specific factor with drug and alcohol age of initiation. Early age of alcohol initiation, for instance, has been long thought to be a marker for an alcoholism subtype marked by a high genetic loading and high criminal behavior. It is possible that we are tapping into this latent dimension with a specific AAB factor." Generally speaking, I want to say, so this is the end of the quote. Generally speaking, I want to tell you that there is an attempt, pretty successful, I think, to reduce all these personality disorders into a dark personality factor. This dark personality factor, in its attenuated form, would give rise to Dark Triad and Dark Tetrad subclinical personality types. In its more malignant or exaggerated form or emphasized form, it would give rise to Cluster B and other personality disorders and other mental health issues. And so this kind of factor, uh, could be the reason we develop various expressions of the factor depending on gender, on age, on society, on culture, on the environment. The environment would define how the factor manifests, and then one manifestation would be borderline personality disorder, and the other would be psychopathy.
Another article, 2026, Muajirin, Howard, and others, "Comorbidity of Borderline with Antisocial and Narcissistic Personality Disorders: A Multi-Method Study." It was published in the, uh, Personality Disorders and Emotion Dysregulation journal. And so, he, I'm quoting from the article: "The results of network analysis showed that the three groups shared the same symptom structure but differed systematically in which symptoms were more strongly endorsed. Identity interpersonal dysfunction in BPD, affective behavioral dysregulation in BPD plus ASPD in the comorbidity borderline psychopathy, and a mixed intermediate profile in BPD plus NPD. BPD plus antisocial personality disorder showed the greatest severity of borderline symptoms, greatest emotional dysregulation, and highest impulsiveness and anger. The BPD group showed the highest identity disturbance and suicidality. BPD plus NPD, the lowest." In their symptom profiles, BPD were more likely to meet criteria for fear of abandonment, unstable relationships, identity disturbance, and suicidality. Whereas BPD plus antisocial personality disorder were more likely to meet criteria for impulsivity, affective instability, and anger control difficulties. The three groups differed on measures of identity and interpersonal relationships, supporting the idea that PD reflects disturbances of relationality. That's what I've been saying for decades. Personality disorders are relational disorders.
Continue with the article. "Conclusions," said the authors, "results highlight that borderline personality disorder can manifest in different ways that depend on its comorbidity. These differences require treatment to be tailored to the individual patient, with a focus on identity interpersonal dysfunction when BPD is present alone, and on affective behavioral dysregulation when BPD co-occurs with antisocial personality disorder."
Thank you for listening. I will now switch to another self-state. Bye-bye.
My name is Sam Vaknin, and I'm the author of Malignant Self-Love, Narcissism Revisited. And don't tell me that you didn't miss this introduction. Today, we are going to discuss borderline personality disorder and psychopathy. Wait a minute. You see, borderlines are the exact opposite of psychopaths. They have emotions. They have empathy. They're disregulated. They're not goal-oriented like psychopaths. What gives?
Well, it seems that we've all been wrong. Borderline and histrionic personality disorders may be manifestations in females, in women, of secondary type psychopathy. Secondary type psychopathy is a variant of antisocial personality disorder, a variant of psychopathy which is measured by factor two, factor number two, in the standard PCL-R test. In other words, borderline and histrionic women may actually be psychopaths. A growing body of recent studies supports this extremely startling conclusion.
Let's add even more. Survivors of CPTSD, survivors of complex post-traumatic stress disorder, victims also manifest psychopathic and narcissistic behaviors, what I call psychopathic and narcissistic overlay. So borderlines, victims of CPTSD, and psychopaths, or psychopathic narcissists, or secondary psychopaths, may actually be one and the same. In the case of victims and survivors of CPTSD, the psychopathic behaviors, the narcissistic choices, the traits that develop, they're all transient. Not so in the case of borderline women.
Intimate partners of borderline women will not be surprised. They are aware of, affected by, and familiar with the borderline woman's impulsivity, her defiant grandiosity, antisocial and interpersonal aggression, her manipulativeness, her disregulated negative emotionality, paranoia, lack of object constancy or object impermanence. In other words, out of sight, out of mind, attachment dysfunctions, hostility, splitting or dichotomous thinking, all white, all black, high levels of distress, anxiety, depression, and substance abuse. This laundry list is typical of and common among secondary psychopaths, but also among borderline women and men, of course. But the majority of people diagnosed with borderline personality disorder are women.
These women also defy gender roles and behavioral norms. They tend to be more masculine. They tend to adopt an ideology of "anything a man can do, I can do better." And in this sense, they emulate and imitate psychopathic men. But the borderline woman adds a twist to this extremely toxic and pernicious cocktail. And this twist is dissociation. Whenever her stress levels, whenever her inner dissonance, for example, feelings of guilt and shame, pain, um, expectation or anticipation of abandonment, whenever there's inner turmoil inside her, when it becomes intolerable, she hands over control to her inner secondary psychopath. And then she proceeds to depersonalize, to derealize, or to develop amnesia. All three are considered dissociative phenomena, and we will discuss them at length a bit later. As she hands over control to her inner psychopath, she becomes malicious, malevolent, some would say even evil.
When the borderline life partner is another, another proud member of the cluster B tribe. In other words, when her partner also suffers from a personality disorder, a dramatic or erratic personality disorder. When her partner is another borderline, or another psychopath, or another narcissist, he reacts with equal measures of abuse to her frequent misconduct, and the relationship ineluctably devolves into a kind of vicious power play and with with numerous warping, cruel mind games, sadism, and this exacerbates the mental health outcomes for everyone involved. Yes, even narcissists, borderlines, and psychopaths can be traumatized, often are.
So, let's go back to dissociation. Dissociative depersonalization and derealization are common reactions in borderline personality disorder, but also in dissociative identity disorder, DID, formerly known as multiple personality disorder. Similarly, dissociation is common in patients with post-traumatic stress disorder, such as PTSD or CPTSD. The experience of derealization and depersonalization is variously described as being on autopilot, sliding into anesthesia, or reverting to the status of an empathic or sad spectator. It is provoked by intolerable dissonance.
As I said, for example, when the borderline woman cheats on her partner, when she is having ambivalent sex, when she's breaking the law, or when she's breaching some deeply held mores and values, in all these cases, which are just examples of dissonance, she would tend to dissociate. Why? Why does she dissociate? What's the aim? What's the psychodynamic aim? Well, by dissociating, the patient distances herself from the events, from her pain, and from anticipated abandonment and rejection. By dissociating, she's no longer there. There are these are mechanisms of estrangement and alienation. It's like she's saying, "This is not happening to me. This is just a nightmare. This is not real."
Substance abuse and ambient distractions tend to exacerbate these reactive patterns. And so we find borderline women with borderline personality disorder bar hopping or getting addicted to video games or similar distracting activities. Activities that are intended to take the borderline's mind off off the cataclysmic agony that she's experiencing, off the impending doom of abandonment and rejection, off the guillotine of intolerable, unbearable pain that is awaiting her once she's dumped. And so these substance abuse and ambient distractions tend to exacerbate reactive patterns. The patient ends up usually misattributing to alcohol or to drugs the behaviors wrought by her alters, wrought by her different self-states.
So here's, here's the sequence. She is in pain, or she anticipates pain. She can't take it. She can't tolerate it. So she distracts herself. She distracts herself by drinking, by engaging in all kinds of activities, by having sex with a stranger. She does all these things as she consumes drugs and alcohol, for example. So then she has amnesia, or she depersonalizes, or or she cuts herself off reality, the realization. And then, in an attempt to explain to herself what had happened, why, why she can't recall anything, she says to herself, "Must have been the alcohol. Must have been an alcoholic blackout. Must have been something the drugs did to me." So she explains the subsequent amnesia via the substance abuse, but that's not the truth. The truth is that another state of self has emerged.
Once the borderline is threatened with abandonment or experiences pain and rejection, another self emerges, the equivalent of an alter, alternative personality in dissociative identity disorder. And this self that emerges is very often a secondary psychopath. Borderline personality disorder can best be described as a subspecies of dissociative identity disorder. The mood lability and emotional dysregulation are merely outward manifestations of changes in self-states. They represent switching from a host personality and P to an alter personality EP.
The dissociative trigger in borderline personality disorder is typically either actual abandonment or the perceived threat of rejection and separation from an intimate partner within an interpersonal relationship, and this results in unbearable abandonment or separation anxiety. This borderline has very low, uh, tolerance of uncertainty and anxiety. She preempts. She generates the various situations that she is so fearful of. So she's afraid of being abandoned, she abandons. She's afraid of being abused, she abuses. Indeed, severe dissociation is even now a diagnostic criterion of BPD, criterion number nine. So borderline personality disorder is diagnosed partly based on dissociative states.
When one of the alters of the borderline is a psychopath, the borderline patient will be antisocial, impulsive, disempathic, mendacious. She, she will lie about everything, all the time, aggressive and defiant. She will be able to go for long periods without any romantic or sexual liaisons. During these periods, she would be like a lone wolf in her lair. This is something that borderline personality disorder patients whose alters are not psychopathic cannot ever countenance or do. So when we want to differentiate the borderline personality disorder patient with a psychopathic self-state from a borderline personality patient without a psychopathic self-state, with some other type of self-state, let's say a grandiose self-state, all we have to do is look at the patterns of behavior and existence. Borderlines with a psych, with an inner psychopath, they are lone wolves. They're, they spend a lot of time alone, and sometimes they are avoidant. They avoid, uh, social contacts or society. And borderlines with a grandiose self-state, with a grand, grandio alter, narcissistic, they would tend actually to seek company, and they are incapable of surviving even for one day without an intimate partner. They feel horrible. They can't. They feel abandoned. They feel dead. They feel dead inside. They don't feel alive unless there's someone who loves them or someone they perceive as loving and caring.
It is a myth that people with borderline personality disorder or even dissociative identity disorder cannot fully control the behaviors and the choices of their alters. They can. This is why the, the courts, courts all over the world reject borderline personality disorder and dissociative identity disorder as a mitigating circumstance, as a defense. They throw people in prison even when it is proven beyond doubt that when they had committed the felony of the crime, they were under the control of an alter, an alternative personality, not the main host personality.
According to Kavanagh, Sullivan, and Malpi, in a long-forgotten clinical note titled "A Clinical Note on Hysterical Psychosis" in the American Journal of Psychiatry, June 1979. Well, according to these three scholars, again, Kavanagh, Sullivan, and Malpi, some narcissistic and histrionic people, mostly women, react with a transient form of psychosis to unwanted sexual advances. But here's the surprise. They react exactly the same way with psychopathy and psychosis. Also when they are interested in someone sexually, when their fervent sexual interest is not reciprocated, when they want someone and they are rejected by that person. In the footsteps of Martin, 1971, the three authors explicitly attribute such decompensation and acting out in some cases to oral narcissistic structures in the personality and to immature object relations. In other words, what the three authors postulate is that in women with borderline personality disorder, they are internal narcissistic structures which cause the borderline to decompensate and to act out, sometimes psychopathically, to sexual rejection or to unwanted sexual advances. In both cases, I would add to this list, women who succeed actually to bed, to have sex with the men that they desire, but are then abandoned or ignored emotionally, contrary to their wishes and fantasies.
So, three cases. If there's unwanted sexual advance, if the woman is interested in sex, but the man is not, or if they both end up having consensual sex, but then the man dumps her, vanishes, abandons her, and ignores her emotionally. In all three cases, there is a process of decompensation. All the defense mechanisms are switched off, and acting out. Acting out means reckless behaviors, uh, such as unprotected sex or binge drinking or reckless driving or a shopping spree. And many of these behaviors today can be described as secondary psychopathy.
The connection between brief reactive psychotic episodes and symptomatic manifestations of dissociation, including amnesia and even dissociative identity disorder. This connection is well-established. See, for example, the definitive work, Dissociation and the Dissociative Disorders, DSM-5 and Beyond, edited by Dell and O'Neil, published by Rutledge in 2009. So when these women, borderline women, disintegrate under stress or trauma or pain or anticipation or abandonment anxiety, when there is this process of decompensation and disintegration, the transition to dissociative psychosis is abrupt and shocking. It resembles switching from the core personality, the host personality, to an alter, alternative personality in multiple personality disorder. Patients describe it as brain fog. Though they may appear to be perfectly oriented and goal-focused, very often you can't tell from the outside that this is happening to them inside. On such occasions, behavior changes markedly, becomes disorganized, and then escalates to become aggressive, impulsive, disempathic, reckless, promiscuous, and antisocial. So while you can't, very often, one cannot tell when the switching, switching took place. After the switching had taken place, a new personality emerges and takes over. And this personality, as you've just heard, is a psychopath.
Amnesia sets in much later, and its aim is to repress painful and acutely egodystonic memories, which had they remained in conscious awareness, would have provoked extreme shame, extreme guilt, and remorse. Where amnesia is absent, the borderline woman undergoes depersonalization and derealization. She feels that she was acting as an observer on autopilot. Substance abuse, such as binge drinking or getting stoned, as I said before, exacerbates all these mental health issues and defenses.
More generally, I've been arguing in the past few years to reverse Kernberg's hierarchy. Otto Kernberg suggested a hierarchy whereby borderlines are closer to psychosis than narcissists. I postulate that the narcissist is far closer to psychosis. His personality is less organized than the borderline. Only the narcissist's rigid grandiosity is keeping the narcissist together. And when this grandiosity is effectively challenged, the narcissist decompensates, acts out, and disintegrates.
Grosstein postulated that the borderline is a failed narcissist. The pathology did not progress or devolve into narcissism, which is a full-fledged form of binary dissociative identity disorder with two selves, the false and the true. The narcissist's solution to this duality of selves, the narcissist's solution to having multiple personality disorder with two selves, true and false, his solution is to switch off the dilapidated, atrophied, and dysfunctional true self, and to relegate the true self to the deepest recesses of the mind where it has no influence whatsoever on the narcissist's psychodynamics. So what is left? The false self. Only the false self is left, and this is the narcissist.
In contrast, the borderline fails to repress and dissociate the true self. Where the narcissist succeeds to eliminate effectively the true self, the borderline fails. Consequently, she never becomes a narcissist. And this so-called failure causes the borderline's two selves, the true and the false, to compete for control of her identity and her memories. There is no such competition within the narcissist. The narcissist is the false self. Take away the false self, and there's nobody there, nobody home. With the borderline, there are two selves in conflict, in battle. It is this inner struggle that mimics other dissociative disorders and led scholars such as Masterson, Dell, Putnam, Ross, Ryle, and many others to suggest that borderline personality disorder may merely be another label for the identity diffusion and alteration common in dissociative disorders.
So what we have in a borderline is a dissociative psychopath. The dissociative psychopath, usually with the pronounced grandiosity of the narcissist and the seductiveness and flirtatiousness of the histrionic, when they are provoked by abandonment anxiety. Borderline personality disorder is a basket diagnosis. It is a diagnosis that unites all cluster B diagnoses, and its foundation is in trauma. Therefore, via the conduit of borderline personality disorder, we can begin to see a unifying picture. These are all post-traumatic conditions, and they all involve forms of all-pervasive, ubiquitous dissociation. We are getting a sniff. We're getting a hint of the future. And the future will center around trauma and dissociation. Psychopathy, borderline, narcissist, these are different, different, uh, behavioral modalities. They are not real clinical constructs. This is exactly what led to the abnormal phenomenon of comorbidity. This is precisely why we had to make laundry lists which overlapped so massively that we had to invent differential diagnosis because these are not real clinical entities. They are simply facets of the kaleidoscope that is the soul of a cluster B. Borderline is another name for dissociation, post-traumatic dissociation. And some borderlines act as psychopaths, others act as narcissists. And all of them usually act as histrionic. It's time to unify all these diagnoses into a single one. A diagnosis of personality disorder with emphasis. Personality disorder with grandio emphasis, with psychopathic or antisocial emphasis, with histrionic emphasis, and with disregulated emphasis, formerly known or called borderline.