Agenda for Reframing Cluster B Personality Disorders as Disrupted Separation-Individuation and Dissociative Post-traumatic Syndromes

To start with, the counterfactual foundations of contemporary psychology – constellated or integrated self, personality, individual - should be replaced with a model of fluid self-states, seamlessly segueing into each other, reactive to environmental cues (see the section on IPAM).

• A Standard Model of Cluster B Personality Disorders 

I propose a standard model of cluster B personality disorders, akin to the standard model of forces and particles in physics. My new suggested diagnosis of covert borderline (and the earlier suggested diagnosis of inverted narcissist) are examples of the kind of clinical entities that emerge from the back and forth transitions between overt and covert cluster B states mediated via and triggered by the processes of collapse and narcissistic mortification. 

This proposed standard model of personality disorders unifies all cluster B (“dramatic” or “erratic”) personality disorders into a single clinical entity with varying emphases and overlays. Like every theoretical model, it yields predictions regarding new diagnoses.

Conceptualizing the mind as an assemblage of ego states or self-states is nothing new. It harks back to work by Philip M. Bromberg, to Jung's complexes, to the model of subpersonalities, to the Internal Family Systems Model (IFS), and to Ego-state therapy. Let us start our review with the most basic unit of self-states: the binary system. 

Binary Systems 

Case studies of clients with comorbid overt narcissism and covert narcissism gave rise to the concept of self-supply. A collapsed narcissist may evolve a binary system of two residual self-states: an overt narcissist and a covert one, both equally inept at securing narcissistic supply from outside sources. 

Such a constellation is geared at generating self-supply in two ways: the overt self-state’s superiority to and rejection of the covert self-state and the covert’s fantasies of overt grandiosity and the narcissistic supply that it garners. 

The overt’s aggression towards the covert is recycled by the covert into a depressive state (self-directed aggression) and incorporated into sadistic fantasies. The overt and the covert collude in creating a sublimatory channel for the pent- up rage, envy, and resentment that the collapsed narcissist is experiencing. 

When aggression is channelled via grandiosity, it can resolve into one or more of these speech acts: 

• Judgmental-contemptuous (I am superior, unequalled)
• Victorious (I am unique, for better or for worse)
• Merciful-empathic (I pity people, have compassion, I act charitably but ostentatiously)
• Educational (I am a guru who elevates others to my level). 

Self-states: The Operating System: The concept of the unitary self is being replaced in my work with the idea that an internal operating system determines which of several self-states emerges, given internally and externally (environmentally) generated information. 

Self-efficacy is the overriding constraint which the system seeks to optimize when hailing forth these sub-personalities or pseudoidentities. 

When all relevant or available self-states at the disposal of the system are equally self-efficacious, the system may opt to keep two or more of them in operation (I call it a “state of residuals”, a transitory binary system). This ineluctably leads to dissonance and internalized aggression. 

Patients with Cluster B personality disorders experience no time (timeless), memory, continuity, self, or core identity. They are mere simulacra and spectacles. Consider narcissists, for example. 

Most narcissists exhibit both overt (grandiose-entitled) and vulnerable traits. In my work, I suggest that cluster B patients transition between overt, collapsed, and covert states of their personality disorders when they are mortified. 

But, how is it possible? After all, the traits of a covert are diametrically opposed to those of an overt! Even in healthy, normal folks, traits are not constant over the lifespan and under conditions of extreme endogenous or exogenous stress or trauma. Such volatility and lability are especially true when the person suffers from identity diffusion or disturbance. Each self-state is a narrative which is allied with a pseudo-identity. Pseudoidentities are ego functions (resources) and simulations (probes). 

In the absence of a unitary, stable core (identity disturbance and identity diffusion), the person shape-shifts between self-states, replete with their own unique traits, affect, cognitions, and behaviors. In extremis, these self-states are utterly dissociated (e.g., in most forms of DID, or Dissociative Identity Disorder).

Psychopathy as self-state is a protective ego resource in DID (Dissociative Identity Disorder), BPD (Borderline Personality Disorder where it manifests as secondary, factor 2 or F2 psychopathy), NPD (Narcissistic Personality Disorder), HPD (Histrionic Personality Disorder), and PPD (Paranoid Personality Disorder). Decompensation occurs owing to intolerable anticipated or actual stress or trauma (CPTSD/PTSD): grandiose and fantasy defenses crumble and lead to acting out or to suicide. It is then that a psychopathic protective self-state emerges. In the case of NPD, the psychopathic protective self-state shields the precariously balanced and disorganized personality from narcissistic injury or narcissistic mortification (it causes hypervigilance). Its emergence results in contact with trauma traces (repressed memories and their attendant emotions), thus transforming NPD into BPD (Grotstein: the BPD patient is a failed narcissist). While emotional dysregulation and suicidal ideation in BPD are common, they are less threatening than the disintegration brought on by shame and humiliation in narcissistic mortification.   

In NPD the psychopathic protective self-state also counters object inconstancy which typically yields abandonment anxiety (separation insecurity). 

In the case of PPD the psychopathic protective self-state protects from perceived or anticipated threats as well as from catastrophizing, paranoid ideation and persecutory delusions. 

In the case of BPD and, more generally, Borderline Personality Organization, the psychopathic protective self-state fends off the twin anxieties: abandonment anxiety (separation insecurity coupled with rejection sensitivity). 

In BPD, the protective self-state also compensates for introject inconstancy (the inability to maintain stable inner representations of external objects). 

In the case of HPD, the protection is from both rejection and injury. When the protective self is overactive or is the only self-state/resource, we get hybrids types (comorbidity) like the malignant narcissist (Fromm, Herbert Rosenfeld, Jeffrey Seinfeld, Otto, Kernberg).

Structural Dissociation forms a part of my newly developed treatment modality, Cold Therapy together with other approaches to trauma and retraumatization. It is at the heart of the post-traumatic condition currently known as “personality disorders”. 

Dissociation is integrative deficit, not a defense (the child has few active defenses, actually). Its symptoms are both psychoform and somatoform. 

Integration and adaptive behavior depend on synthesis (association of all components of experiences and functions into meaningful and coherent mental structures both episodically and across time). 

They also depend on realization: analysis and assimilation of information via personification and presentification, bringing past and future to bear on the present, a kind of mindfulness and reflexivity. Depersonalization is a failure at personification (semantic not episodic memory). Trauma and the Integrated Self. 

• Trauma reduces integrative capacity 

 In premorbid personalities with low integrative capacity, it may lead to dissociation. 

Action systems (inborn, self-organizing, self-stabilizing, and homeostatic emotional operating systems): 

1. Guide daily living and survival of the species;
2. Afford physical defense under threat (currently known as the 4 Fs), social defense against abandonment and rejection (which goes haywire in BPD), and interoreceptive defense against mental content (akin to defense mechanisms, either primitive like splitting or sophisticated like passive-aggression). 

Charles Samuel Myers studied acutely traumatized war veterans in the 1940s. He proposed a model which comprises AS1 (Action System 1) linked to ANP (Apparently Normal Parts) and AS2 linked to EP (Emotional Parts of the personality). Myers called these “personalities”, but today we call them “parts”. EP contain vivid trauma recall (revividness or flashbacks) and vehement negative emotionality and affectivity (fear, horror, helplessness, anger, guilt, shame – or being listless, non-responsive, and submissive – or dissociative states of being derealized and depersonalized). They are linked to body dysmorphia and a separate sense of self. 

ANP represse traumatic memories and avoid triggers via amnesia, sensory anesthesia, restricted emotions, numbness, and depersonalization. ANP conditioned to fear EP and react to any EP intrusion with altering or lowering consciousness, substance abuse, addictions, compulsions, self-mutilation (to silence the inner voices of EP), phobias or mental action. 

The dissociative parts affect attachment and intimacy and lead to attachment loss. ANP are intent on vouchsafing a normal life and fostering growth via change. 

They frequently operate via evaluative conditioning (associating neutral stimuli with negative or positive outcomes and feelings owing to prior association with negative or positive stimuli), diversion, or estrangement.

Individual can have one of each ANP and EP (Primary Structural Dissociation), one ANP with two or more EP (Secondary SD), or multiple ANP and EP (Tertiary SD). 

Both ANP and EP maintain a rudimentary sense of self (“I”) and exclusive access to some memories (aka core identity) Dissociative parts vary in the degree of their intrusion and avoidance of trauma-related cues, affect regulation, psychological defenses, capacity for insight, response to stimuli, body movements, behaviors, cognitive schemas, attention, attachment styles, sense of self, self-destructiveness, promiscuity, suicidality, flexibility and adaptability in daily life, structural division, autonomy, number, subjective experience, overt manifestations. 

The dissociative symptoms could either negative (amnesia, numbness, impaired thinking, loss of skills, needs, wishes, fantasies, loss of motor functions or skills, loss of sensation) or positive when mental content or functions of one part introduce on another part’s (psychotic/schizophrenia: voices, nonvolitional behaviors, tics, pains; psychoform or somatoform conversion symptoms).

In cluster B personality disorders, the biological mother is a source of frustration, hurt, shame, and rage, often unconsciously. Consider, for example, the emergence of Narcissistic Personality Disorder (NPD): the “dead” mother mortifies the nascent narcissist by shaming the child. The transition from the symbiotic (enmeshment) phase to separation-individuation (ages 18-36 months of life) is thus aborted (according to Margret Mahler's theory of separation-individuation). This prevents the full constellation of the self and of an integrated ego.

Individuation is not about becoming an adult, but about becoming an individual with boundaries, self, and ego (one of whose functions is reality testing). 

Such a mother is an illegitimate target of aggression, so the child redirects it at mother substitutes. It attempts to accomplish separation by proxy (via his/her intimate partners in a shared fantasy) and thus become (individuate).

The child reframes the frustrating and withholding primary object (mother or caregiver) by splitting her: she is either all good (martyr) or all bad (evil). Correspondingly, he is either all bad (grandiose monster) or all good (grandiose victim). 

Typically, the child will adopt a bad object: consider itself unworthy, inadequate, evil, ugly, stupid, and so on. The child will assume responsibility for the abuse and trauma it is experiencing. The child becomes by being mirrored through the mother’s gaze.A gaze is not physical fact: it is a caregiving attitude. 

The infant has no conception of a self, of the other, and of the world (no distinction between external and internal). It is, therefore, initially unable to identify itself in the mother’s gaze (symbiotic phase). When it finally does recognize itself in her gaze, the child experiences a trauma, the schism of the world, and the emergence of the other. 

Initially, the child rejects the mother’s traumatizing gaze. He pushes her away, thus realizing her externality. Ironically, it is precisely this rejection that leads to differentiation, the first instance of proto-separation (Lacan's apperception or self-objectification or ambivalent self-alienation). 

Lacan suggested that the unconscious - the seat of repressed traumas - is a compendium of other people’s gazes. Thus, the mother’s gaze is the cause of the formation of the unconscious, its nucleus is this primal trauma of being seen.

Why does the unconscious emerge? To resolve the existential dissonance between the survival need to be seen - and the trauma of being seen. The latter has to be repressed in the interest of survival. 

Now, the child is ready to objectify and instrumentalise the mother as its first mirror. This gives rise to primary narcissism. The mother actively reflects the child to itself, idealized and aggrandized (“hall of mirrors effect”).

This affords the child the grandiose energy to take on the world and cathect it. The mother’s proactive benevolent gaze is synonymous with her secure base and gives rise to healthy attachment.

The mother’s gaze engenders mentalizing and object relations founded on the separateness of external objects subject to secure attachment (“safe bases”). 

But when the mother is “dead”, so is her gaze. The child sees only her (the mirror) and the world, not himself. He fails to develop a concept of the external, operative object relations, as well as a constellated self and an ego.

Such a child is incapable of mentalizing (attributing states of mind to others). He remains stuck in narcissism. He offers to his partners the hall of mirrors effect but without mentalizing and object relations, it does not progress beyond grandiose cathexis and causes regressive infantile retraumatization. 

At the same time, the partner is converted into a dead, frustrating, withholding, betraying mother who mirrors herself and the world rather than the narcissist - thus undermining the shared fantasy having become an internal persecutory object. 

This is reminiscent of Hegel's negation of the negation: child, negated child, negated negated (become) child.

In the absence of external, separate others, empathy is precluded. Empathy is a self-contained internal set of processes, triggered by the presence and self-reporting of another person. 

Empathy involves two confabulated self-deceptions: 

1. That the internal experience of empathy is actually external (has to do with the other person). This confusion between internal and external objects is called “psychosis”; and
2. That the experience of empathy is altruistic and focused on the other person when in reality it is solipsistic and revolves exclusively around self-centred emotional regulation and cognitive processing. 

Thus, empathy has all the hallmarks of both healthy and pathological narcissism. Empathy is the most famous form of other-directed mentalizing. Other proposed variants haven’t fared as well. “Automaticity” is probably the wrong model for human behavior – but so is rationality. Even bounded rationality is an optimistic approach. 

Fonagy’s teleological non-mentalizing fits insects as well as humans. It is tautological. The existence of a goal implies perforce the existence of intentionality (Brentano) and vice versa. What we cannot be sure of is the existence of GOALS! This is why teleology is a bogeyman in science.

The infant (ages 0 to 3) does not verbally formulate "thoughts" or goals regarding his pressing needs (which are part cognitive, part instinctual). This nagging uncertainty is more akin to a discomfort, like being thirsty or wet (states of being). These are transformed into permanent self-states only if the needs are not met. 

Even in classical theories, from Jung to Fairbairn, the Self is constellated and integrated via satisfactory object relations. When object relations are frustrating or hurtful, the self remains fragmented into states, each state corresponding to an unfulfilled, unmet need. 

Each state has its own set of coping strategies, cognitions, and emotions (affects) which revolve around resolving the lack. Each state is invested with aggression. 

The self-states are dormant and reactive to stressors. During hibernation, they are perceived as internal objects.

The cluster B personality disorders (narcissistic, borderline, and antisocial-psychopathy) may be mere kaleidoscopic facets of an underlying dissociative process, amounting, in extreme cases, to full-fledged DID (Dissociative Identity Disorder, formerly known as Multiple Personality Disorder) or maybe OSDD (Other Specified Dissociative Disorder). In other words: these personality types may be conceived as self-states, "alters" of each other. 

Having endured narcissistic injury or mortification, a trauma, or severe anxiety and stress, these patients decompensate and act out along predictable pathways: the borderline becomes a vicious secondary psychopath, the primary psychopath morphs into a rabid grandiose narcissist, and the quavering narcissist shape-shifts into a codependent clinging borderline. These phase transitions are startling to behold and throw off even the most experienced clinician. 

A lot of this has to do with the fact that cluster B disordered personalities find it nearly impossible to access, process, or regulate both emotions and cognitions. 

These gaping deficits interfere with the meanings that these patients attribute to the events in their lives and to people around them. 

The psychopath sees no meaning whatsoever in anything or anyone. The borderline regards herself as meaningless and everyone and everything else as mission critical to her personal autonomy and self-efficacious agency. The narcissist regards only himself as totally meaningful, draining all the rest of any significance. 

When under radical pressure, these actors attempt to reframe the situation in a less injurious manner by reallocating and relocating the foci of meaning, thus seamlessly and smoothly transitioning between these extended and extensive role plays that we call "personality disorders".''

Both narcissists and borderlines alternate between fantasy and reality - but their fantasies are very different. The borderline's is object (person)-centred, the narcissist's is process (narrative)-centred.  Moreover: the fantasies cater to the narcissist's and borderline's deepest psychological needs.  

1. Co-Idealization through lovebombing: the introjected partner is idealized and the narcissist is all good because he is the owner of an ideal object;
2. Dual mothership in a shared fantasy: a recreation of early childhood by converting both partners into maternal figures, unconditionally accepting and loving. The partner regresses and, as an infant, falls in love with her own idealized image via the narcissist’s gaze (“hall of mirrors” effect);
3. The need to reenact the failed separation in the narcissist’s childhood leads to a mental discard which results in a narcissistic injury as it implies that the narcissist is not omniscient because his judgment of his erstwhile partner as ideal was wrong;
4. Devaluation of the external object in order to restore the narcissist’s grandiosity (make an ego-congruent sense of the discard of an hitherto idealized object);
5. Devaluation of the partner’s introject via the splitting defense (introject is now all-bad, the narcissist is grandiosely all-good);
6. Real life discard: projection of introject onto the partner in an attempt to integrate it with the external object. This attempt at projection-integration fails owing to abandonment anxiety triggered by the partner’s introject inconstancy and refusal to own a split, all-bad introject. Thus, the devalued, split, all-bad introject remains as an internal object, in narcissist's mind. This creates anxiety and dissonance (owing to the internalization-introjection of a bad object which represents the partner);
7. The only way to reintegrate this internal object and reduce anxiety is by re-idealizing the external object and the corresponding introject. This is impossible to accomplish if the narcissist has been mortified. He then departs from his previous version and reinvents himself which allows for self-idealization and self-supply (grandiosity restored).

A scientifically rigorous psychology should start with the external environment: stimuli conveyed to the brain via sensa and the ecosystem of information, 95% of which remains unconscious. 

The internal environment is comprised of reactions to the external environment and interactions between processes such as cognitions and emotions. The idea of an immutable core identity is, therefore, counterfactual: no fixed entity can efficaciously cope with a shapeshifting and ever-transforming reality. Instead of a unitary lifespan-long Self, in the footsteps of the likes of Philip Bromberg, I propose an ensemble of self-states, each one of which is optimized for a specific environment. 

The self-states are automatically triggered. The one best adapted to the exigencies and demands of an idiosyncratic milieu becomes dominant while the others are rendered latent and dormant. The self-states are not dissociated. They share resources and assets such as the individual’s intelligence and memories. 

Some autonomous or continuous background mental processes might conflict with the self-state. To avoid dissonance and the ensuing anxiety, they are silenced with the aid of constructs. Each construct is unique to a specified self-state. 

The constructs are stable organizing and hermeneutic-exegetic (interpretative) principles. Constructs mediate, structure, and filter external reality (experience) by reframing it while also regulating the internal environment.

Constructs make sense and impose a meaningful narrative on raw sensa as well as on internal data. They are like theories: they yield predictions. But all the output is censored to conform to the self-state (cognitively and emotionally distorted). 

The ego and the persona are instances of constructs. Like defense mechanisms, constructs impair reality testing in order to buttress the self-state and maintain its coherence and cohesion. Like membranes, constructs selectively suppress any input that challenges the self-state or undermines it. 

Constructs, therefore, ensure ego-congruency and ego-syntony by generating a database of information that is both relevant to the self-state and supportive of it. 

Constructs also tackle memories that vitiate or contradict the self-state and thus engender dissonance and anxiety.

The construct either silences such memories or reframes them into compatibility with the self-state. It accomplishes this feat in one of three ways: 1. By dissociating the memories; 2. By altering the emotional content and correlates of the memory to conform to that of the self-state; and 3. By weighing memories differently and selectively (selective memory). 

To accomplish the reconciliation of the self-state to both the external and the internal environments, the constructs call upon (interpellate) introjects (internalized voices of meaningful others, such as parents, teachers, peers, and society at large). The conscience is an example of a cluster of introjects that is often made use of by constructs. 

In order to avoid dissonance and anxiety, we make peace with our introjects by misidentifying them as our own authentic voices (attribution error).The introjects generate automatic thoughts, both positive and negative. They are always on standby. They interfere with daily functioning once they are triggered. 

The constructs organize the introjects’s output according to a set of selection criteria and principles (“identity”).

“Identity” is an algorithm which maps self-states and their attendant constructs to specific environments. It determines which introjects are activated. It is a set of principles and operating routines which regulate the emergence and submergence of self-states. Identity changes only glacially and so gives the illusory impression of stability and continuity. The “personality” is comprised of the selection criteria (aforementioned algorithm) combined with the resultant self-states. 

The individual is cathected (emotionally invested) in the self-state. S/he wants to validate it and thus preserve the comfort zone. One of the functions of the automatic thoughts is to drown out the processes which negate the self-state or conflict with it. The other function is to affect and modify behaviors. 

Some behaviors are inhibited or negatively reinforced by the construct, using the automatic thoughts spewed out by the introjects. Other actions are positively reinforced. 

This way, the construct induces or fosters only behaviors whose consequences modify the environment to fit the self-state even as it suppresses all other forms of conduct. 

The construct is goal-oriented. The choice of behaviors is secondary and rationalized. Self-efficacy is the overriding aim. The construct leverages external inputs to regulate the internal landscape. The construct creates a paracosm, a virtual reality to fit and uphold the self-state. It is a harmonizing central authority. 

This model sheds new light on basic concepts in psychology. “Defense mechanisms” render palatable the outcomes of positively reinforced behaviors and prevent secondary anxiety, shame, and guilt. “Mental illness” occurs when the self-states are mutually exclusive or oppositional or incompatible and the transition from one self-state to another is disrupted for a variety of reasons (mainly when the self-state is suboptimal). 

The principle of non-contradiction in the repertory of self-states and the smooth transmission of power between self-states are the bedrocks of mental health. Conflicting self-states coupled with constructs compete for resources in a host of mental health disorders. 

With every new environment, the algorithm selects an optimal self-state which takes over the individual. There is a momentary disorientation in the dissociative gaps between consecutive self-states.In other words: the continuity of memory, identity, and personality is a myth or, at best, a convenient and idealized abstraction. 

Self-states are anxiolytic and therapy is anxiogenic. But gradually, therapy helps the client evolve a new algorithm which selects for self-states which are less self-defeating or self-destructive and more functional. Constructs, introjects, memories, defences [1-36].

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