QUESTION NUMBER 8 - Narcissistic Personality Disorder and other mental health disorders
What is the difference between NPD and BPD (borderline Personality Disorder), OCD (Obsessive-Compulsive Disorder), AsPD (Antisocial PD), and other mental health disorders?
The Pathological Solutions
We are all narcissists at an early stage of our lives. As infants, we feel that we are the centre of the universe, omnipotent and omniscient. Our parents, those mythical figures, immortal and awesomely powerful, are there only to protect us. Both self and others are viewed immaturely, as idealisations. Inevitably, the inexorable processes and conflicts of life erode these perceptions. Disappointment follows disillusionment. If gradual and tolerable they yield adaptation. If abrupt, capricious, arbitrary, and intense the injuries sustained by the tender, budding, self-esteem, are irreversible. Moreover, the empathic support of caretakers (the Primary Objects, the parents), role models, and peers is crucial. In its absence, the self-esteem in adulthood tends to fluctuate, to alternate between over-valuation (idealisation) and devaluation of both the self and others. Narcissistic adults are the result of bitter disappointment, of radical disillusionment with their parents. Healthy adults accept their self-limitations (=the limitations, the boundaries, of their selves). They accept disappointments, setbacks, failures, criticism and disillusionment with grace and tolerance. Their self-esteem is constant and positive, not affected by outside events, no matter how severe.
Horrified by the absence of a clearly bounded, cohesive, coherent, reliable, and self-regulating self the mentally abnormal person resorts to one of the following solutions, all of which involve reliance upon fake or invented personality elements:
a. The Narcissistic Solution The substitution of the True Self with a False Self. The narcissistic solution is the subject of this book. The Schizotypal Personality Disorder largely belongs here because of its emphasised fantastic and magical thinking. The Borderline Personality Disorder is a case of a failed narcissistic solution. In BPD, the patient is aware (at least unconsciously) that the solution that he adopted is "not working". This is the source of his anxiety (something is fuzzily wrong, or a foreboding sense, a premonition is present), of his fear of abandonment (by the solution). This generates his identity disturbance, his affective instability, suicidal ideation and suicidal action, chronic feelings of emptiness, rage attacks, and transient (stress related) paranoid ideation.
b. The Appropriation Solution This is the appropriation, the confiscation of someone else's self in order to fill the vacuum left by the absence of a functioning Ego. While some of the Ego functions are available the others are assumed and adopted by the "appropriating personality". The Histrionic Personality Disorder is an example of this solution. Mothers who "sacrifice" their lives for their children, people who live vicariously, through others all belong to this category. So do people who dramatise their lives and their behaviour, in order to attract attention. The "appropriators" misjudge the intimacy of their relationships and the degree of commitment involved, they are easily suggestible and their whole personality seems to shift and fluctuate with input from the outside. Because they have no Self of their own (even more so then narcissists) the "appropriators" tend to over-rate and over-emphasise their bodies. Perhaps the most striking example of this type of solution is the Dependent Personality Disorder.
c. The Schizoid Solution These patients are mental zombies, trapped forever in the no-man's land between stunted growth and the narcissistic default. They are not narcissists because they lack a False Self nor are they fully developed adults, because their True Self is immature and dysfunctional. They prefer to avoid contact with others (they lack empathy, as the narcissist does) in order not to upset their delicate tightrope act. Withdrawing from the world is an adaptive solution because it does not expose the inadequate personality structures (especially the self) to onerous and failure bound tests. The Schizotypal Personality Disorder patient is a mixture of the narcissistic and the schizoid solutions. The Avoidant Personality Disorder is a close kin.
d. The Aggressive Destructive Solution These people suffer from hypochondriasis, depression, suicidal ideation, dysphoria, anhedonia, compulsions and obsessions and other expressions of internalised and transformed aggression directed at a self which is perceived to be inadequate, guilty, disappointing and worthy of nothing but elimination. Many of the narcissistic elements are present in an exaggerated form. Lack of empathy becomes reckless disregard for others, irritability, deceitfulness and criminal violence. Undulating self-esteem is transformed into impulsiveness and failure to plan ahead. The Antisocial Personality Disorder is a prime example of this solution, whose essence is: the total control of a False Self, without the mitigating presence of a shred of True Self.
Perhaps this common feature the replacement of the original structures of the personality by new, invented, mostly false ones is what causes one to see narcissists everywhere. This common denominator is most accentuated in the Narcissistic Personality Disorder. The interaction, really, the battle, between the struggling original remnants of the personality and the malignant and omnivorous new structures can be discerned in all forms of psychic abnormality. The question is: if many phenomena have one thing in common should they be considered one and the same?
I say that the answer in the case of personality disorders should be in the affirmative. I think that all the known personality disorders are forms of malignant self-love. In each personality disorder, different attributes are differently emphasised, different weights attach to different behaviour patterns. But these, in my view, are all matters of quantity, not of quality. The myriad heads of the deformation of the reactive patterns collectively known as "personality" all belong to the same medusa.
NPD (Narcissistic Personality Disorder) is often diagnosed with other mental health disorders (such as the Borderline, Histrionic, or Antisocial personality disorder). This is called "co-morbidity". It is also often accompanied by substance abuse and other reckless and impulsive behaviours and this is called "dual diagnosis".
But there is one curious match, one logic-defying co-appearance of mental health disorders: narcissism and the Schizoid personality disorder (see FAQ 67).
Narcissistic PD and Schizoid PD
The basic dynamic of this particular brand of co-morbidity goes like this:
As you can easily see, the narcissistic landscape is fraught with contradictions. The Narcissist depends on people - but hates and despises them. He wants to control them unconditionally - but is also looking to punish himself savagely. He is terrified of persecution ("persecutory delusions") - but seeks the company of his own "persecutors" compulsively. The narcissist is the victim of incompatible inner dynamics, ruled by numerous vicious circles, pushed and pulled simultaneously by irresistible forces. A minority of narcissists choose the SCHIZOID SOLUTION. They choose, in effect, to disengage, both emotionally and socially (see below and in FAQ 67).
HPD (Histrionic Personality Disorder) and Somatic NPD
I "invented" another twilight zone category between NPD and HPD, which I call "somatic narcissists". These are narcissists who acquire their narcissistic supply by making use of their bodies, of sex, of physical of physiological achievements, traits, health, exercise, or relationships.
Here is how the DSM IV defines HPD:
"A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
Narcissists and Depression
If by "depression" we also mean "numbness" then narcissists are often depressed. Most narcissists are simply numb, emotionally absent, non-existent. Their emotions are not accessible, not "available" to them. So, they inhabit a grey emotional twilight zone. The world looks false, fake, invented, contrived, in wrong hues. But they do not have a sense of living in prison. Once in prison, the inmate remembers there's an outside world and a way out. Not so in narcissism. The outside has long faded into oblivion. And there's no way out.
Narcissism and OCD
Both narcissists and people suffering from OCD (Obsessive-Compulsive Disorder) obey a False Self - an artificial psychological construct that undermines the True Self and replaces it. The False Self is concerned exclusively with outward appearances and with the securing of narcissistic supply (approval, adulation, acceptance, attention, fame). It is rigid, sadistic, and demanding. Both OCD's and narcissists behave like "machines" or "automata". This inner compulsion is coupled with lack of empathy, relentlessness, and ruthlessness in the pursuit of goals set by the False Self.
The OCD's structured and ritualistic False Self compensates for the paralyzing anxiety that is the outcome of lack of self-confidence and self-worth, and severe and tormenting self-doubt and self-criticism. The narcissist's False Self shields him from narcissistic injuries and helps to regulate his fluctuating sense of self-worth. Thus, the narcissist lacks the perfectionism of the OCD. But both deny reality, are self-delusional, and socially inept.
Narcissists and OCD's are terrified of their own (overwhelmingly negative) emotions. They "choose" not to feel at all - rather than risk emotional flooding. Both types are prone to an inexplicable and fierce rage attacks - the results of inner dynamics. They both feel superior to others and entertain grandiose notions of themselves - though the focus of grandiosity would be different. The Narcissist is proud of his "achievements", "standing", "reputation", "possessions". The OCD is proud of his virtuous traits - self control, reliability, perfection, restraint, knowledge, intelligence, righteousness, etc. They both expend inordinate amount of mental energy on managing their anxieties and tensions and on maintaining their precariously balanced personalities by repressing their emotions. This - and their obsession with hierarchy, power, and control - prevent them from having meaningful, or successful, or long term relationships.
Paradoxically, both narcissists and OCD's are likely to engage in reckless and self-defeating behaviours. They derive their sense of self worth from their interactions with their environment. They are, thus, compelled to ACT incessantly and impulsively. When, inevitably, reality falls short of their invariably unrealistic expectations and grandiose fantasies ("the grandiosity gap") - they experience depression and even suicidal ideation.
DID and NPD
Is the False Self an alter? In other words: is the True Self of a narcissist the equivalent of a host personality in a DID (Dissociative Identity Disorder) and the False Self - one of the fragmented personalities, also known as "alters"?
My personal opinion is that the False Self is a construct, not a self in the full sense. It is the locus of the fantasies of grandiosity, the feelings of entitlements, omnipotence, magical thinking, omniscience and magical immunity of the narcissist. It lacks so many other elements that it can hardly be called a "self". Moreover, it has no "cut-off" date. DID alters have a date of inception, as a reaction to trauma or abuse (they have an age). The False Self is a process, not an entity, it is a reactive pattern and a reactive formation. All taken into account, the choice of words by various theoreticians was poor. The False Self is not a self, nor is it false. It is very real, more real to the narcissist than his True Self. A better choice would have been "abuse reactive self" or something to that effect.
I say that narcissists vanish and are replaced by a False Self (Kernberg). There is NO True Self in there. It's gone. The Narcissist is a hall of mirrors but the hall itself is an optical illusion created by the mirrors... This is a little like the paintings of Escher.
MPD (DID) is more common than believed. Those are the emotions that are segregated. The notion of "unique separate multiple whole personalities" is primitive and untrue. DID is a continuum. The inner language breaks down into polyglotal chaos. Emotions cannot communicate with each other for fear of pain (and its fatal results). So, they are being kept apart by various mechanisms (a host or birth personality, a facilitator, a moderator and so on).
All PDs except NPD suffer from a modicum of dissociation. The narcissistic solution is to emotionally disappear. Hence, the tremendous, insatiable need of the narcissist for external approval. He exists ONLY as a reflection. Since he is forbidden to love his self he chooses to have no self at all. It is not dissociation it is a vanishing act.
This is why I regard pathological narcissism as THE source of all PDs. The total, "pure" solution is NPD: self-extinguishing, self-abolishing, totally fake. Then come variations on the self-hate and perpetuated self-abuse themes: HPD (NPD with sex/body as the source of the narcissistic supply), BPD (lability, movement between poles of life wish and death wish) and so on.
Why are narcissists not prone to suicide? Simple: they died a long time ago. They are the true zombies of the world. Read vampire and zombie legends and you will see how narcissistic these creatures are.
NPD and ADHD
NPD has been associated lately with Attention Deficit / Hyperactivity Disorder (ADHD or ADD) and with RAD (attachment Disorder). The rationale is that children suffering from ADHD are unlikely to develop the attachment necessary to prevent a narcissistic regression (Freud) or adaptation (Jung). Bonding and object relations ought to be affected by ADHD. Research, which supports this has yet to be made available. Still, many psychotherapists and psychiatrists use it as a working hypothesis. Another proposed linkage is between autistic disorders (such as Asperger's Syndrome) and Narcissism. The fact is that both ADHD and patients suffering from Asperger's syndrome are often mis-diagnosed as pathological narcissists (NPD) - and vice versa.
BPD, NPD and other Cluster B PDs
People who suffer from Cluster B personality disorders have many things in common:
The Diagnostics and Statistics Manual (DSM) IV (1994) defines "personality" as:
"...Enduring patterns of perceiving, relating to, and thinking about the environment and oneself... exhibited in a wide range of important social and personal contexts."
It defines personality disorders as:
A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
a. Cognition (i.e., ways of perceiving and interpreting self, other people, and events);
b. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response);
c. Interpersonal functioning;
d. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).
I think that each PD has its own form of narcissistic supply:
To my mind, BPDs, for instance, are NPDs who are scared of being abandoned. They know that if they hurt people, the latter might abandon them. So, they are very careful. They DO care deeply about not hurting others but this is a selfish motivation: they don't want to lose those others, they are dependent on them. If you are a drug addict, you are not likely to pick up a fight with your pusher. BPDs also have deficient impulse control and emotional lability, as do AsPDs.
Each PD has its own "story", a "narrative". The way to healing is replete with the ostracons of these narratives. To heal, a PD MUST break through his or her narrative and OUT into the world and to assume personal responsibility.
All PDs engage in scapegoating and bag-punching. Their parents, abusers, the world, God, or history are responsible for what they are and what we do DECADES after the original abuse. Research shows that the brain is more plastic than many thought it to be. One can CHOOSE to heal. If one doesn't it is because there is gain in infirmity.
The important differences between narcissism and the antisocial personality disorder (AsPD or psychopaths, in the old terminology) are:
As opposed to what Scott Peck says, narcissists are not evil they lack the intention to cause harm.
They are simply indifferent, callous and careless in their conduct and in their treatment of their fellow humans.
NPDs and Other PDs
A few points to ponder:
The Hated-Hating Personality Disordered
Personality disordered people are usually hated. One needs only to read professional texts to see how despised, derided, hated and avoided the personality disordered are even by the therapeutic professions. Because many people don't even realize that they suffer from a personality disorder they feel victimized, wronged, discriminated against and hopeless. They don't understand why they are so hated, avoided and abandoned. They define themselves as victims and attribute mental disorders to others ("pathologizing").
They employ the primitive defence mechanisms of splitting and projection augmented by the more sophisticated mechanism of projective identification.
In other words:
They "split off" from their personality the bad feelings of hating and being hated because they cannot cope with negative feelings.
Then, they project these feelings unto others ("He hates me, I don't hate anyone", "I am a good soul, but he is a psychopath", "He is stalking me, I just want to stay away from him", "He is a con-artist, I am the innocent victim").
Then they FORCE others to behave in a way that JUSTIFIES their projections and models (projective identification followed by counter projective identification).
Some narcissists, for instance, firmly "believe" that women are evil predators, out to suck their lifeblood and then abandon them. So, they try and make them fulfill the prophecy. They try and make sure that women behave exactly in this manner, that they do not abnegate and ruin the model that the narcissist so craftily, so elaborately and so studiously designed.
Such narcissists tease women and betray them and bad mouth them and taunt them and torment them and stalk them and haunt them and pursue them and subjugate them and frustrate them until they do abandon them.
At this stage the narcissist feels vindicated not realizing HIS contribution to this recurrent pattern.
The personality disordered are full of negative emotions. They are filled to the brim with aggression and its transmutations, hatred and pathological envy. They are constantly seething with rage, repressed anger, jealousy and other corroding emotions. Unable to release these emotions (personality disorders are defence mechanisms against "forbidden" emotions) they split them, project them and force others to behave in a way which LEGITIMIZES and EXPLAINS these negative emotions. "No wonder I hate him so look what he did to me." The personality disordered are doomed to inhabit the land of self inflicted injuries. They generate the very hate that legitimizes their hate, which generated the hate in the first place.
The Borderline Narcissist A Psychotic?
Kernberg came up with the "Borderline" diagnosis. It is somewhere between psychotic and neurotic (actually between psychotic and the personality disordered). The differentiation is this:
ALL personality disorders have a clear psychotic streak. Borderlines have psychotic episodes. Narcissists react with psychosis to life crises and in treatment ("psychotic micro-episodes" which can last...days!!!).
NPD and Neuroses
The differences between PDs and neuroses is that PDs have ALLOPLASTIC defenses (react to stress by attempting to change the external environment or by shifting the blame to it) while neurotics have AUTOPLASTIC defenses (react to stress by attempting to change their internal processes, or assuming blame). The second important difference is that PDs TEND to be ego-syntonic (perceived by the patient to be acceptable, unobjectionable and part of the self) while neurotics tend to be ego-dystonic (the opposite).
This is exactly why "PD Clusters" were invented in 1987. I, personally, as I said, feel that there is a continuum BPD-HPD-NPD-AsPD.
A sense of entitlement, for instance, is common to ALL Cluster B disorders. Narcissists almost never act on their suicidal ideation BPDs do so incessantly (cutting Self Injury or mutilation). But both tend to become suicidal in crisis.
NPDs can suffer from brief reactive psychoses exactly as BPDs suffer from psychotic micro-episodes. Actually, there is a whole sub-field in psychodynamic theories of narcissism, which tries to explain the dynamics of reactive psychoses in pathological narcissism.
There are some differences between NPD and BPD, though:
Psychopaths or Sociopaths are the old names for antisocial PD. They are no longer in use, generally. But, the line between NPD and AsPD is very thin. I, personally, believe (especially after my work in prison) that AsPD is simply a less inhibited form of NPD and that applying the two diagnoses to the same person is superfluous.
The differential diagnoses are nowhere near where they should be ideally but are developing by the day. At this stage, diagnosticians are in the habit of diagnosing multiple PDs ("co-morbidity"). It is extremely rare to diagnose a single pure PD. Some textbooks at home which URGE diagnosticians NEVER to render in single diagnosis.
Masochism and Narcissism
Isn't seeking punishment a form of assertiveness and self-affirmation if one is a masochist?
Author Cheryl Glickauf-Hughes, in American Journal of Psychoanalysis, June 97, 57:2, pp 141-148:
"Masochists tend to defiantly assert themselves to the narcissistic parent in the face of criticism and even abuse. For example, one masochistic patient's narcissistic father told him as a child that if he said 'one more word' that he would hit him with a belt and the patient defiantly responded to his father by saying 'One more word!' Thus, what may appear, at times, to be masochistic or self-defeating behaviour may also be viewed as self-affirming behaviour on the part of the child toward the narcissistic parent."
The Inverted Narcissist A Masochist?
The Inverted Narcissist (IN) is described in great detail in FAQ 66.
The IN is much closer to being a co-dependent than a masochist.
Masochism is a whole different ballgame. Strictly speaking it is only of a sexual nature (as in sado-masochism). But the colloquial term means "seeking gratification through pain".
This is not the case with co-dependents or IN. The latter is a specific variant of codependent that derives gratification from a relationship with a narcissist or an anti-social personality disordered partner. But the gratification has nothing to do with the (very real) emotional (and, at times, physical) pain inflicted upon the IN.
Rather, in the case of the IN, the gratification has to do with shadows of the past re-awakened. In the narcissist, the IN feels that he found a lost parent. The IN seeks to re-enact old unresolved conflicts through the agency of the narcissist. There is a latent hope that this time, the IN will get it "right", that THIS emotional liaison or interaction will not end in bitter disappointment and lasting agony.
Yet, by choosing a narcissist, the IN ensures an identical outcome of his relationships time and again. Why should one elect to FAIL in his or her relationships, is an intriguing question. Partly, it is the comfort of familiarity. The IN is used since childhood to failing relationships. It seems that the IN prefers predictability to emotional gratification and to personal development. There are also strong elements of self-punishment and self-destruction added to the combustible mix that is the dyad narcissist-inverted narcissist.
Narcissists and Sexual Perversions
Narcissism has long been thought to be a form of paraphilia (sexual deviation or perversion). It has been closely associated with incest (research supports this) and paedophilia (which research does not, as yet, support).
Incest might be an AUTO-EROTIC act and, therefore, narcissistic.
When a father makes love to his daughter he is making love to himself because she IS 50% himself. It is a form of masturbation and reassertion of control over oneself.
Homosexuality is NOT a sexual perversion. I analyzed the relationship between narcissism and homosexuality in FAQ 19.
A short dialogue regarding FAQ28.
Sam, you're describing here what the empirical-descriptive folks have called "hysteroid dysphoria" (among other things).
No, I am not. I am describing the narcissist's pattern of reaction to deficient narcissistic supply.
A personality disorder is a COMPLEX of hundreds of separate behaviors.
Surely, each behavior pattern taken separately can have a different label.
Moreover, the same behavior pattern can (and often does) occur in a few mental health disorders.
For instance, "hysteroid dysphoria" (I am not a fan of this "definition") is also a part of the cyclothimic disorder.
But, in the CONTEXT of the narcissistic personality disorder what I describe in FAQ 28 is one of a group of recurrent dysphorias identified as early as 1960.
Additionally, do not forget that the Narcissistic PD has finally crystallized as a mental health diagnostic category in 1980. "Discoveries" from 1969 preceding Kohut, Kernberg and even early Millon are absolutely irrelevant in view of today's understanding of narcissism.
Below, I outline the differences based on the text you chose.
It's atypical depression (a specific subtype of nonmelancholic depression) with narcissistic/histrionic/borderline "personality" features. A characterization (from "Atypical Depression" Quitkin et al in "Clinical Advances in Monoamine Oxidase Inhibitor Therapies", Kennedy ed.):
"In 1969, Klein and Davis described a group of patients referred to as `hysteroid dysphorics'. These patients were characterized by strong desire for attention and applause, positive response to amphetamines, and a marked rejection sensitivity (especially in romantic contexts)."
Narcissists do not react only to rejection.
They react to any input verbal, nonverbal, social, implied, real or imagined which is deemed by them to be incommensurate with their inflated self-image.
Often, narcissists react badly to ACCEPTANCE and LOVE rather than to rejection because they have a self-image as mean, vicious, frightening, etc.
XXX (still quoting):
"Leading to frequent depressive episodes."
The narcissist is mostly ego-syntonic (this is why treatment fails in most cases).
His dysphorias are so rare and "reactive" (I don't find the term reactive particularly instructive either) that they have been classified and characterized with great ease.
He is more likely to react with narcissistic rage to rejection of the type described above.
"Features of these depressive episodes frequently included loss of ability to anticipate but not experience pleasure."
One of the major differentiating factors:
Narcissists do not experience serious, prolonged anhedonia.
They immediately distort cognitive input to fit their self-image (It was discovered that they enhance positive inputs rather than reject negative ones).
"Hyperphagia or craving for sweets."
Never noted in narcissists but research is rather lacking, I admit.
"Hypersomnolence, lethargy or inertia, and marked reactivity of mood."
These are classic depressive signs. They describe well a major depressive episode, cyclothimia, dysthimia and other types of depression.
Onset frequently occurred in adolescence without a history of adequate premorbid functioning.
Onset of narcissism AND its dyphorias is at age 2-4. Klein talks about age 6 months and she has a depressive construct (see FAQ 67).
True, the PD itself sets on in early adolescence.
Another interesting feature is, in addition to the general hyperphagia, specific cravings for chocolate (and amphetamines). There is a link to family history of alcoholism (not necessarily in the family of origin). It's thought to be related to a dysregulation in the systems governing reward.
No such connections have been discovered in research. Narcissists are often prone to substance abuse, though (dual diagnosis).
Personally I don't think it's useful to label these folks as personality-disordered ("especially" narcissistic), as it tends to stigmatize them, as well as depriving them of potentially useful medical interventions (response rates to MAOIs, for example, are comparable to those of melancholic depressives). I'm sure that a lot of them do have chaotic childhoods, but then again, a lot of people with chaotic childhoods DON'T grow up to become hysteroid dysphorics, so there has to be more to it than just that, even if it does play some role. The use of the word "hysteroid" emphasizes this it LOOKS like what we assume is a "personality" disorder, but it isn't safe to assume that it IS a PD.
No one diagnoses someone as a narcissist just because he is sad.
FAQ 28 that you are referring to is one of many FAQs. Narcissism is a hypercomplex phenomenon.
I didn't suggest that anyone who matches FAQ 28 is a narcissist (=didn't label and stigmatize them, though I do not regard a mental health diagnosis as a stigma) I suggested that many narcissists match the behaviours described in FAQ 28.
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