Narcissism with Other Mental Health Disorders (Co-Morbidity and Dual Diagnosis)

Question:

Does narcissism often occur with other mental health disorders (co-morbidity) or with substance abuse (dual diagnosis)?

Answer:

NPD (Narcissistic Personality Disorder) is often diagnosed with other mental health disorders (such as the Borderline, Histrionic, or Antisocial personality disorders). This is called "co-morbidity". It is also often accompanied by substance abuse and other reckless and impulsive behaviors and this is called "dual diagnosis".

The Schizoid and Paranoid Personality Disorders

The basic dynamic of this particular brand of co-morbidity goes like this:

1. 1. The narcissist feels superior, unique, entitled and better than his fellow men. He thus tends to despise them, to hold them in contempt and to regard them as lowly and subservient beings.
   2. The narcissist feels that his time is invaluable, his mission of cosmic importance, his contributions to humanity priceless. He, therefore, demands total obedience and catering to his ever-changing needs. Any demands on his time and resources is deemed to be both humiliating and wasteful.
   3. But the narcissist is dependent on input from other people for the performance of certain ego functions (such as the regulation of his sense of self worth). Without Narcissistic Supply (adulation, adoration, attention), the narcissist shrivels and withers and is dysphoric (=depressed).
   4. The narcissist resents this dependence. He is furious at himself for his neediness and - in a typical narcissistic maneuver (called "alloplastic defence") - he blames others for his anger. He displaces his rage and its roots.
   5. Many narcissists are paranoids. This means that they are afraid of people and of what people might do to them. Wouldn't you be scared and paranoid if your very life depended continually on the goodwill of others? The narcissist's very life depends on others providing him with Narcissistic Supply. He becomes suicidal if they stop doing so.
   6. To counter this overwhelming feeling of helplessness (=dependence on Narcissistic Supply), the narcissist becomes a control freak. He sadistically manipulates others to satisfy his needs. He derives pleasure from the utter subjugation of his human environment.
   7. Finally, the narcissist is a latent masochist. He seeks punishment, castigation and ex-communication. This self-destruction is the only way to validate powerful voices he had internalized as a child ("you are a bad, rotten, hopeless child").

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 more on Narcissists and Schizoids in FAQ 67.

Read more about the narcissist's reactions to deficient Narcissistic Supply:

The Delusional Way Out

The Roots of Paranoia

HPD (Histrionic Personality Disorder) and Somatic NPD

"Somatic narcissists" acquire their Narcissistic Supply by making use of their bodies, of sex, of physical of physiological achievements, traits, health, exercise, or relationships. They possess many Histrionic features.

Click here to read the DSM-IV-TR (2000) definition of the Histrionic Personality Disorder.

Narcissists and Depression

Many scholars consider pathological narcissism to be a form of depressive illness. This is the position of the authoritative magazine "Psychology Today". The life of the typical narcissist is, indeed, punctuated with recurrent bouts of dysphoria (ubiquitous sadness and hopelessness), anhedonia (loss of the ability to feel pleasure), and clinical forms of depression (cyclothymic, dysthymic, or other). This picture is further obfuscated by the frequent presence of mood disorders, such as Bipolar I (co-morbidity).

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While the distinction between reactive (exogenous) and endogenous depression is obsolete, it is still useful in the context of narcissism. Narcissists react with depression not only to life crises but to fluctuations in Narcissistic Supply.

The narcissist's personality is disorganised and precariously balanced. He regulates his sense of self-worth by consuming Narcissistic Supply from others. Any threat to the uninterrupted flow of said supply compromises his psychological integrity and his ability to function. It is perceived by the narcissist as life threatening.

I. Loss Induced Dysphoria

This is the narcissist's depressive reaction to the loss of one or more Sources of Narcissistic Supply or to the disintegration of a Pathological Narcissistic Space (PN Space, his stalking or hunting grounds, the social unit whose members lavish him with attention).

II. Deficiency Induced Dysphoria

Deep and acute depression which follows the aforementioned losses of Supply Sources or a PN Space. Having mourned these losses, the narcissist now grieves their inevitable outcome the absence or deficiency of Narcissistic Supply. Paradoxically, this dysphoria energises the narcissist and moves him to find new Sources of Supply to replenish his dilapidated stock (thus initiating a Narcissistic Cycle).

III. Self-Worth Dysregulation Dysphoria

The narcissist reacts with depression to criticism or disagreement, especially from a trusted and long-term Source of Narcissistic Supply. He fears the imminent loss of the source and the damage to his own, fragile, mental balance. The narcissist also resents his vulnerability and his extreme dependence on feedback from others. This type of depressive reaction is, therefore, a mutation of self-directed aggression.

IV. Grandiosity Gap Dysphoria

The narcissist's firmly, though counterfactually, perceives himself as omnipotent, omniscient, omnipresent, brilliant, accomplished, irresistible, immune, and invincible. Any data to the contrary is usually filtered, altered, or discarded altogether. Still, sometimes reality intrudes and creates a Grandiosity Gap. The narcissist is forced to face his mortality, limitations, ignorance, and relative inferiority. He sulks and sinks into an incapacitating but short-lived dysphoria.

V. Self-Punishing Dysphoria

Deep inside, the narcissist hates himself and doubts his own worth. He deplores his desperate addiction to Narcissistic Supply. He judges his actions and intentions harshly and sadistically. He may be unaware of these dynamics but they are at the heart of the narcissistic disorder and the reason the narcissist had to resort to narcissism as a defence mechanism in the first place.

This inexhaustible well of ill will, self-chastisement, self-doubt, and self-directed aggression yields numerous self-defeating and self-destructive behaviours from reckless driving and substance abuse to suicidal ideation and constant depression.

It is the narcissist's ability to confabulate that saves him from himself. His grandiose fantasies remove him from reality and prevent recurrent narcissistic injuries. Many narcissists end up delusional, schizoid, or paranoid. To avoid agonising and gnawing depression, they give up on life itself.

Dissociative Identity Disorder and NPD

Is the True Self of the narcissist the equivalent of the host personality in the DID (Dissociative Identity Disorder) and the False Self one of the fragmented personalities, also known as "alters"?

The False Self is a mere construct rather than a full-fledged self. It is the locus of the narcissist's fantasies of grandiosity, his feelings of entitlement, omnipotence, magical thinking, omniscience and magical immunity. But it lacks many other functional and structural elements.

Moreover, it has no "cut-off" date. DID alters have a date of inception, usually 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. The False Self is not a self, nor is it false. It is very real, more real to the narcissist than his True Self.

As Kernberg observed, the narcissist actually vanishes and is replaced by a False Self. There is no True Self inside the narcissist. The narcissist is a hall of mirrors but the hall itself is an optical illusion created by the mirrors. Narcissism is reminiscent of a painting by Escher.

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In DID, the emotions are segregated into personality-like internal constructs ("entities"). The notion of "unique separate multiple whole personalities" is primitive and untrue. DID is a continuum. The inner language breaks down into polyglottal chaos. In DID, emotions cannot communicate with each other for fear of provoking overwhelming pain (and its fatal consequences). So, they are being kept apart by various mechanisms (a host or birth personality, a facilitator, a moderator and so on).

All personality disorders involve a modicum of dissociation. But the narcissistic solution is to emotionally disappear altogether. Hence, the tremendous, insatiable need of the narcissist for external approval. He exists only as a reflection. Since he is forbidden to love his true self he chooses to have no self at all. It is not dissociation it is a vanishing act.

NPD is a total, "pure" solution: self-extinguishing, self-abolishing, entirely fake. Other personality disorders are diluted variations on the themes of self-hate and perpetuated self-abuse. HPD is NPD with sex and body as the source of the Narcissistic Supply. The Borderline Personality Disorder involves lability, the movement between poles of life wish and death wish and so on.

Read more about Pathological Narcissism as the Root of all Personality Disorders:

The Use and Abuse of Differential Diagnoses

Other Personality Disorders

NPD and Attention Deficit Hyperactivity Disorder

NPD has been associated with Attention Deficit / Hyperactivity Disorder (ADHD, or ADD) and with RAD (Reactive 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 to supports this has yet to come to light, though. Still, many psychotherapists and psychiatrists use this linkage as a working hypothesis. Another proposed dynamic is between autistic disorders (such as Asperger's Syndrome) and narcissism.

Misdiagnosing Narcissism - Asperger's Disorder

Narcissism and Bipolar Disorder

Bipolar patients in the manic phase exhibit most of the signs and symptoms of pathological narcissism - hyperactivity, self-centeredness, and control freakery.

More about this connection here:

Misdiagnosing Narcissism - The Bipolar I Disorder

Stormberg, D., Roningstam, E., Gunderson, J., & Tohen, M. (1998) Pathological Narcissism in Bipolar Disorder Patients. Journal of Personality Disorders, 12, 179-185

Roningstam, E. (1996), Pathological Narcissism and Narcissistic Personality Disorder in Axis I Disorders. Harvard Review of Psychiatry, 3, 326-340

Narcissism and Asperger's Disorder

Asperger's Disorder is often misdiagnosed as Narcissistic Personality Disorder (NPD), though evident as early as age 3 (while pathological narcissism cannot be safely diagnosed prior to early adolescence).

More about Autism Spectrum Disorders here:

McDowell, Maxson J. (2002) The Image of the Mother's Eye: Autism and Early Narcissistic Injury , Behavioral and Brain Sciences (Submitted)

Benis, Anthony - "Toward Self & Sanity: On the Genetic Origins of the Human Character" - Narcissistic-Perfectionist Personality Type (NP) with special reference to infantile autism

Stringer, Kathi (2003) An Object Relations Approach to Understanding Unusual Behaviors and Disturbances

James Robert Brasic, MD, MPH (2003) Pervasive Developmental Disorder: Asperger Syndrome

Misdiagnosing Narcissism - Asperger's Disorder

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Narcissism and Generalized Anxiety Disorder

Anxiety Disorders - and especially Generalized Anxiety Disorder (GAD) - are often misdiagnosed as Narcissistic Personality Disorder (NPD).

Misdiagnosing Narcissism - Generalized Anxiety Disorder

BPD, NPD and other Cluster B PDs (Personality Disorders)

All personality disorders are interrelated, at least phenomenologically. There is no Grand Unifying Theory of Psychopathology. We do not know whether there are and what are the mechanisms underlying mental disorders. At best, mental health professionals record symptoms (as reported by the patient) and signs (as observed). Then, they group them into syndromes and, more specifically, into disorders.

This is descriptive, not explanatory science. The few theories extant (psychoanalysis, to mention the most famous) all fail miserably at providing a coherent, consistent theoretical framework with predictive powers.

Patients suffering from personality disorders have many things in common:

1. Most of them are insistent (except those suffering from the Schizoid or the Avoidant Personality Disorders). They demand treatment on a preferential and privileged basis. They complain about numerous symptoms. They never obey the physician or his treatment recommendations and instructions.
2. They regard themselves as unique, display a streak of grandiosity and a diminished capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the physician as inferior to them, alienate him using umpteen techniques and bore him with their never-ending self-preoccupation.
3. They are manipulative and exploitative because they trust no one and usually cannot love or share. They are socially maladaptive and emotionally unstable.
4. Most personality disorders start out as problems in personal development which peak during adolescence. They are enduring qualities of the individual. Personality disorders are stable and all-pervasive not episodic. They affect most of areas of life: the patient's career, his interpersonal relationships, his social functioning.
5. Patients with personality disorders are rarely happy. They are depressed and suffer from auxiliary mood and anxiety disorders. But their defenses are so strong that they are aware only of their recurrent dysphorias and not of the underlying etiology (problems and reasons that cause their mood swings and anxiety). Patients with personality disorders are, in other words, consciously ego-syntonic, except in the immediate aftermath of a life crisis.
6. The patient with a personality disorder is vulnerable to and prone to suffer from a host of other psychiatric problems. It is as though his psychological immunological system is disabled by the personality disorder and he falls prey to other variants of mental illness. So much energy is consumed by the disorder and by its corollaries (example: by obsessions-compulsions), that the patient is rendered defenseless.
7. Patients with personality disorders have alloplastic defenses (external loci of control). In other words: they tend to blame the world for their mishaps and failures. In stressful situations, they try to preempt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the outside world to fulfil their needs. This is as opposed to autoplastic defenses (internal loci of control) typical of neurotics (who change their internal psychological processes in stressful situations).
8. The character problems, behavioral and cognitive deficits and emotional deficiencies and instability encountered by the patient with personality disorders are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behavior objectionable, unacceptable, disagreeable, or alien to his self. Neurotics, in contrast, are ego-dystonic: they do not like who they are and how they behave.
9. The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from the Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (American Psychiatric Association, DSM-IV-TR, Washington D.C., 2000) 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."

Click here to read the DSM-IV-TR (2000) definition of personality disorders.

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Each personality disorder has its own form of Narcissistic Supply:

• HPD (Histrionic PD) Derive their supply from their heightened sexuality, seductiveness, flirtatiousness, from serial romantic and sexual encounters, from physical exercises, and from the shape and state of their body;
• NPD (Narcissistic PD) Derive their supply from garnering attention, both positive (adulation, admiration) and negative (being feared, notoriety);
• BPD (Borderline PD) Derive their supply from the presence of others (they suffer from separation anxiety and are terrified of being abandoned);
• AsPD (Antisocial PD) Derive their supply from accumulating money, power, control, and having (sometimes sadistic) "fun".

Borderlines, for instance, can be described as narcissists with an overwhelming fear of abandonment. They are careful not to abuse people. They do care deeply about not hurting others but for a selfish motivation (they want to avoid rejection).

Borderlines depend on other people for emotional sustenance. A drug addict is unlikely to pick up a fight with his pusher. But Borderlines also have deficient impulse control, as do Antisocials. Hence their emotional lability, erratic behavior, and the abuse they do heap on their nearest and dearest. 

Abandonment, NPDs and Other PDs

• Both narcissists and Borderlines are afraid of abandonment. Only their coping strategies differ. Narcissists do everything they can to bring about their own rejection (and thus "control" it and "get it over with"). Borderlines do everything they can either to avoid relationships in the first place or to prevent abandonment once in a relationship by clinging to the partner or by emotionally extorting his continued presence and commitment.
• Seductive behavior alone is not necessarily indicative of Histrionic PD. Somatic narcissists behave this way as well.
• The differential diagnoses between the various personality disorders are blurred. It is true that some traits are much more pronounced (or even qualitatively different) in specific disorders. For example: delusional, expansive, and all-pervasive grandiose fantasies are typical of the narcissist. But, in a milder form, they also appear in many other personality disorders, such as the Paranoid, the Schizotypal, and the Borderline.
• It would seem that personality disorders occupy a continuum.

NPD and BPD - Suicide and Psychosis

A sense of entitlement is common to all Cluster B disorders.

Narcissists almost never act on their suicidal ideation Borderlines do so incessantly (by cutting, self injury, or mutilation). But both tend to become suicidal under severe and prolonged stress.

NPDs can suffer from brief reactive psychoses in the same way that Borderlines suffer from psychotic microepisodes.

There are some differences between NPD and BPD, though:

1. 1. The narcissist is way less impulsive;
   2. The narcissist is less self-destructive, rarely self-mutilates, and practically never attempts suicide;
   3. The narcissist is more stable (displays reduced emotional lability, maintains stability in interpersonal relationships and so on).

NPD and Antisocial PD

Psychopaths or Sociopaths are the old names for Antisocial Personality Disorder (AsPD). The line between NPD and AsPD is very thin. AsPD may simply be a less inhibited and less grandiose form of NPD.

The important differences between narcissism and the antisocial personality disorder are:

• Inability or unwillingness to control impulses (AsPD);
• Enhanced lack of empathy on the part of the psychopath;
• The psychopath's inability to form relationships, not even narcissistically twisted relationships, with other humans;
• The psychopath's total disregard for society, its conventions, social cues and social treaties.

As opposed to what Scott Peck says, narcissists are not evil they lack the intention to cause harm (mens rea). As Millon notes, certain narcissists "incorporate moral values into their exaggerated sense of superiority. Here, moral laxity is seen (by the narcissist) as evidence of inferiority, and it is those who are unable to remain morally pure who are looked upon with contempt." (Millon, Th., Davis, R. - Personality Disorders in Modern Life - John Wiley and Sons, 2000)

Narcissists are simply indifferent, callous and careless in their conduct and in their treatment of others. Their abusive conduct is off-handed and absent-minded, not calculated and premeditated like the psychopath's.

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NPD and Neuroses

The personality disordered maintain alloplastic defenses (react to stress by attempting to change the external environment or by shifting the blame to it). Neurotics have autoplastic defenses (react to stress by attempting to change their internal processes, or assuming blame). Personality disorders also tend to be ego-syntonic (i.e., to be perceived by the patient as acceptable, unobjectionable and part of the self) while neurotics tend to be ego-dystonic (the opposite).

The Hated-Hating Personality Disordered

One needs only to read scholarly texts to learn how despised, derided, hated and avoided patients with personality disorders are even by mental health practitioners. Many people don't even realize that they have a personality disorder. Their social ostracism makes them feel victimized, wronged, discriminated against and hopeless. They don't understand why they are so detested, shunned and abandoned.

They cast themselves in the role of 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 emotions. They project these 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 expectations and their view of the world (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 their partners fulfill this prophecy. They try and make sure that the women in their lives behave exactly in this manner, that they do not abnegate and ruin the narcissist's craftily, elaborately, and studiously designed Weltanschauung (worldview).

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 these women do, indeed, abandon them. The narcissist then feels vindicated and validated totally ignoring his contribution to this recurrent pattern.

The personality disordered are full of negative emotions, with aggression and its transmutations, hatred and pathological envy. They are constantly seething with rage, jealousy, and other corroding sentiments. Unable to release these emotions (personality disorders are defence mechanisms against "forbidden" feelings) they split them, project them and force others to behave in a way which legitimizes and rationalizes this overwhelming negativity. "No wonder I hate everyone look what people repeatedly did to me." The personality disordered are doomed to incur self-inflicted injuries. They generate the very hate that legitimizes their hatred, which fosters their social ex-communication.

The Borderline Narcissist A Psychotic?

Kernberg suggested a "Borderline" diagnosis. It is somewhere between psychotic and neurotic (actually between the psychotic and the personality disordered):

• Neurotic autoplastic defenses (something's wrong with me);
• Personality disordered alloplastic defenses (something's wrong with the world);
• Psychotics something's wrong with those who say that something's wrong with me.

All personality disorders have a clear psychotic streak. Borderlines have psychotic episodes. Narcissists react with psychosis to life crises and in treatment ("psychotic microepisodes" which can last for days).

Narcissism, Psychosis, and Delusions

Masochism and Narcissism

Isn't seeking punishment a form of assertiveness and self-affirmation?

Author Cheryl Glickauf-Hughes, in the 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 behavior may also be viewed as self-affirming behavior on the part of the child toward the narcissistic parent."

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The Inverted Narcissist A Masochist?

The Inverted Narcissist (IN) is more of a codependent than a masochist.

Strictly speaking masochism is sexual (as in sado-masochism). But the colloquial term means "seeking gratification through self-inflicted pain or punishment". This is not the case with codependents or IN's.

The Inverted Narcissist is a specific variant of codependent that derives gratification from her relationship with a narcissistic or a psychopathic (Antisocial personality disordered) partner. But her gratification has nothing to do with the (very real) emotional (and, at times, physical) pain inflicted upon her by her mate.

Rather the IN is gratified by the re-enactment of past abusive relationships. In the narcissist, the IN feels that she has found a lost parent. The IN seeks to re-create 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 for her partner, the IN ensures an identical outcome time and again. Why should one choose to repeatedly fail in her relationships is an intriguing question. Partly, it has to do with 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 and pedophilia.

Incest is an autoerotic 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.

I analyzed the relationship between narcissism and homosexuality in FAQ 18.

 

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