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Personality Disorders: BPD and Narcissism

Posted Feb 24 2010 12:00am

This is my third iteration of this post. I change it each time, but there is a discussion in the checkin thread about narcissists and I thought I’d post this here so you can share.


I am reposting the Personality Disorder post and adding a discussion of Borderline Personality Disorder. The other post has hundreds of comments so this might help with navigation. I will also address having Axis I along with Axis II diagnosis. If there is any question about what is written here, please let me know:

People often ask me what exactly is a personality disorder in the clinical sense. Since I was a diagnostic clinician for 5 years I will try to explain this without being too clinical. But feel free to ask questions if I’m not clear.

We used the DSM IV (Diagnostic and Statistical Manual of Mental Disorders) to make clinical diagnoses but I think there is another book for Europe and the rest of the world. In the US we used the DSM and we would have to diagnose 5 axes. The evaluation form would ask for it as well as the insurance company so you had to evaluate the 5 axes.

Axis I is mood disorders, clinical disorders, learning disorders, developmental disorders. When I was practicing, there needs to be something on Axis I. Usually when I was evaluating in the ER it was Major Depressive Episode. That was the most common but also schizophrenia, anxiety disorder, panic disorder, bipolar, ADHD.

If you really don’t want to saddle someone with a diagnosis or don’t really have one, Adjustment Disorder NOS would be the general diagnosis (NOS stands for “not otherwise specified” really a catchall). I usually gave teenagers a diagnosis of Adjustment Disorder. I did not want to saddle a teenager with anything more serious unless it was SO obvious. Many times teenagers who present in the ER with psychiatric complaints are the Identified Patient. I had many an argument with parents and other clinicians and sometimes the ER doc in charge when I would not give a teenager anything stronger than an Adjustment Disorder diagnosis.

Most people will have an Axis I diagnosis and it is not only possible but highly probable that a person with an Axis II diagnosis will also have an Axis I diagnosis. However, Axis I is the common diagnosis and Axis II is not.

If a person has a personality disorder (Axis II), their Axis I may exaggerate it or visa versa. Often times patients with personality disorders will not be med compliant and this will include all of their meds so if there is an Axis I diagnosis, the presence of Axis II will make it more difficult to treat the Axis I.

Axis II is Personality Disorders. Borderline, Narcisstic, Paranoid, Schizoid, Obsessive Compulsive, Histrionic (I think there are 12-15 personality disorders). In most people this would be N/A.

Axis III is medical if you have a medical condition.

Axis IV is any psycho/social factors affecting the diagnosis

Axis V is global assessment functioning on a scale of 1-100

So Axis I are very common disorders. NOTE: people often (and incorrectly) shorten Bipolar Disorder as BPD. Bipolar IS NOT A PERSONALITY DISORDER. It is an Axis I diagnosis. Not that there are not people with both Bipolar and Borderline but please do not confuse the two. They are very very very different clinical presentations and treatment.

Personality Disorders

Axis II is fairly uncommon but characterized by the fact that they are so ingrained in the person and difficult to treat. No matter what the personality disorder, they are extremely difficult to treat and almost impossible to eradicate completely.

There are different “clusters” of personality disorders so it’s best to think of them that way. The first cluster is paranoid and schizoid (not the same as schizophrenic which is an Axis I diagnosis).

The second cluster is histrionic, narcissistic, borderline, antisocial.
These are the personality disorders we will deal with in this post because they have direct bearing on relationships and are also called the dramatic-erratic cluster. If you think about a relationship with someone who has an Axis II, Cluster 2 diagnosis, the term “dramatic-erratic” usually sums it up nicely.

The third cluster is the OCD and dependent and avoidant personalities.

The one that affects relationships the most is the second cluster.

Borderline personalities were the ones that showed up most in my practice and this is characterized by impulse control difficulty, stormy relationships, pushing people away though afraid of being alone, frequent and dramatic mood changes, manipulative behavior.

From the DSM:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. identity disturbance: markedly and persistently unstable self-image or sense of self.

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. chronic feelings of emptiness

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. transient, stress-related paranoid ideation or severe dissociative symptoms

The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.

Borderlines tend to have very tumultuous relationships that are marked by their extreme feelings and the expression of those feelings toward their mate. They swing wildly between intense love and intense hate. The shifts are dramatic. They can veer into intense anger over small matters and veer into intense feelings of loss and abandonment when their mate reacts to the intensity.

The borderline intensity stems from the inability to see anything or experience anything in shades of grey. Borderlines see everything in black and white and many times simply cannot get to the grey. Therefore their partner is often viewed as the most wonderful person on earth one day and the most horrible person the next (the change can also be hour to hour or minute to minute). Because of this continual thrusting of their partner into “all good” or “all bad,” the partners find the relationships very wearing and upsetting.

Borderlines can be impulsive and engage in risky behavior. They have strong emotions and cycle through them rapidly. They can be overcome with intense periods of anxiety or depression. Borderlines have intense bouts of anger and can become physically abusive. It is almost impossible for them to control their emotions and they will sometimes become suicidal. Cutting behavior is often a borderline trait and it stems from having such intense feelings they need to let them out. The pain from the self-mutilation takes the focus off the internal pain.

Although borderlines challenge their loved ones (not just partners but everyone in their lives) with manipulative behavior and angry outbursts and histrionics, they are often petrified of being alone.

Borderlines often feel very misunderstood, judged, persecuted, empty and alone. Despite the fact that their behavior is puzzling and alienating, they don’t understand when people around them have had enough.


Partners of Borderlines:
Having a relationship with someone who has intense fears of abandonment while actively pushing you away, who engages in self-destructive behavior (and sometimes suicidal), has intense and unpredictable mood swings and overpowering feelings of emptiness is difficult if not impossible.

The partners of borderlines tend to be extreme codependents (people I call clinical codependents, meaning that they really need clinical intervention to break the bond with the sick person). They hold on and hold out for the times when the borderline thinks they are the most wonderful person in the world. They gain something from the roller coaster ride, often perceive themselves as nice people who are trying to “help” and can suffer martyrdom (but do not doubt, for one minute, that someone is getting something from being with a borderline–remember–WATER SEEKS ITS OWN LEVEL.…people involved with difficult personalities, whether clinically diagnose-able or not, have their own issues they need to look at.)(A more comprehensive discussion is found below in the narcissism section of this post).

It is very very difficult to recover from BPD. A borderline must work very hard and should be working with a DBT therapist and stay compliant with medication. Most borderlines tend to be manipulative and non-compliant around their medication and oftentimes, less than honest. A borderline personality MUST MUST MUST work very hard and often their disease takes over and undermines the treatment.

I worked with chronic BPDs and saw some progression in very acute cases but there are so many factors that are involved. The most successful patients usually had close relationships with their therapists, committed to the process, usually engaged in DBT therapy and medication and contracted to not cut or self-harm when under duress. But I am not sure that translates into the ability to have a happy and healthy relationship. Their success is usually measured by the ability to not self-mutilate, to stay out of the hospital and to live a fairly functional life. The success is typically NOT measured by happy, healthy relationships because a borderline in a happy, healthy relationship is EXTREMELY rare. While I would never say never, I would say it’s very rare.


People have asked me if borderlines of capable of love. Meaning do they, unlike narcissists, FEEL emotion toward others and I believe that they do absolutely. While narcissists do NOT feel love or empathy toward others I believe that borderlines are indeed capable of that. They are even capable of showing love (as in love is an action) for short periods of time. But their extreme fear of abandonment and deep feelings of emptiness do not allow them to sustain those feelings or those expressions of love. They become consumed by their own pain and turmoil So it is very hard to sustain a relationship with them. Not impossible, but very difficult. Their very fear of abandonment usually (ultimately) causes abandonment (and this is true for anyone that has fear of abandonment even on a lesser scale and was true for me when my fear of abandonment was running the show. In fact, I’ve often said that if I had been evaluated at the peak of my abandonment acting out, I probably would have been diagnosed as a BPD…that is how severe it was).


Narcissism:

Narcisstic personalities tend to have an inflated sense of self, does not respond well to criticism, criticizes others, manipulates, inability to emphathize with others, attention seeking.

From the DSM:

The clinical criteria is: A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:

1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
3. requires excessive admiration
4. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
5. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
6. lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
7. is often envious of others or believes that others are envious of him or her
8. shows arrogant, haughty behaviors or attitudes

Personality disorders, especially cluster 2, are very difficult to overcome and make the partner of the person who has them pretty miserable.

NOTE: Approx 75% of those with NPD are male. NPDs make up about 2-15% of the clinical population (people actively seeking services from mental health providers) and about 1% of the general population. Although “narcissistic defense mechansims” might be common (having some of the criteria), having true NPD is much less common.

Axis II Cluster 2 personalities tend to abuse the people they are in relationships with. For the life of me I don’t understand why the DSM doesn’t list abuse of others as a criteria for NPDs. I would bet the house that every narcissist abuses almost everyone in their life.

Partners of Narcissists

I tend to disagree with studies I’ve read that healthy, stable people can find themselves in relationships with narcissists or borderlines. Most healthy people would intuitively RUN from relationships with these people. I can see how someone can “seem” to have it altogether but has unfinished business or some other self-doubt that attracts a narcissist or borderline and the doubt grows and grows as a result of the treatment/abuse by the narcissist.

But a common partner of a narcissist is someone who is a perennial victim or martyr. Another common partner of a narcissist is someone who gets their self worth from the narcissist’s self-aggrandizing. In other words the narcissist thinks he or she is something special and the partner wants to be with someone special therefore they will be someone special. (complicated to describe).

However, there are people who are perfectly normal and reasonably happy who get sucked in by narcissists because they really haven’t been exposed to such crazy people and cannot fathom for one New York second that anyone is as crazy as narcissists are. This is more of a naive thing. Not terribly unhealthy but not healthy in the sense of having their people skills honed and ready. A very trusting, docile person can get involved with (and run over by) a narcissist. But even there the involvement reveals things that need to be worked on (naivete, for one). Smarten up, thicken the skin, put on your street smart glasses and refuse to be suckered in by a charmer.

Most partners of people with personality disorders are very codependent. I define them as “clinically codependent” (my term) even though there is no codependent term in clinical diagnosis this is my word for someone who needs aggressive intervention.

I find there are those who are everyday codependent, people who can read Codependent No More, go to a few CODA meetings, become very aware of their codep traits and change them.

Clinical codependents
need more rigorous intervention. Therapy, tough love, and a complete withdrawal from the person with a personality disorder. If someone has been sucked into a relationship with a person with a personality disorder, especially cluster 2 personality disorder, my recommended first line of treatment is GET AWAY FROM THEM AND STAY AWAY FROM THEM. Otherwise you’re never going to get well.

As discussed on the comments in another thread, I read the book The Wizard of Oz and Other Narcissists. I do find it dangerous that she suggests therapy with people who have NPD but she seems to waver throughout the book as to whether she wants to address people with TRUE NPD (evaluated as having an Axis II diagnosis) and people who have “narcissistic defense mechanisms.” I was a clinician and trained in the DSM and had trouble keeping straight what she was talking about.

A true NPD is not only going to be immune to couples therapy but I would bet my house that in 99 percent of the cases they use the therapy against their partner and maybe even against the therapists. I’ve seen therapists manipulated by narcissists and borderlines more times than I care to recount.

When I worked in Emergency Psychiatric Services our evaluations always commented on the person’s “insight” meaning their ability to understand their own problems. When a person has an Axis II, esp cluster 2, diagnosis, it was fairly usually to see “lacks insight” on their eval. A person who lacks insight cannot change because they don’t know how to change. My experience with NPDs is they don’t want to change and if they did, they wouldn’t know where to begin.

Borderlines and narcissists, especially narcissists, do not give up their victims easily. They do not respond well to rejection and it is part of the overblown sense of self that causes them to reel someone back in. It has NOTHING TO DO with any “feelings” they have toward their victim because they don’t have any (I don’t care WHAT they say, the feelings are NOT PRESENT.) Borderlines tend to manipulate the people back into their lives with stormy drama. I spent a lot of time in the ER with borderlines who were making a very lighthearted attempt at “suicide” which was mostly a histrionic effort to reel someone in their life back in after the person had announced they had had enough.

NPDs have NO ABILITY TO LOVE and NO ABILITY to EMPHATHIZE and NO ABILITY to be SORRY and NO ABILITY to CARE ABOUT WHAT THEY HAVE DONE WRONG TO YOU.

Most narcissists will make you believe it is ALL YOUR FAULT. It is RARELY about them. The world is wrong not them. Most of the time they keep their victim in one place with blame and a constant erosion of any self-worth the victim might muster. Occasionally they will say they love you and they are sorry but as a last resort.

If they say they are sorry or they love you or they care it is merely part of the game. BELIEVE NONE OF IT. Narcissists are PATHOLOGICAL LIARS and will say whatever they have to in order to keep their victim where they want her (or him but most [around 80 percent] narcissists are men).

Getting out is not easy but it really has to be done if you ever hope to have even a semblence of happiness. As I’ve said in other posts about getting way from your abuser, make sure you have a PLAN and you can stay SAFE. Abusers often kill or severely harm the person trying to leave. PLEASE TALK TO A DOMESTIC ABUSE SPECIALIST OR CALL THE 800 NUMBERS HERE: 1 800 799 SAFE which is 1 800 799 7233 .

Also read Staying Safe by the National Domestic Violence Helpline: http://www.ndvh.org/help/planning.html

Borderline Personality Disorder is actually easier to treat. Borderlines are difficult personalities and when they are in a lot of pain can be difficult to be around. But compared to an NPD a BPD is a walk in the park.

When I was a clinician about 75 percent of my population were borderlines and I found most of them to be incredibly likable people. Most were women who had cutting issues which is fairly common among borderlines. They can be very manipulative and when they are in the throes of their rejecting behavior, they can be quite frustrating.

I believe that my adoptive mother was borderline and I adapted some of her push me/pull me personality when I was younger. Through therapy and insight I was able to see it for what it was and stop it but sometimes partners or children of borderlines take on their maladaptive traits.

I get a lot of questions about NPD but not many about BPD. If you want more information about borderlines, let me know.

Stay Safe All!!!

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