The Narcissist

And Psychopath
In Therapy
1st EDITION

Sam Vaknin, Ph.D.

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
Diagnosing Personality Disorders

Psychological Tests and Interviews

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Therapy and Treatment of Personality Disorders

The Hateful Patient: Difficult Patients in Psychotherapy

The Narcissist in Therapy

The Narcissistic Patient - A Case Study

The Psychopathic Patient - A Case Study

Narcissistic Personality Disorder Treatment Modalities

and Therapies
Reconditioning the Narcissist

Narcissists, Medication, and Chemical Imbalances

The Narcissist and Psychopath Getting Better

Misdiagnosing the Narcissistic Personality Disorder

Is the Narcissist Legally Insane?

Appendices

The Myth of Mental Illness

Psychology and Psychotherapy

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A Profile of the
Narcissist and
Psychopath

Pathological Narcissism – An Overview

 A Primer on Narcissism
And the Narcissistic Personality Disorder
(NPD)

What is Pathological Narcissism?

Pathological narcissism is a life-long pattern of traits
and behaviours which signify infatuation and obsession
with one's self to the exclusion of all others and the
egotistic and ruthless pursuit of one's gratification,
dominance and ambition.
As distinct from healthy narcissism which we all
possess, pathological narcissism is maladaptive, rigid,
persisting, and causes significant distress, and functional
impairment.
Pathological narcissism was first described in detail by
Freud in his essay "On Narcissism" [1915]. Other major
contributors to the study of narcissism are: Melanie
Klein, Karen Horney, Franz Kohut, Otto Kernberg,
Theodore Millon, Elsa Roningstam, Gunderson, and
Robert Hare.
What is Narcissistic Personality Disorder (NPD)?
The Narcissistic Personality Disorder (NPD) (formerly
known as megalomania or, colloquially, as egotism) is a
form of pathological narcissism. It is a Cluster B
(dramatic, emotional, or erratic) Personality Disorder.
Other Cluster B personality disorders are the Borderline
Personality Disorder (BPD), the Antisocial Personality
Disorder (APD), and the Histrionic Personality Disorder
(HPD). The Narcissistic Personality Disorder (NPD)
first appeared as a mental health diagnosis in the DSM-
III-TR (Diagnostic and Statistical Manual) in 1980.
Diagnostic Criteria
The ICD-10, the International Classification of
Diseases, published by the World Health Organisation
in Geneva [1992] regards the Narcissistic Personality
Disorder (NPD) as "a personality disorder that fits none
of the specific rubrics". It relegates it to the category
"Other Specific Personality Disorders" together with the
eccentric, "haltlose", immature, passive-aggressive, and
psychoneurotic personality disorders and types.
The American Psychiatric Association, based in
Washington D.C., USA, publishes the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition,
Text Revision (DSM-IV-TR) [2000] where it provides
the diagnostic criteria for the Narcissistic Personality
Disorder (301.81, p. 717).
The DSM-IV-TR defines Narcissistic Personality
Disorder (NPD) as "an all-pervasive pattern of
grandiosity (in fantasy or behaviour), need for
admiration or adulation and lack of empathy, usually
beginning by early adulthood and present in various
contexts", such as family life and work.
The DSM specifies nine diagnostic criteria. Five (or
more) of these criteria must be met for a diagnosis of
Narcissistic Personality Disorder (NPD) to be rendered.
[In the text below, I have proposed modifications to
the language of these criteria to incorporate current
knowledge about this disorder. My modifications appear
in italics.]
[My amendments do not constitute a part of the text of
the DSM-IV-TR, nor is the American Psychiatric
Association (APA) associated with them in any way.]
[Click here to download a bibliography of the studies
and research regarding the Narcissistic Personality
Disorder (NPD) on which I based my proposed
revisions.]
Proposed Amended Criteria for the
Narcissistic Personality Disorder
• Feels grandiose and self-important (e.g., exaggerates
accomplishments, talents, skills, contacts, and
personality traits to the point of lying, demands to be
recognised as superior without commensurate
achievements);
• Is obsessed with fantasies of unlimited success,
fame, fearsome power or omnipotence, unequalled
brilliance (the cerebral narcissist), bodily beauty or
sexual performance (the somatic narcissist), or ideal,
everlasting, all-conquering love or passion;
• Firmly convinced that he or she is unique and, being
special, can only be understood by, should only be
treated by, or associate with, other special or unique,
or high-status people (or institutions);
• Requires excessive admiration, adulation, attention
and affirmation – or, failing that, wishes to be feared
and to be notorious (Narcissistic Supply);
• Feels entitled. Demands automatic and full
compliance with his or her unreasonable
 expectations for special and favourable priority
treatment;
• Is "interpersonally exploitative", i.e., uses others to
achieve his or her own ends;
• Devoid of empathy. Is unable or unwilling to
identify with, acknowledge, or accept the feelings,
needs, preferences, priorities, and choices of others;
• Constantly envious of others and seeks to hurt or
destroy the objects of his or her frustration. Suffers
from persecutory (paranoid) delusions as he or she
believes that they feel the same about him or her and
are likely to act similarly;
• Behaves arrogantly and haughtily. Feels superior,
omnipotent, omniscient, invincible, immune, "above
the law", and omnipresent (magical thinking). Rages
when frustrated, contradicted, or confronted by
people he or she considers inferior to him or her and
unworthy.
Prevalence and Age and Gender Features
According to the DSM-IV-TR, between 2% and 16% of
the population in clinical settings (between 0.5-1% of
the general population) are diagnosed with Narcissistic
Personality Disorder (NPD). Most narcissists (50-75%,
according to the DSM-IV-TR) are men.
We must carefully distinguish between the narcissistic
traits of adolescents – narcissism is an integral part of
their healthy personal development – and the full-fledge
disorder. Adolescence is about self-definition,
differentiation, separation from one's parents, and
individuation. These inevitably involve narcissistic
assertiveness which is not to be conflated or confused
with Narcissistic Personality Disorder (NPD).
"The lifetime prevalence rate of NPD is approximately
0.5-1 percent; however, the estimated prevalence in
clinical settings is approximately 2-16 percent. Almost
75 percent of individuals diagnosed with NPD are male
(APA, DSM-IV-TR 2000)."
[From the Abstract of Psychotherapeutic Assessment
and Treatment of Narcissistic Personality Disorder By
Robert C. Schwartz, Ph.D., DAPA and Shannon D.
Smith, Ph.D., DAPA (American Psychotherapy
Association, Article #3004 Annals July/August 2002)]
Narcissistic Personality Disorder (NPD) is
exacerbated by the onset of aging and the physical,
mental, and occupational restrictions it imposes.
In certain situations, such as under constant public
scrutiny and exposure, a transient and reactive form of
the Narcissistic Personality Disorder (NPD) has been
observed by Robert Milman and labelled "Acquired
Situational Narcissism".
There is only scant research regarding the Narcissistic
Personality Disorder (NPD), but studies have not
demonstrated any ethnic, social, cultural, economic,
genetic, or professional predilection to it.
Co-Morbidity and Differential Diagnoses
Narcissistic Personality Disorder (NPD) is often
diagnosed with other mental health disorders ("co-
morbidity"), such as mood disorders, eating disorders,
and substance-related disorders. Patients with
Narcissistic Personality Disorder (NPD) are frequently
abusive and prone to impulsive and reckless behaviours
("dual diagnosis").
Narcissistic Personality Disorder (NPD) is commonly
diagnosed with other personality disorders, such as the
Histrionic, Borderline, Paranoid, and Antisocial
Personality Disorders.
The personal style of those suffering from the
Narcissistic Personality Disorder (NPD) should be
distinguished from the personal styles of patients with
other Cluster B personality disorders. The narcissist is
grandiose, the histrionic coquettish, the antisocial
(psychopath) callous, and the borderline needy.
As opposed to patients with the Borderline Personality
Disorder, the self-image of the narcissist is stable, he or
she are less impulsive and less self-defeating or self-
destructive and less concerned with abandonment issues
(not as clinging).
Contrary to the histrionic patient, the narcissist is
achievements-orientated and proud of his or her
possessions and accomplishments. Narcissists also
rarely display their emotions as histrionics do and they
hold the sensitivities and needs of others in contempt.
According to the DSM-IV-TR, both narcissists and
psychopaths are "tough-minded, glib, superficial,
exploitative, and un-empathic". But narcissists are less
impulsive, less aggressive, and less deceitful.
Psychopaths rarely seek Narcissistic Supply. As
opposed to psychopaths, few narcissists are criminals.
Patients suffering from the range of obsessive-
compulsive disorders are committed to perfection and
believe that only they are capable of attaining it. But, as
opposed to narcissists, they are self-critical and far more
aware of their own deficiencies, flaws, and
shortcomings.
Clinical Features of the Narcissistic Personality
Disorder
The onset of pathological narcissism is in infancy,
childhood and early adolescence. It is commonly
attributed to childhood abuse and trauma inflicted by
parents, authority figures, or even peers. Pathological
narcissism is a defence mechanism intended to deflect
hurt and trauma from the victim's "True Self" into a
"False Self" which is omnipotent, invulnerable, and
omniscient. The narcissist uses the False Self to regulate
his or her labile sense of self-worth by extracting from
his environment Narcissistic Supply (any form of
attention, both positive and negative).
There is a whole range of narcissistic reactions, styles,
and personalities – from the mild, reactive and transient
to the permanent personality disorder.
Patients with Narcissistic Personality Disorder (NPD)
feel injured, humiliated and empty when criticised.
They often react with disdain (devaluation), rage, and
defiance to any slight, real or imagined. To avoid such
situations, some patients with Narcissistic Personality
Disorder (NPD) socially withdraw and feign false
modesty and humility to mask their underlying
grandiosity. Dysthymic and depressive disorders are
common reactions to isolation and feelings of shame
and inadequacy.
The interpersonal relationships of patients with
Narcissistic Personality Disorder (NPD) are typically
impaired due to their lack of empathy, disregard for
others, exploitativeness, sense of entitlement, and
constant need for attention (Narcissistic Supply).
Though often ambitious and capable, inability to
tolerate setbacks, disagreement, and criticism make it
difficult for patients with Narcissistic Personality
Disorder (NPD) to work in a team or to maintain long-
term professional achievements. The narcissist's
fantastic grandiosity, frequently coupled with a
hypomanic mood, is typically incommensurate with his
or her real accomplishments (the "Grandiosity Gap").
Patients with Narcissistic Personality Disorder (NPD)
are either "cerebral" (derive their Narcissistic Supply
from their intelligence or academic achievements) or
"somatic" (derive their Narcissistic Supply from their
physique, exercise, physical or sexual prowess and
romantic or physical "conquests").
Patients with Narcissistic Personality Disorder (NPD)
are either "classic" (meet five of the nine diagnostic
criteria included in the DSM), or they are
"compensatory" (their narcissism compensates for deep-
set feelings of inferiority and lack of self-worth).
Some narcissists are covert, or inverted narcissists. As
co-dependents, they derive their Narcissistic Supply
from their relationships with classic narcissists.
Treatment and Prognosis
The common treatment for patients with Narcissistic
Personality Disorder (NPD) is talk therapy (mainly
psychodynamic psychotherapy or cognitive-behavioural
treatment modalities). Talk therapy is used
to modify the narcissist's antisocial, interpersonally
exploitative, and dysfunctional behaviours, often with
some success. Medication is prescribed to control and
ameliorate attendant conditions such as mood disorders
or obsessive-compulsive disorders.
The prognosis for an adult suffering from the
Narcissistic Personality Disorder (NPD) is poor, though
his adaptation to life and to others can improve with
treatment.
[Bibliography:
Goldman, Howard H., Review of General Psychiatry,
fourth edition, 1995. Prentice-Hall International,
London.
Gelder, Michael, Gath, Dennis, Mayou, Richard,
Cowen, Philip (eds.), Oxford Textbook of Psychiatry,
third edition, 1996, reprinted 2000. Oxford University
Press, Oxford.
Vaknin, Sam, Malignant Self Love – Narcissism
Revisited, seventh revised impression, 1999-2007.
Narcissus Publications, Prague and Skopje.]

Return
 The Antisocial Psychopath
Roots of the Disorder

Are the psychopath, sociopath, and someone with the

Antisocial Personality Disorder one and the same? The
DSM says "yes". Scholars such as Robert Hare and
Theodore Millon beg to differ. The psychopath has
antisocial traits for sure but they are coupled with and
enhanced by callousness, ruthlessness, extreme lack of
empathy, deficient impulse control, deceitfulness, and
sadism.

Like other personality disorders, psychopathy becomes

evident in early adolescence and is considered to be
chronic. But unlike most other personality disorders, it
is frequently ameliorated with age and tends to
disappear altogether in by the fourth or fifth decade of
life. This is because criminal behavior and substance
abuse are both determinants of the disorders and
behaviors more typical of young adults.

Psychopathy may be hereditary. The psychopath's

immediate family usually suffer from a variety of
personality disorders.

Cultural and Social Considerations

The Antisocial Personality Disorder is a controversial

mental health diagnoses. The psychopath refuses to
conform to social norms and obey the law. He often
inflicts pain and damage on his victims. But does that
make this pattern of conduct a mental illness? The
psychopath has no conscience or empathy. But is this
necessarily pathological? Culture-bound diagnoses are
often abused as tools of social control. They allow the
establishment, ruling elites, and groups with vested
interests to label and restrain dissidents and
troublemakers. Such diagnoses are frequently employed
by totalitarian states to harness or even eliminate
eccentrics, criminals, and deviants.

Characteristics and Traits

Like narcissists, psychopaths lack empathy and regard

other people as mere instruments of gratification and
utility or as objects to be manipulated. Psychopaths and
narcissists have no problem to grasp ideas and to
formulate choices, needs, preferences, courses of action,
and priorities. But they are shocked when other people
do the very same.

Most people accept that others have rights and

obligations. The psychopath rejects this quid pro quo.
As far as he is concerned, only might is right. People
have no rights and he, the psychopath, has no
obligations that derive from the "social contract". The
psychopath holds himself to be above conventional
morality and the law. The psychopath cannot delay
gratification. He wants everything and wants it now. His
whims, urges, catering to his needs, and the satisfaction
of his drives take precedence over the needs,
preferences, and emotions of even his nearest and
dearest.

Consequently, psychopaths feel no remorse when they

hurt or defraud others. They don't possess even the most
rudimentary conscience. They rationalize their (often
criminal) behavior and intellectualize it. Psychopaths
fall prey to their own primitive defense mechanisms
(such as narcissism, splitting, and projection). The
psychopath firmly believes that the world is a hostile,
merciless place, prone to the survival of the fittest and
that people are either "all good" or "all evil". The
psychopath projects his own vulnerabilities,
weaknesses, and shortcomings unto others and forces
them to behave the way he expects them to (this defense
mechanism is known as "projective identification").
Like narcissists, psychopaths are abusively exploitative
and incapable of true love or intimacy.

Narcissistic psychopath are particularly ill-suited to

participate in the give and take of civilized society.
Many of them are misfits or criminals. White collar
psychopaths are likely to be deceitful and engage in
rampant identity theft, the use of aliases, constant lying,
fraud, and con-artistry for gain or pleasure.

Psychopaths are irresponsible and unreliable. They do

not honor contracts, undertakings, and obligations. They
are unstable and unpredictable and rarely hold a job for
long, repay their debts, or maintain long-term intimate
relationships.

Psychopaths are vindictive and hold grudges. They

never regret or forget a thing. They are driven, and
dangerous.

I wrote this in the Open Site Encyclopedia:

"Always in conflict with authority and frequently on

the run, psychopaths possess a limited time horizon
and seldom make medium or long term plans. They
are impulsive and reckless, aggressive, violent,
irritable, and, sometimes, the captives of magical
thinking, believing themselves to be immune to the
consequences of their own actions.

Thus, psychopaths often end up in jail, having

repeatedly flouted social norms and codified laws.
Partly to avoid this fate and evade the law and partly to
extract material benefits from unsuspecting victims,
psychopaths habitually lie, steal others' identities,
deceive, use aliases, and con for "personal profit or
pleasure" as the Diagnostic and Statistical Manual
puts it."

The Anxious Psychopath

Psychopaths are said to be fearless and sang-froid. Their

pain tolerance is very high. Still, contrary to popular
perceptions and psychiatric orthodoxy, some
psychopaths are actually anxious and fearful. Their
psychopathy is a defense against an underlying and all-
pervasive anxiety, either hereditary, or brought on by
early childhood abuse.

Read Notes from the therapy of a Psychopathic Patient

Read Narcissist vs. Psychopath

What’s the difference between a narcissist and a

psychopath?

We all heard the terms "psychopath" or "sociopath".

These are the old or colloquial names for a patient with
the Antisocial Personality Disorder (AsPD). It is hard to
distinguish narcissists from psychopaths. The latter may
simply be a less inhibited and less grandiose form of the
former. Some scholars have suggested the existence of a
hybrid "psychopathic narcissist", or "narcissistic
psychopath". Indeed, the DSM V Committee is
considering to merge these personality disorders.

Still, there are some important nuances setting the two

disorders apart:

As opposed to most narcissists, psychopaths are either

unable or unwilling to control their impulses or to delay
gratification. They use their rage to control people and
manipulate them into submission.

Psychopaths, like narcissists, lack empathy but many of

them are also sadistic: they take pleasure in inflicting
pain on their victims or in deceiving them. They even
find it funny!

Psychopaths are far less able to form interpersonal

relationships, even the twisted and tragic relationships
that are the staple of the narcissist.

Both the psychopath and the narcissist disregard society,

its conventions, social cues and social treaties. But the
psychopath carries this disdain to the extreme and is
likely to be a scheming, calculated, ruthless, and callous
career criminal. Psychopaths are deliberately and
gleefully evil while narcissists are absent-mindedly and
incidentally evil.

From my book "Malignant Self-love: Narcissism

Revisited":
"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."

Psychopaths really do not need other people while

narcissists are addicted to narcissistic supply (the
admiration, attention, and envy of others).

Millon and Davis (supra) add (p. 299-300):

"When the egocentricity, lack of empathy, and sense

of superiority of the narcissist cross-fertilize with the
impulsivity, deceitfulness, and criminal tendencies of
the antisocial, the result is a psychopath, an individual
who seeks the gratification of selfish impulses through
any means without empathy or remorse."

Read The Antisocial and Psychopath

Read Notes from the therapy of a Narcissistic Patient

Read Notes from the therapy of a Psychopathic Patient

Return
 Bibliography
I. Online

The Narcissist and Psychopath in Society

The Narcissist and Psychopath as Criminals

http://health.groups.yahoo.com/group/narcissisticab
use/message/5003

The Narcissist is Above the Law

http://health.groups.yahoo.com/group/narcissisticab
use/message/4983

The Narcissist as Liar and Con-man

http://health.groups.yahoo.com/group/narcissisticab
use/message/4951

Pathological Narcissism, Narcissistic Personality

disorder and Psychopathy

Does the Narcissist Have a Multiple Personality

(Dissociative Identity Disorder)?

http://health.groups.yahoo.com/group/narcissisticab
use/message/4950
 Narcissists as Drama Queens

http://health.groups.yahoo.com/group/narcissisticab
use/message/4948

The Narcissist as Know-it-all

http://health.groups.yahoo.com/group/narcissisticab
use/message/4945

The Narcissist as VAMPIRE or MACHINE

http://health.groups.yahoo.com/group/narcissisticab
use/message/4944

Narcissists and Psychopaths Devalue Their

Psychotherapists

http://health.groups.yahoo.com/group/narcissisticab
use/message/4939

Violent, Vindictive, Sadistic, and Psychopathic

Narcissists

http://health.groups.yahoo.com/group/narcissisticab
use/message/4938

Portrait of the Narcissist as a Young Man

http://health.groups.yahoo.com/group/narcissisticab
use/message/5048
 Grandiosity, Fantasies, and Narcissism

http://health.groups.yahoo.com/group/narcissisticab
use/message/4923

Narcissists and Emotions

http://health.groups.yahoo.com/group/narcissisticab
use/message/5248

Narcissists and Mood Disorders

http://health.groups.yahoo.com/group/narcissisticab
use/message/5067

II. Print

1. Alford, C. Fred. Narcissism: Socrates, the Frankfurt

School and Psychoanalytic Theory. New Haven and
London, Yale University Press, 1988
2. Devereux, George. Basic Problems of Ethno-
Psychiatry. University of Chicago Press, 1980
3. Fairbairn, W. R. D. An Object Relations Theory of
the Personality. New York, Basic Books, 1954
4. Freud S. Three Essays on the Theory of Sexuality
[1905]. Standard Edition of the Complete
Psychological Works of Sigmund Freud. Vol. 7.
London, Hogarth Press, 1964
5. Freud, S. On Narcissism. Standard Ed. Vol. 14, pp.
73-107
6. Goldman, Howard H. (Ed.). Review of General
Psychiatry. 4th Ed. London, Prentice Hall
International, 1995
7. Golomb, Elan. Trapped in the Mirror: Adult Children
of Narcissists in Their Struggle for Self. Quill, 1995
8. Greenberg, Jay R. and Mitchell, Stephen A. Object
Relations in Psychoanalytic Theory. Cambridge,
Mass., Harvard University Press, 1983
9. Grunberger, Bela. Narcissism: Psychoanalytic
Essays. New York, International Universities Press,
1979
10. Guntrip, Harry. Personality Structure and
Human Interaction. New York, International
Universities Press, 1961
11. Horowitz M. J. Sliding Meanings: A Defence
against Threat in Narcissistic Personalities.
International Journal of Psychoanalytic
Psychotherapy, 1975; 4:167
12. Horovitz M. J. Stress Response Syndromes:
PTSD, Grief and Adjustment Disorders. 3rd Ed. New
York, NY University Press, 1998
13. Jacobson, Edith. The Self and the Object World.
New York, International Universities Press, 1964
14. Jung, C.G. Collected Works. G. Adler, M.
Fordham and H. Read (Eds.). 21 volumes. Princeton
University Press, 1960-1983
15. Kernberg O. Borderline Conditions and
Pathological Narcissism. New York, Jason Aronson,
1975
16. Klein, Melanie. The Writings of Melanie Klein.
Roger Money-Kyrle (Ed.). 4 Vols. New York, Free
Press, 1964-75
17. Kohut H. The Chicago Institute Lectures 1972-
1976. Marian and Paul Tolpin (Eds.). Analytic Press,
1998
18. Kohut M. The Analysis of the Self. New York,
International Universities Press, 1971
19. Lasch, Christopher. The Culture of Narcissism.
New York, Warner Books, 1979
20. Levine, J. D., and Weiss, Rona H. The
Dynamics and Treatment of Alcoholism. Jason
Aronson, 1994
21. Lowen, Alexander. Narcissism: Denial of the
True Self. Touchstone Books, 1997
22. Millon, Theodore (and Roger D. Davis,
contributor). Disorders of Personality: DSM-IV and
Beyond. 2nd ed. New York, John Wiley and Sons,
1995
23. Millon, Theodore. Personality Disorders in
Modern Life. New York, John Wiley and Sons, 2000
24. Riso, Don Richard. Personality Types: Using the
Enneagram for Self-Discovery. Boston: Houghton
Mifflin 1987
25. Roningstam, Elsa F. (Ed.). Disorders of
Narcissism: Diagnostic, Clinical, and Empirical
Implications. American Psychiatric Press, 1998
26. Rothstein, Arnold. The Narcissistic Pursuit of
Reflection. 2nd revised Ed. New York, International
Universities Press, 1984
27. Schwartz, Lester. Narcissistic Personality
Disorders – A Clinical Discussion. Journal of
American Psychoanalytic Association – 22 [1974]:
292-305
28. Salant-Schwartz, Nathan. Narcissism and
Character Transformation. Inner City Books, 1985 –
pp. 90-91
29. Stern, Daniel. The Interpersonal World of the
Infant: A View from Psychoanalysis and
Developmental Psychology. New York, Basic Books,
1985
30. Vaknin, Sam. Malignant Self Love – Narcissism
Revisited. Skopje and Prague, Narcissus
Publications, 2007
31. Zweig, Paul. The Heresy of Self Love: A Study
of Subversive Individualism. New York, Basic
Books, 1968
 The Narcissist
And Psychopath
In Therapy
 Diagnosing Personality Disorders

The Diagnostic and Statistical Manual (DSM) describes

12 ideal "prototypes" of personality disorders. It
provides lists of seven to nine personality traits per each
disorder. These are called "diagnostic criteria".
Whenever five of these criteria are met, a qualified
mental health diagnostician can safely diagnose the
existence of a personality disorder.

But important caveats apply.

No two people are alike. Even subjects suffering from

the same personality disorder can be worlds apart as far
as their backgrounds, actual conduct, inner world,
character, social interactions, and temperament go.

Diagnosing the existence of a personality trait (applying

the diagnostic criteria) is an art, not a science.
Evaluating someone's conduct, appraising the patient's
cognitive and emotional landscape, and attributing
motivation to him or her, is a matter of judgment. There
is no calibrated scientific instrument that can provide us
with an objective reading of whether one lacks empathy,
is unscrupulous, is sexualizing situations and people, or
is clinging and needy.

Regrettably, the process is inevitably tainted by value

judgments as well. Mental health practitioners are only
human (well, OK, some of them are...:o)). They hail
from specific social, economic, and cultural
backgrounds. They do their best to neutralize their
personal bias and prejudices but their efforts often fail.
Many critics charge that certain personality disorders
are "culture-bound". They reflect our contemporary
sensitivities and values rather than invariable
psychological entities and constructs.

Thus, someone with the Antisocial Personality Disorder

is supposed to disrespect social rules and regard himself
as a free agent. He lacks conscience and is often a
criminal. This means that non-conformists, dissenters,
and dissidents can be pathologized and labeled
"antisocial". Indeed, authoritarian regimes often
incarcerate their opponents in mental asylums based on
such dubious "diagnoses". Moreover, crime is a career
choice. Granted, it is a harmful and unpalatable one. But
since when is one's choice of vocation a mental health
problem?

If you believe in telepathy and UFOs and have bizarre

rituals, mannerisms, and speech patterns, you may be
diagnosed with the Schizotypal Personality Disorder. If
you shun others and are a loner, you may be a Schizoid.
And the list goes on.

To avoid these pitfalls, the DSM came up with a multi-

axial model of personality evaluation.

Personality disorders are like tips of icebergs. They rest

on a foundation of causes and effects, interactions and
events, emotions and cognitions, functions and
dysfunctions that together form the patient and make
him or her what s/he is.

The DSM uses five axes to analyze, classify, and

describe these data. The patient (or subject) presents
himself to a mental health diagnostician, is evaluated,
tests are administered, questionnaires fulfilled, and a
diagnosis rendered. The diagnostician uses the DSM's
five axes to "make sense" and meaningfully organize of
the information he had gathered in this process.

Axis I demands that he specify all the patient's clinical

mental health problems that are not personality
disorders or mental retardation. Thus, Axis I includes
issues first diagnosed in infancy, childhood, or
adolescence; cognitive problems (e.g., delirium,
dementia, amnesia); mental disorders due to a medical
condition (for instance, dysfunctions caused by brain
injury or metabolic diseases); substance-related
disorders; schizophrenia and psychosis; mood disorders;
anxiety and panic; somatoform disorders; factitious
disorders; dissociative disorders; sexual paraphilias;
eating disorders; impulse control problems and
adjustment issues.

We will discuss Axis II at length in our next articles. It

comprises personality disorders and mental retardation
(interesting conjunction!).

If the patient suffers from medical conditions that affect

his state of mind and mental health, these are noted
under Axis III. Some psychological problems are
directly caused by medical issues (hyperthyroidism
causes depression). In other cases, the latter are
concurrent with or exacerbate the former. Virtually all
biological illnesses may provoke changes in the patient's
psychological make-up, behavior, cognitive functioning,
and emotional landscape.

But the machinery of life - both body and "soul" - is

reactive as well as proactive. It is molded by one's
psychosocial circumstances and environment. Life
crises, stresses, deficiencies, and inadequate support all
conspire to destabilize and, if sufficiently harsh, ruin
one's mental health. The DSM enumerates dozens of
adverse influences that should be recorded by the
diagnostician under Axis IV: death in the family or of a
close friend; health problems; divorce; remarriage;
abuse; doting or smothering parenting; neglect; sibling
rivalry; social isolation; discrimination; life cycle
transition (such as retirement); unemployment;
workplace bullying; housing or economic problems;
limited or no access to health care services;
incarceration or litigation; traumas and many more
events and situations.

Finally, the DSM recognizes that the clinician's direct

impression of the patient is at least as important as any
"objective" data he may gather during the evaluation
phase. Axis V allows the diagnostician to record his
judgment of "the individual's overall level of
functioning". This, admittedly, is a vague remit, open to
ambiguity and bias. To counter these risk, the DSM
recommends that mental health professionals use the
Global assessment of Functioning (GAF) Scale. Merely
administering this structured test forces the
diagnostician to formulate his views rigorously and to
weed out cultural and social prejudices.

Having gone through this long and convoluted process,

the therapist, psychologist, psychiatrist, or social worker
now has a complete picture of the subject's life, personal
history, medical background, environment, and psyche.
She is now ready to move on and formally diagnose a
personality disorder with or without co-morbid
(concurrent) conditions.
It is not easy to tell when the patient's anxiety and
depression are autonomous and neurotic problems or
symptoms of a personality disorder. These should,
therefore, be ruled out as differential diagnostic criteria.
In other words, the mere existence of depression or
anxiety in a patient does not prove that he or she has a
personality disorder.

Instead, the diagnostician should concentrate on the

patient's defenses and perceived locus of control.

Patients with personality disorders have alloplastic

defenses and an external locus of control. In other
words, they blame outside influences, people, events,
and circumstances for their own failures. Under stress
and when they experience frustration, disappointment,
and pain - they seek to change the external environment.
For instance, such patients may try to manipulate others
to gratify them and thus alleviate their distress. They
achieve such manipulative outcome by threatening,
cajoling, seducing, tempting, or co-opting their "sources
of supply".

Patients with personality disorders also lack self-

awareness and are ego-syntonic. They do not find
themselves, their conduct, traits, or the lives they lead to
be objectionable, unacceptable or alien to their true self.
They are mostly happy-go-lucky people.

Consequently, they rarely assume responsibility for the

consequences of their actions. This is further
compounded, in some personality disorders, by a
startling absence of empathy and scruples (conscience).
The lives of personality disordered subjects are chaotic.
Both the patient's social (interpersonal) and
occupational functioning suffer grievously. But though
cognitive and emotional processes may be disturbed,
psychosis is rare. Thought disorders (the loosening of
associations), delusions, and hallucinations are either
absent or restricted to transient and self-limiting
micropsychotic episodes under duress.

Finally, some medical conditions (such as brain trauma)

and organic issues (such as metabolic problems)
produce behaviors and traits more often associated with
personality disorders. The onset of these behaviors and
traits is a crucial differentiating criterion. Personality
disorders start their pernicious work during early
adolescence. They involve a clear sensorium (processed
input from sense organs), good temporal and spatial
orientation, and normal intellectual functioning
(memory, fund of general knowledge, ability to read and
calculate, etc.)

Return
 Psychological Tests and Interviews

I. Introduction

Personality assessment is perhaps more an art form than

a science. In an attempt to render it as objective and
standardized as possible, generations of clinicians came
up with psychological tests and structured interviews.
These are administered under similar conditions and use
identical stimuli to elicit information from respondents.
Thus, any disparity in the responses of the subjects can
and is attributed to the idiosyncrasies of their
personalities.

Moreover, most tests restrict the repertory of permitted

of answers. "True" or "false" are the only allowed
reactions to the questions in the Minnesota Multiphasic
Personality Inventory II (MMPI-2), for instance.
Scoring or keying the results is also an automatic
process wherein all "true" responses get one or more
points on one or more scales and all "false" responses
get none.

This limits the involvement of the diagnostician to the

interpretation of the test results (the scale scores).
Admittedly, interpretation is arguably more important
than data gathering. Thus, inevitably biased human
input cannot and is not avoided in the process of
personality assessment and evaluation. But its
pernicious effect is somewhat reined in by the
systematic and impartial nature of the underlying
instruments (tests).
Still, rather than rely on one questionnaire and its
interpretation, most practitioners administer to the same
subject a battery of tests and structured interviews.
These often vary in important aspects: their response
formats, stimuli, procedures of administration, and
scoring methodology. Moreover, in order to establish a
test's reliability, many diagnosticians administer it
repeatedly over time to the same client. If the
interpreted results are more or less the same, the test is
said to be reliable.

The outcomes of various tests must fit in with each

other. Put together, they must provide a consistent and
coherent picture. If one test yields readings that are
constantly at odds with the conclusions of other
questionnaires or interviews, it may not be valid. In
other words, it may not be measuring what it claims to
be measuring.

Thus, a test quantifying one's grandiosity must conform

to the scores of tests which measure reluctance to admit
failings or propensity to present a socially desirable and
inflated facade ("False Self"). If a grandiosity test is
positively related to irrelevant, conceptually
independent traits, such as intelligence or depression, it
does not render it valid.

Most tests are either objective or projective. The

psychologist George Kelly offered this tongue-in-cheek
definition of both in a 1958 article titled "Man's
construction of his alternatives" (included in the book
"The Assessment of Human Motives", edited by
G.Lindzey):
"When the subject is asked to guess what the examiner
is thinking, we call it an objective test; when the
examiner tries to guess what the subject is thinking, we
call it a projective device."

The scoring of objective tests is computerized (no

human input). Examples of such standardized
instruments include the MMPI-II, the California
Psychological Inventory (CPI), and the Millon Clinical
Multiaxial Inventory II. Of course, a human finally
gleans the meaning of the data gathered by these
questionnaires. Interpretation ultimately depends on the
knowledge, training, experience, skills, and natural gifts
of the therapist or diagnostician.

Projective tests are far less structured and thus a lot

more ambiguous. As L. K.Frank observed in a 1939
article titled "Projective methods for the study of
personality":

"(The patient's responses to such tests are projections

of his) way of seeing life, his meanings, signficances,
patterns, and especially his feelings."

In projective tests, the responses are not constrained and

scoring is done exclusively by humans and involves
judgment (and, thus, a modicum of bias). Clinicians
rarely agree on the same interpretation and often use
competing methods of scoring, yielding disparate
results. The diagnostician's personality comes into
prominent play. The best known of these "tests" is the
Rorschach set of inkblots.
II. MMPI-2 Test

The MMPI (Minnesota Multiphasic Personality

Inventory), composed by Hathaway (a psychologist)
and McKinley (a physician) is the outcome of decades
of research into personality disorders. The revised
version, the MMPI-2 was published in 1989 but was
received cautiously. MMPI-2 changed the scoring
method and some of the normative data. It was,
therefore, hard to compare it to its much hallowed (and
oft validated) predecessor.

The MMPI-2 is made of 567 binary (true or false) items

(questions). Each item requires the subject to respond:
"This is true (or false) as applied to me". There are no
"correct" answers. The test booklet allows the
diagnostician to provide a rough assessment of the
patient (the "basic scales") based on the first 370 queries
(though it is recommended to administer all of 567 of
them).

Based on numerous studies, the items are arranged in

scales. The responses are compared to answers provided
by "control subjects". The scales allow the diagnostician
to identify traits and mental health problems based on
these comparisons. In other words, there are no answers
that are "typical to paranoid or narcissistic or antisocial
patients". There are only responses that deviate from an
overall statistical pattern and conform to the reaction
patterns of other patients with similar scores. The nature
of the deviation determines the patient's traits and
tendencies - but not his or her diagnosis!

The interpreted outcomes of the MMPI-2 are phrased

thus: "The test results place subject X in this group of
patients who, statistically-speaking, reacted similarly.
The test results also set subject X apart from these
groups of people who, statistically-speaking, responded
differently". The test results would never say: "Subject
X suffers from (this or that) mental health problem".

There are three validity scales and ten clinical ones in

the original MMPI-2, but other scholars derived
hundreds of additional scales. For instance: to help in
diagnosing personality disorders, most diagnosticians
use either the MMPI-I with the Morey-Waugh-
Blashfield scales in conjunction with the Wiggins
content scales - or (more rarely) the MMPI-2 updated to
include the Colligan-Morey-Offord scales.

The validity scales indicate whether the patient

responded truthfully and accurately or was trying to
manipulate the test. They pick up patterns. Some
patients want to appear normal (or abnormal) and
consistently choose what they believe are the "correct"
answers. This kind of behavior triggers the validity
scales. These are so sensitive that they can indicate
whether the subject lost his or her place on the answer
sheet and was responding randomly! The validity scales
also alert the diagnostician to problems in reading
comprehension and other inconsistencies in response
patterns.

The clinical scales are dimensional (though not

multiphasic as the test's misleading name implies). They
measure hypochondriasis, depression, hysteria,
psychopathic deviation, masculinity-femininity,
paranoia, psychasthenia, schizophrenia, hypomania, and
social introversion. There are also scales for alcoholism,
post-traumatic stress disorder, and personality disorders.
The interpretation of the MMPI-2 is now fully
computerized. The computer is fed with the patients'
age, sex, educational level, and marital status and does
the rest. Still, many scholars have criticized the scoring
of the MMPI-2.

III. MCMI-III Test

The third edition of this popular test, the Millon Clinical

Multiaxial Inventory (MCMI-III), has been published in
1996. With 175 items, it is much shorter and simpler to
administer and to interpret than the MMPI-II. The
MCMI-III diagnoses personality disorders and Axis I
disorders but not other mental health problems. The
inventory is based on Millon's suggested multiaxial
model in which long-term characteristics and traits
interact with clinical symptoms.

The questions in the MCMI-III reflect the diagnostic

criteria of the DSM. Millon himself gives this example
(Millon and Davis, Personality Disorders in Modern
Life, 2000, pp. 83-84):

"... (T)he first criterion from the DSM-IV dependent

personality disorder reads 'Has difficulty making
everyday decisions without an excessive amount of
advice and reassurance from others,' and its parallel
MCMI-III item reads 'People can easily change my
ideas, even if I thought my mind was made up.'"

The MCMI-III consists of 24 clinical scales and 3

modifier scales. The modifier scales serve to identify
Disclosure (a tendency to hide a pathology or to
exaggerate it), Desirability (a bias towards socially
desirable responses), and Debasement (endorsing only
responses that are highly suggestive of pathology).
Next, the Clinical Personality Patterns (scales) which
represent mild to moderate pathologies of personality,
are: Schizoid, Avoidant, Depressive, Dependent,
Histrionic, Narcissistic, Antisocial, Aggressive
(Sadistic), Compulsive, Negativistic, and Masochistic.
Millon considers only the Schizotypal, Borderline, and
Paranoid to be severe personality pathologies and
dedicates the next three scales to them.

The last ten scales are dedicated to Axis I and other

clinical syndromes: Anxiety Disorder, Somatoform
Disorder, Bipolar Manic Disorder, Dysthymic Disorder,
Alcohol Dependence, Drug Dependence, Posttraumatic
Stress, Thought Disorder, Major Depression, and
Delusional Disorder.

Scoring is easy and runs from 0 to 115 per each scale,

with 85 and above signifying a pathology. The
configuration of the results of all 24 scales provides
serious and reliable insights into the tested subject.

Critics of the MCMI-III point to its oversimplification

of complex cognitive and emotional processes, its over-
reliance on a model of human psychology and behavior
that is far from proven and not in the mainstream
(Millon's multiaxial model), and its susceptibility to bias
in the interpretative phase.

IV. Rorschach Inkblot Test

The Swiss psychiatrist Hermann Rorschach developed a

set of inkblots to test subjects in his clinical research. In
a 1921 monograph (published in English in 1942 and
1951), Rorschach postulated that the blots evoke
consistent and similar responses in groups patients.
Only ten of the original inkblots are currently in
diagnostic use. It was John Exner who systematized the
administration and scoring of the test, combining the
best of several systems in use at the time (e.g., Beck,
Kloper, Rapaport, Singer).

The Rorschach inkblots are ambiguous forms, printed

on 18X24 cm. cards, in both black and white and color.
Their very ambiguity provokes free associations in the
test subject. The diagnostician stimulates the formation
of these flights of fantasy by asking questions such as
"What is this? What might this be?". S/he then proceed
to record, verbatim, the patient's responses as well as the
inkblot's spatial position and orientation. An example of
such record would read: "Card V upside down, child
sitting on a porch and crying, waiting for his mother to
return."

Having gone through the entire deck, the examiner than

proceeds to read aloud the responses while asking the
patient to explain, in each and every case, why s/he
chose to interpret the card the way s/he did. "What in
card V prompted you to think of an abandoned child?".
At this phase, the patient is allowed to add details and
expand upon his or her original answer. Again,
everything is noted and the subject is asked to explain
what is the card or in his previous response gave birth to
the added details.

Scoring the Rorschach test is a demanding task.

Inevitably, due to its "literary" nature, there is no
uniform, automated scoring system.
Methodologically, the scorer notes four items for each
card:

I. Location - Which parts of the inkblot were singled out

or emphasized in the subject's responses. Did the patient
refer to the whole blot, a detail (if so, was it a common
or an unusual detail), or the white space.

II. Determinant - Does the blot resemble what the

patient saw in it? Which parts of the blot correspond to
the subject's visual fantasy and narrative? Is it the blot's
form, movement, color, texture, dimensionality,
shading, or symmetrical pairing?

III. Content - Which of Exner's 27 content categories

was selected by the patient (human figure, animal detail,
blood, fire, sex, X-ray, and so on)?

IV. Popularity - The patient's responses are compared to

the overall distribution of answers among people tested
hitherto. Statistically, certain cards are linked to specific
images and plots. For example: card I often provokes
associations of bats or butterflies. The sixth most
popular response to card IV is "animal skin or human
figure dressed in fur" and so on.

V. Organizational Activity - How coherent and

organized is the patient's narrative and how well does
s/he link the various images together?

VI. Form Quality - How well does the patient's

"percept" fit with the blot? There are four grades from
superior (+) through ordinary (0) and weak (w) to minus
(-). Exner defined minus as:
"(T)he distorted, arbitrary, unrealistic use of form as
related to the content offered, where an answer is
imposed on the blot area with total, or near total,
disregard for the structure of the area."

The interpretation of the test relies on both the scores

obtained and on what we know about mental health
disorders. The test teaches the skilled diagnostician how
the subject processes information and what is the
structure and content of his internal world. These
provide meaningful insights into the patient's defenses,
reality test, intelligence, fantasy life, and psychosexual
make-up.

Still, the Rorschach test is highly subjective and

depends inordinately on the skills and training of the
diagnostician. It, therefore, cannot be used to reliably
diagnose patients. It merely draws attention to the
patients' defenses and personal style.

V. TAT Diagnostic Test

The Thematic Appreciation Test (TAT) is similar to the

Rorschach inkblot test. Subjects are shown pictures and
asked to tell a story based on what they see. Both these
projective assessment tools elicit important information
about underlying psychological fears and needs. The
TAT was developed in 1935 by Morgan and Murray.
Ironically, it was initially used in a study of normal
personalities done at Harvard Psychological Clinic.

The test comprises 31 cards. One card is blank and the

other thirty include blurred but emotionally powerful (or
even disturbing) photographs and drawings. Originally,
Murray came up with only 20 cards which he divided to
three groups: B (to be shown to Boys Only), G (Girls
Only) and M-or-F (both sexes).

The cards expound on universal themes. Card 2, for

instance, depicts a country scene. A man is toiling in the
background, tilling the field; a woman partly obscures
him, carrying books; an old woman stands idly by and
watches them both. Card 3BM is dominated by a couch
against which is propped a little boy, his head resting on
his right arm, a revolver by his side, on the floor.

Card 6GF again features a sofa. A young woman

occupies it. Her attention is riveted by a pipe-smoking
older man who is talking to her. She is looking back at
him over her shoulder, so we don't have a clear view of
her face. Another generic young woman appears in card
12F. But this time, she is juxtaposed against a mildly
menacing, grimacing old woman, whose head is
covered with a shawl. Men and boys seem to be
permanently stressed and dysphoric in the TAT. Card
13MF, for instance, shows a young lad, his lowered
head buried in his arm. A woman is bedridden across
the room.

With the advent of objective tests, such as the MMPI

and the MCMI, projective tests such as the TAT have
lost their clout and luster. Today, the TAT is
administered infrequently. Modern examiners use 20
cards or less and select them according to their
"intuition" as to the patient's problem areas. In other
words, the diagnostician first decides what may be
wrong with the patient and only then chooses which
cards will be shown in the test! Administered this way,
the TAT tends to become a self-fulfilling prophecy and
of little diagnostic value.
The patient's reactions (in the form of brief narratives)
are recorded by the tester verbatim. Some examiners
prompt the patient to describe the aftermath or outcomes
of the stories, but this is a controversial practice.

The TAT is scored and interpreted simultaneously.

Murray suggested to identify the hero of each narrative
(the figure representing the patient); the inner states and
needs of the patient, derived from his or her choices of
activities or gratifications; what Murray calls the
"press", the hero's environment which imposes
constraints on the hero's needs and operations; and the
thema, or the motivations developed by the hero in
response to all of the above.

Clearly, the TAT is open to almost any interpretative

system which emphasizes inner states, motivations, and
needs. Indeed, many schools of psychology have their
own TAT exegetic schemes. Thus, the TAT may be
teaching us more about psychology and psychologists
than it does about their patients!

VI. Structured Interviews

The Structured Clinical Interview (SCID-II) was

formulated in 1997 by First, Gibbon, Spitzer, Williams,
and Benjamin. It closely follows the language of the
DSM-IV Axis II Personality Disorders criteria.
Consequently, there are 12 groups of questions
corresponding to the 12 personality disorders. The
scoring is equally simple: either the trait is absent,
subthreshold, true, or there is "inadequate information to
code".
The feature that is unique to the SCID-II is that it can be
administered to third parties (a spouse, an informant, a
colleague) and still yield a strong diagnostic indication.
The test incorporates probes (sort of "control" items)
that help verify the presence of certain characteristics
and behaviors. Another version of the SCID-II
(comprising 119 questions) can also be self-
administered. Most practitioners administer both the
self-questionnaire and the standard test and use the
former to screen for true answers in the latter.

The Structured Interview for Disorders of Personality

(SIDP-IV) was composed by Pfohl, Blum and
Zimmerman in 1997. Unlike the SCID-II, it also covers
the self-defeating personality disorder from the DSM-
III. The interview is conversational and the questions
are divided into 10 topics such as Emotions or Interests
and Activities. Succumbing to "industry" pressure, the
authors also came up with a version of the SIDP-IV in
which the questions are grouped by personality disorder.
Subjects are encouraged to observe the "five year rule":

"What you are like when you are your usual self ...
Behaviors. cognitions, and feelings that have
predominated for most of the last five years are
considered to be representative of your long-term
personality functioning ..."

The scoring is again simple. Items are either present,

subthreshold, present, or strongly present.

VII. Disorder-specific Tests

There are dozens of psychological tests that are

disorder-specific: they aim to diagnose specific
personality disorders or relationship problems.
Example: the Narcissistic Personality Inventory (NPI)
which is used to diagnose the Narcissistic Personality
Disorder (NPD).

The Borderline Personality Organization Scale (BPO),

designed in 1985, sorts the subject's responses into 30
relevant scales. These indicates the existence of identity
diffusion, primitive defenses, and deficient reality
testing.

Other much-used tests include the Personality

Diagnostic Questionnaire-IV, the Coolidge Axis II
Inventory, the Personality Assessment Inventory (1992),
the excellent, literature-based, Dimensional assessment
of Personality Pathology, and the comprehensive
Schedule of Nonadaptive and Adaptive Personality and
Wisconsin Personality Disorders Inventory.

Having established the existence of a personality

disorder, most diagnosticians proceed to administer
other tests intended to reveal how the patient functions
in relationships, copes with intimacy, and responds to
triggers and life stresses.

The Relationship Styles Questionnaire (RSQ) (1994)

contains 30 self-reported items and identifies distinct
attachment styles (secure, fearful, preoccupied, and
dismissing). The Conflict Tactics Scale (CTS) (1979) is
a standardized scale of the frequency and intensity of
conflict resolution tactics and stratagems (both
legitimate and abusive) used by the subject in various
settings (usually in a couple).
The Multidimensional Anger Inventory (MAI) (1986)
assesses the frequency of angry responses, their
duration, magnitude, mode of expression, hostile
outlook, and anger-provoking triggers.

Yet, even a complete battery of tests, administered by

experienced professionals sometimes fails to identify
abusers with personality disorders. Offenders are
uncanny in their ability to deceive their evaluators.

VIII. PCL-R (Psychopathy Checklist Revised) Test

The second edition of the PCL-R test, originally

designed by the controversial maverick Canadian
criminologist Robert Hare in 1980 and again in 1991,
contains 20 items designed to rate symptoms which are
common among psychopaths in forensic populations
(such as prison inmates or child molesters). It is
designed to cover the major psychopathic traits and
behaviours: callous, selfish, remorseless use of others
(Factor 1), chronically unstable and antisocial lifestyle
(Factor 2), interpersonal and affective deficits, an
impulsive lifestyle and antisocial behaviour.
The twenty traits assessed by the PCL-R score are: glib
and superficial charm; grandiose (exaggeratedly high)
estimation of self; need for stimulation; pathological
lying; cunning and manipulativeness; lack of remorse or
guilt; shallow affect (superficial emotional
responsiveness); callousness and lack of empathy;
parasitic lifestyle; poor behavioral controls; sexual
promiscuity; early behavior problems; lack of realistic
long-term goals; impulsivity; irresponsibility; failure to
accept responsibility for own actions; many short-term
marital relationships; juvenile delinquency; revocation
of conditional release; and criminal versatility.
Psychopaths score between 30 and 40. Normal people
score between 0 and 5. But Hare himself was known to
label as psychopaths people with a score as low as 13.
The PCL-R is, therefore, an art rather than science and
is leaves much to the personal impressions of those who
administer it.

The PCL-R is based on a structured interview and collateral data

gathered from family, friends, and colleagues and from
documents. The questions comprising the structured interview are
so transparent and self-evident that it is easy to lie one’s way
through the test and completely skew its results. Moreover,
scoring by the diagnostician is highly subjective (which is why the
DSM and the ICD stick to observable behaviours in its criteria for
Antisocial or Dissocial Personality Disorder).

The hope is that information gathered outside the scope

of the structured interview will serve to rectify such
potential abuse, diagnostic bias, and manipulation by
both testee and tester. The PCL-R, in other words, relies
on the truthfulness of responses provided by notorious
liars (psychopaths) and on the biased memories of
multiple witnesses, all of them close to the psychopath
and with an axe to grind.

APPENDIX: Common Problems with Psychological

Laboratory Tests

Psychological laboratory tests suffer from a series of

common philosophical, methodological, and design
problems.

A. Philosophical and Design Aspects

1. Ethical – Experiments involve the patient and

others. To achieve results, the subjects have to
be ignorant of the reasons for the experiments
 and their aims. Sometimes even the very
performance of an experiment has to remain a
secret (double blind experiments). Some
experiments may involve unpleasant or even
traumatic experiences. This is ethically
unacceptable.

2. The Psychological Uncertainty Principle – The

initial state of a human subject in an experiment
is usually fully established. But both treatment
and experimentation influence the subject and
render this knowledge irrelevant. The very
processes of measurement and observation
influence the human subject and transform him
or her - as do life's circumstances and
vicissitudes.

3. Uniqueness – Psychological experiments are,

therefore, bound to be unique, unrepeatable,
cannot be replicated elsewhere and at other
times even when they are conducted with the
SAME subjects. This is because the subjects are
never the same due to the aforementioned
psychological uncertainty principle. Repeating
the experiments with other subjects adversely
affects the scientific value of the results.

4. The undergeneration of testable hypotheses –

Psychology does not generate a sufficient
number of hypotheses, which can be subjected to
scientific testing. This has to do with the
fabulous (=storytelling) nature of psychology. In
a way, psychology has affinity with some private
languages. It is a form of art and, as such, is self-
sufficient and self-contained. If structural,
 internal constraints are met – a statement is
deemed true even if it does not satisfy external
scientific requirements.

B. Methodology

1. Many psychological lab tests are not blind. The

experimenter is fully aware who among his subjects has
the traits and behaviors that the test is supposed to
identify and predict. This foreknowledge may give rise
to experimenter effects and biases. Thus, when testing
for the prevalence and intensity of fear conditioning
among psychopaths (e.g., Birbaumer, 2005), the
subjects were first diagnosed with psychopathy (using
the PCL-R questionnaire) and only then underwent the
experiment. Thus, we are left in the dark as to whether
the test results (deficient fear conditioning) can actually
predict or retrodict psychopathy (i.e., high PCL-R
scores and typical life histories).

2. In many cases, the results can be linked to multiple

causes. This gives rise to questionable cause fallacies
in the interpretation of test outcomes. In the
aforementioned example, the vanishingly low pain
aversion of psychopaths may have more to do with
peer-posturing than with a high tolerance of pain:
psychopaths may simply be too embarrassed to
"succumb" to pain; any admission of vulnerability is
perceived by them as a threat to an omnipotent and
grandiose self-image that is sang-froid and, therefore,
impervious to pain. It may also be connected to
inappropriate affect.

3. Most psychological lab tests involve tiny samples

(as few as 3 subjects!) and interrupted time series. The
fewer the subjects, the more random and less significant
are the results. Type III errors and issues pertaining to
the processing of data garnered in interrupted time
series are common.

4. The interpretation of test results often verges on

metaphysics rather than science. Thus, the Birbaumer
test established that subjects who scored high on the
PCL-R have different patterns of skin conductance
(sweating in anticipation of painful stimuli) and brain
activity. It did not substantiate, let alone prove, the
existence or absence of specific mental states or
psychological constructs.

5. Most lab tests deal with tokens of certain types of

phenomena. Again: the fear conditioning (anticipatory
aversion) test pertains only to reactions in anticipation
of an instance (token) of a certain type of pain. It does
not necessarily apply to other types of pain or to other
tokens of this type or any other type of pain.

6. Many psychological lab tests give rise to the

petitio principii (begging the question) logical
fallacy. Again, let us revisit Birbaumer's test. It deals
with people whose behavior is designated as
"antisocial". But what constitute antisocial traits and
conduct? The answer is culture-bound. Not surprisingly,
European psychopaths score far lower on the PCL-R
than their American counterparts. The very validity of
the construct "psychopath" is, therefore, in question:
psychopathy seems to be merely what the PCL-R
measures!

7. Finally, the "Clockwork Orange" objection:

psychological lab tests have frequently been abused by
reprehensible regimes for purposes of social control
and social engineering.

Return
 Therapy and Treatment of
Personality Disorders

I. Introduction

The dogmatic schools of psychotherapy (such as

psychoanalysis, psychodynamic therapies, and
behaviorism) more or less failed in ameliorating, let
alone curing or healing personality disorders.
Disillusioned, most therapists now adhere to one or
more of three modern methods: Brief Therapies, the
Common Factors approach, and Eclectic techniques.

Conventionally, brief therapies, as their name implies,

are short-term but effective. They involve a few rigidly
structured sessions, directed by the therapist. The
patient is expected to be active and responsive. Both
parties sign a therapeutic contract (or alliance) in which
they define the goals of the therapy and, consequently,
its themes. As opposed to earlier treatment modalities,
brief therapies actually encourage anxiety because they
believe that it has a catalytic and cathartic effect on the
patient.

Supporters of the Common Factors approach point out

that all psychotherapies are more or less equally
efficient (or rather similarly inefficient) in treating
personality disorders. As Garfield noted in 1957, the
first step perforce involves a voluntary action: the
subject seeks help because he or she experiences
intolerable discomfort, ego-dystony, dysphoria, and
dysfunction. This act is the first and indispensable factor
associated with all therapeutic encounters, regardless of
their origins.
Another common factor is the fact that all talk therapies
revolve around disclosure and confidences. The patient
confesses his or her problems, burdens, worries,
anxieties, fears, wishes, intrusive thoughts,
compulsions, difficulties, failures, delusions, and,
generally invites the therapist into the recesses of his or
her innermost mental landscape.

The therapist leverages this torrent of data and

elaborates on it through a series of attentive comments
and probing, thought-provoking queries and insights.
This pattern of give and take should, in time, yield a
relationship between patient and healer, based on
mutual trust and respect. To many patients this may well
be the first healthy relationship they experience and a
model to build on in the future.

Good therapy empowers the client and enhances her

ability to properly gauge reality (her reality test). It
amount to a comprehensive rethink of oneself and one's
life. With perspective comes a stable sense of self-
worth, well-being, and competence (self-confidence).

In 1961, a scholar, Frank made a list of the important

elements in all psychotherapies regardless of their
intellectual provenance and technique:

1. The therapist should be trustworthy, competent, and

caring.

2. The therapist should facilitate behavioral

modification in the patient by fostering hope and
"stimulating emotional arousal" (as Millon puts it). In
other words, the patient should be re-introduced to his
repressed or stunted emotions and thereby undergo a
"corrective emotional experience."

3. The therapist should help the patient develop insight

about herself - a new way of looking at herself and her
world and of understanding who she is.

4. All therapies must weather the inevitable crises and

demoralization that accompany the process of
confronting oneself and one's shortcomings. Loss of
self-esteem and devastating feelings of inadequacy,
helplessness, hopelessness, alienation, and even despair
are an integral, productive, and important part of the
sessions if handled properly and competently.

II. Eclectic Psychotherapy

The early days of the emerging discipline of psychology

were inevitably rigidly dogmatic. Clinicians belonged to
well-demarcated schools and practiced in strict
accordance with canons of writings by "masters" such
as Freud, or Jung, or Adler, or Skinner. Psychology was
less a science than an ideology or an art form. Freud's
work, for instance, though incredibly insightful, is
closer to literature and cultural studies than to proper,
evidence-based, medicine.

Not so nowadays. Mental health practitioners freely

borrow tools and techniques from a myriad therapeutic
systems. They refuse to be labeled and boxed in. The
only principle that guides modern therapists is "what
works" - the effectiveness of treatment modalities, not
their intellectual provenance. The therapy, insists these
eclecticists, should be tailored to the patient, not the
other way around.
This sounds self-evident but as Lazarus pointed out in a
series of articles in the 1970s, it is nothing less than
revolutionary. The therapist today is free to match
techniques from any number of schools to presenting
problems without committing himself to the theoretical
apparatus (or baggage) that is associated with them. She
can use psychoanalysis or behavioral methods while
rejecting Freud's ideas and Skinner's theory, for
instance.

Lazarus proposed that the appraisal of the efficacy and

applicability of a treatment modality should be based on
six data: BASIC IB (Behavior, Affect, Sensation,
Imagery, Cognition, Interpersonal Relationships, and
Biology). What are the patient's dysfunctional behavior
patterns? How is her sensorium? In what ways does her
imagery connect with her problems, presenting
symptoms, and signs? Does he suffer from cognitive
deficits and distortions? What is the extent and quality
of the patient's interpersonal relationships? Does the
subject suffer from any medical, genetic, or
neurological problems that may affect his or her conduct
and functioning?

Once the answers to these questions are collated, the

therapist should judge which treatment options are
likely to yield the fastest and most durable outcomes,
based on empirical data. As Beutler and Chalkin noted
in a groundbreaking article in 1990, therapists no longer
harbor delusions of omnipotence. Whether a course of
therapy succeeds or not depends on numerous factors
such as the therapist's and the patient's personalities and
past histories and the interactions between the various
techniques used.
So what's the use of theorizing in psychology? Why not
simply revert to trial and error and see what works?

Beutler, a staunch supporter and promoter of

eclecticism, provides the answer:

Psychological theories of personality allow us to be

more selective. They provide guidelines as to which
treatment modalities we should consider in any given
situation and for any given patient. Without these
intellectual edifices we would be lost in a sea of
"everything goes". In other words, psychological
theories are organizing principles. They provide the
practitioner with selection rules and criteria that he or
she would do well to apply if they don't want to drown
in a sea of ill-delineated treatment options.

Learn more about psychoanalysis - click HERE!

Read more about treatment modalities and therapies -

click HERE!

Return
 The Hateful Patient
Difficult Patients in Psychotherapy

In 1978, a medical doctor by the name of J.E. Groves

published in the prestigious New England Journal of
Medicine an article titled "Taking Care of the Hateful
Patient". In it he admitted that patients with personality
disorders often evoke in their physicians dislike or even
outright hatred.

Groves described four types of such undesirable

patients: "dependent clingers" (codependents), "entitled
demanders" (narcissists and borderlines), "manipulative
help rejectors" (typically psychopaths and paranoids,
borderlines and negativistic passive-aggressives), and
"self-destructive deniers" (schizoids and schizotypals,
for instance, or histrionics and borderlines).

Therapists, psychologists, social workers, and

psychiatrists report similar negative feelings towards
such patients. Many of them try to ignore, deny, and
repress them. The more mature health professionals
realize that denial only exacerbates the undercurrents of
tension and resentment, prevents effective patient
management, and undermines any therapeutic alliance
between healer and the ill.

It is not easy to cater to the needs of patients with

personality disorders. By far the worst is the narcissistic
(patient with Narcissistic Personality Disorder).

From my book "Malignant Self Love - Narcissism

Revisited":
"One of the most important presenting symptoms of
the narcissist in therapy is his (or her) insistence that
he (or she) is equal to the psychotherapist in
knowledge, in experience, or in social status. The
narcissist in the therapeutic session spices his speech
with psychiatric lingo and professional terms.

The narcissist distances himself from his painful

emotions by generalising and analyzing them, by
slicing his life and hurt and neatly packaging the
results into what he thinks are "professional insights".
His message to the psychotherapist is: there is nothing
much that you can teach me, I am as intelligent as you
are, you are not superior to me, actually, we should
both collaborate as equals in this unfortunate state of
things in which we, inadvertently, find ourselves
involved."

In their seminal tome, "Personality Disorders in

Modern Life" (New York, John Wiley & Sons, 2000),
Theodore Millon and Roger Davis write (p. 308):

"Most narcissists strongly resist psychotherapy. For

those who choose to remain in therapy, there are
several pitfalls that are difficult to avoid ...
Interpretation and even general assessment are often
difficult to accomplish..."

The third edition of the "Oxford Textbook of

Psychiatry" (Oxford, Oxford University Press,
reprinted 2000), cautions (p. 128):

"... (P)eople cannot change their natures, but can only

change their situations. There has been some progress
in finding ways of effecting small changes in disorders
of personality, but management still consists largely of
helping the person to find a way of life that conflicts
less with his character ... Whatever treatment is used,
aims should be modest and considerable time should
be allowed to achieve them."

The fourth edition of the authoritative "Review of

General Psychiatry" (London, Prentice-Hall
International, 1995), says (p. 309):

"(People with personality disorders) ... cause

resentment and possibly even alienation and burnout
in the healthcare professionals who treat them ... (p.
318) Long-term psychoanalytic psychotherapy and
psychoanalysis have been attempted with (narcissists),
although their use has been controversial."

Read more about therapy of personality disorders

Return
 The Narcissist in Therapy

The narcissist regards therapy as a competitive sport. In

therapy the narcissist usually immediately insists that he
(or she) is equal to the psychotherapist in knowledge, in
experience, or in social status. To substantiate this claim
and "level the playing field", the narcissist in the
therapeutic session spices his speech with professional
terms and lingo.

The narcissist sends a message to his psychotherapist:

there is nothing you can teach me, I am as intelligent as
you are, you are not superior to me, actually, we should
both collaborate as equals in this unfortunate state of
things in which we, inadvertently, find ourselves
involved.

The narcissist at first idealizes and then devalues the

therapist. His internal dialogue is:

"I know best, I know it all, the therapist is less

intelligent than I, I can't afford the top level therapists
who are the only ones qualified to treat me (as my
equals, needless to say), I am actually as good as a
therapist myself…"

"He (my therapist) should be my colleague, in certain

respects it is he who should accept my professional
authority, why won't he be my friend, after all I can use
the lingo (psycho-babble) even better than he does? It's
us (him and me) against a hostile and ignorant world
(shared psychosis, folie a deux)…".
"Just who does he think he is, asking me all these
questions? What are his professional credentials? I am a
success and he is a nobody therapist in a dingy office,
he is trying to negate my uniqueness, he is an authority
figure, I hate him, I will show him, I will humiliate him,
prove him ignorant, have his licence revoked
(transference). Actually, he is pitiable, a zero, a
failure…"

These self-delusions and fantastic grandiosity are,

really, the narcissist's defences and resistance to
treatment. This abusive internal exchange becomes
more vituperative and pejorative as therapy progresses.

The narcissist distances himself from his painful

emotions by generalising and analyzing them, by slicing
his life and hurt into neat packages of what he thinks are
"professional insights".

The narcissist has a dilapidated and dysfunctional True

Self, overtaken and suppressed by a False Self. In
therapy, the general idea is to create the conditions for
the True Self to resume its growth: safety, predictability,
justice, love and acceptance. To achieve this ambience,
the therapist tries to establish a mirroring, re-parenting,
and holding environment.

From my book "Malignant Self Love - Narcissism

Revisited":

"Therapy is supposed to provide these conditions of

nurturance and guidance (through transference,
cognitive re-labelling or other methods). The narcissist
must learn that his past experiences are not laws of
nature, that not all adults are abusive, that
relationships can be nurturing and supportive.

Most therapists try to co-opt the narcissist's inflated

ego (False Self) and defences. They compliment the
narcissist, challenging him to prove his omnipotence
by overcoming his disorder. They appeal to his quest
for perfection, brilliance, and eternal love - and his
paranoid tendencies - in an attempt to get rid of
counterproductive, self-defeating, and dysfunctional
behaviour patterns."

Some therapists try to stroke the narcissist's grandiosity.

By doing so, they hope to modify or counter cognitive
deficits, thinking errors, and the narcissist's victim-
stance. They contract with the narcissist to alter his
conduct. Psychiatrists tend to medicalize the disorder by
attributing it to genetic or biochemical causes.
Narcissists like this approach as it absolves
them from responsibility for their actions.

Therapists with unresolved issues and narcissistic

defenses of their own sometimes feel compelled to
confront the narcissist head on and to engage in power
politics, for instance by instituting disciplinary
measures. They compete with the narcissist and try to
establish their superiority: "I am cleverer than you are",
"My will should prevail", and so on. This form of
immaturity is decidedly unhelpful and could lead to rage
attacks and a deepening of the narcissist's persecutory
delusions, bred by his humiliation in the therapeutic
setting.

Narcissists generally are averse to being medicated as

this amounts to an admission that something is,
indeed, wrong and "needs fixing". Narcissists are
control freaks and hate to be "under the influence" of
"mind altering" drugs prescribed to them by others.

From my book "Malignant Self Love - Narcissism

Revisited":

"Many (narcissists) believe that medication is the

"great equaliser": it will make them lose their
uniqueness, superiority and so on. That is unless they
can convincingly present the act of taking their
medicines as "heroism", a daring enterprise of self-
exploration, part of a breakthrough clinical trial, and
so on.

(Narcissists) often claim that the medicine affects them

differently than it does other people, or that they have
discovered a new, exciting way of using it, or that they
are part of someone's (usually themselves) learning
curve ("part of a new approach to dosage", "part of a
new cocktail which holds great promise"). Narcissists
must dramatise their lives to feel worthy and special.
Aut nihil aut unique – either be special or don't be at
all. Narcissists are drama queens.

Very much like in the physical world, change is

brought about only through incredible powers of
torsion and breakage. Only when the narcissist's
elasticity gives way, only when he is wounded by his
own intransigence – only then is there hope.

It takes nothing less than a real crisis. Ennui is not

enough."

Read more about therapy of personality disorders

Narcissistic Personality Disorder - Treatment
Modalities and Therapies

Your Abuser in Therapy

Your abuser "agrees" (is forced) to attend therapy. But

are the sessions worth the effort? What is the success
rate of various treatment modalities in modifying the
abuser's conduct, let alone in "healing" or "curing" him?
Is psychotherapy the panacea it is often made out to be
– or a nostrum, as many victims of abuse claim? And
why is it applied only after the fact – and not as a
preventive measure?

Courts regularly send offenders to be treated as a

condition for reducing their sentences. Yet, most of the
programs are laughably short (between 6 to 32 weeks)
and involve group therapy – which is useless with
abusers who are also narcissists or psychopaths.

Rather than cure him, such workshops seek to "educate"

and "reform" the culprit, often by introducing him to the
victim's point of view. This is supposed to inculcate in
the offender empathy and to rid the habitual batterer of
the residues of patriarchal prejudice and control
freakery. Abusers are encouraged to examine gender
roles in modern society and, by implication, ask
themselves if battering one's spouse was proof of
virility.

Anger management – made famous by the eponymous

film – is a relatively late newcomer, though currently it
is all the rage. Offenders are taught to identify the
hidden – and real – causes of their rage and learn
techniques to control or channel it.

But batterers are not a homogeneous lot. Sending all of

them to the same type of treatment is bound to end up in
recidivism. Neither are judges qualified to decide
whether a specific abuser requires treatment or can
benefit from it. The variety is so great that it is safe to
say that – although they share the same misbehavior
patterns – no two abusers are alike.

In their article, "A Comparison of Impulsive and

Instrumental Subgroups of Batterers", Roger Tweed
and Donald Dutton of the Department of Psychology of
the University of British Columbia, rely on the current
typology of offenders which classifies them as:

"... Overcontrolled-dependent, impulsive-borderline

(also called 'dysphoric-borderline' – SV) and
instrumental-antisocial. The overcontrolled-dependent
differ qualitatively from the other two expressive or
'undercontrolled' groups in that their violence is, by
definition, less frequent and they exhibit less florid
psychopathology. (Holtzworth-Munroe & Stuart 1994,
Hamberger & hastings 1985) ... Hamberger &
Hastings (1985,1986) factor analyzed the Millon
Clinical Multiaxial Inventory for batterers, yielding
three factors which they labeled 'schizoid/borderline'
(cf. Impulsive), 'narcissistic/antisocial' (instrumental),
and 'passive/dependent/compulsive' (overcontrolled)...
Men, high only on the impulsive factor, were described
as withdrawn, asocial, moody, hypersensitive to
perceived slights, volatile and over-reactive, calm and
controlled one moment and extremely angry and
oppressive the next – a type of 'Jekyll and Hyde'
personality. The associated DSM-III diagnosis was
Borderline Personality. Men high only on the
instrumental factor exhibited narcissistic entitlement
and psychopathic manipulativeness. Hesitation by
others to respond to their demands produced threats
and aggression ..."

But there are other, equally enlightening, typologies

(mentioned by the authors). Saunders suggested 13
dimensions of abuser psychology, clustered in three
behavior patterns: Family Only, Emotionally Volatile,
and Generally Violent. Consider these disparities: one
quarter of his sample – those victimized in childhood –
showed no signs of depression or anger! At the other
end of the spectrum, one of every six abusers was
violent only in the confines of the family and suffered
from high levels of dysphoria and rage.

Impulsive batterers abuse only their family members.

Their favorite forms of mistreatment are sexual and
psychological. They are dysphoric, emotionally labile,
asocial, and, usually, substance abusers. Instrumental
abusers are violent both at home and outside it – but
only when they want to get something done. They are
goal-orientated, avoid intimacy, and treat people as
objects or instruments of gratification.

Still, as Dutton pointed out in a series of acclaimed

studies, the "abusive personality" is characterized by a
low level of organization, abandonment anxiety (even
when it is denied by the abuser), elevated levels of
anger, and trauma symptoms.

It is clear that each abuser requires individual

psychotherapy, tailored to his specific needs – on top of
the usual group therapy and marital (or couple) therapy.
At the very least, every offender should be required to
undergo these tests to provide a complete picture of his
personality and the roots of his unbridled aggression:

1. The Relationship Styles Questionnaire (RSQ)

2. Millon Clinical Multiaxial Inventory-III
(MCMI-III)
3. Conflict Tactics Scale (CTS)
4. Multidimensional Anger Inventory (MAI)
5. Borderline Personality Organization Scale
(BPO)
6. The Narcissistic Personality Inventory (NPI)

Return
 The Narcissistic Patient - A Case Study

Notes of first therapy session with Sam V., male, 43,

diagnosed with Narcissistic Personality Disorder
(NPD)

Sam presents with anhedonia (failure to enjoy or find

pleasure in anything) and dysphoria bordering on
depression. He complains of inability to tolerate
people's stupidity and selfishness in a variety of settings.
He admits that as a result of his "intellectual superiority"
he is not well placed to interact with others or even to
understand them and what they are going through. He is
a recluse and fears that he is being mocked and ridiculed
behind his back as a misfit and a freak. Throughout the
first session, he frequently compares himself to a
machine, a computer, or a member of an alien and
advanced race, and talks about himself in the third
person singular.

Life, bemoans Sam, has dealt him a bad hand. He is

consistently and repeatedly victimized by his clients, for
instance. They take credit for his ideas and leverage
them to promote themselves, but then fail to re-hire him
as a consultant. He seems to attract hostility and
animosity incommensurate with his good and generous
deeds. He even describes being stalked by two or three
vicious women whom he had spurned, he claims, not
without pride in his own implied irresistibility. Yes, he
is abrasive and contemptuous of others at times but only
in the interests of "tough love." He is never obnoxious
or gratuitously offensive.

Sam is convinced that people envy him and are "out to

get him" (persecutory delusions). He feels that his work
(he is also a writer) is not appreciated because of its
elitist nature (high-brow vocabulary and such). He
refuses to "dumb down". Instead, he is on a mission to
educate his readers and clients and "bring them up to his
level." When he describes his day, it becomes clear that
he is desultory, indolent, and lacks self-discipline and
regular working habits. He is fiercely independent (to
the point of being counter-dependent - click on this
link: http://samvak.tripod.com/faq66.html ) and highly
values his self-imputed "brutal honesty" and "original,
non-herd, outside the box" thinking.

He is married but sexually inactive. Sex bores him and

he regards it as a "low-level" activity practiced by
"empty-headed" folk. He has better uses for his limited
time. He is aware of his own mortality and conscious of
his intellectual legacy. Hence his sense of entitlement.
He never goes through established channels. Instead,
he uses his connections to secure anything from medical
care to car repair. He expects to be treated by the best
but is reluctant to buy their services, holding himself to
be their equal in his own field of activity. He gives little
or no thought to the needs, wishes, fears, hopes,
priorities, and choices of his nearest and dearest. He is
startled and hurt when they become assertive and
exercise their personal autonomy (for instance, by
setting boundaries).

Sam is disarmingly self-aware and readily lists his

weaknesses and faults - but only in order to preempt real
scrutiny or to fish for compliments. He constantly
brags about his achievements but feels deprived ("I
deserve more, much more than that"). When any of his
assertions or assumptions is challenged he
condescendingly tries to prove his case. If he fails to
convert his interlocutor, he sulks and even rages. He
tends to idealize everyone or devalue them: people are
either clever and good or stupid and malicious. But,
everyone is a potential foe.

Sam is very hypervigilant and anxious. He expects the

worst and feels vindicated and superior when he is
punished ("martyred and victimized"). Sam rarely
assumes total responsibility for his actions or accepts
their consequences. He has an external locus of control
and his defenses are alloplastic. In other words: he
blames the world for his failures, defeats, and "bad
luck". This "cosmic conspiracy" against him is why his
grandiose projects keep flopping and why he is so
frustrated.

Read more about the Narcissistic Personality Disorder (NPD) -

click on these links:

Who is a Narcissist?

Narcissistic Personality Disorder - Diagnostic Criteria

Narcissistic Personality Disorder - Prevalence and Comorbidity

Narcissistic Personality Disorder - Clinical Features

The Inverted Narcissist

Return
 The Psychopathic Patient - A Case Study

Notes of first therapy session with Ani Korban, male,

46, diagnosed with Antisocial Personality Disorder
(AsPD), or Psychopathy and Sociopathy

Ani was referred to therapy by the court, as part of a

rehabilitation program. He is serving time in prison,
having been convicted of grand fraud. The scam
perpetrated by him involved hundreds of retired men
and women in a dozen states over a period of three
years. All his victims lost their life savings and suffered
grievous and life-threatening stress symptoms.

He seems rather peeved at having to attend the sessions

but tries to hide his displeasure by claiming to be eager
to "heal, reform himself and get reintegrated into
normative society". When I ask him how does he feel
about the fact that three of his victims died of heart
attacks as a direct result of his misdeeds, he barely
suppresses an urge to laugh out loud and then denies
any responsibility: his "clients" were adults who knew
what they were doing and had the deal he was working
on gone well, they would all have become "filthy rich."
He then goes on the attack: aren't psychiatrists supposed
to be impartial? He complains that I sound exactly like
the "vicious and self-promoting low-brow" prosecutor at
his trial.

He looks completely puzzled and disdainful when I ask

him why he did what he did. "For the money, of course"
- he blurts out impatiently and then recomposes himself:
"Had this panned out, these guys would have had a great
retirement, far better than their meager and laughable
pensions could provide." Can he describe his typical
"customer"? Of course he can - he is nothing if not
thorough. He provides me with a litany of detailed
demographics. No, I say - I am interested to know about
their wishes, hopes, needs, fears, backgrounds, families,
emotions. He is stumped for a moment: "Why would I
want to know these data? It's not like I was their bloody
grandson, or something!"

Ani is contemptuous towards the "meek and weak". Life

is hostile, one long cruel battle, no holds barred. Only
the fittest survive. Is he one of the fittest? He shows
signs of unease and contrition but soon I find out that he
merely regrets having been caught. It depresses him to
face incontrovertible proof that he is not as intellectually
superior to others as he had always believed himself to
be.

Is he a man of his word? Yes, but sometimes

circumstances conspire to prevent one from fulfilling
one's obligations. Is he referring to moral or to
contractual obligations? Contracts he believes in
because they represent a confluence of the self-interests
of the contracting parties. Morality is another thing
altogether: it was invented by the strong to emasculate
and enslave the masses. So, is he immoral by choice?
Not immoral, he grins, just amoral.

How does he choose his business partners? They have

to be alert, super-intelligent, willing to take risks,
inventive, and well-connected. "Under different
circumstance, you and I would have been a great team"
- he promises me as I, his psychiatrist, am definitely
"one of the most astute and erudite persons he has ever
met." I thank him and he immediately asks for a favor:
could I recommend to the prison authorities to allow
him to have free access to the public pay phone? He
can't run his businesses with a single daily time-limited
call and this is "adversely affecting the lives and
investments of many poor people." When I decline to do
his bidding, he sulks, clearly consumed by barely
suppressed rage.

How is he adapting to being incarcerated? He is not

because there is no need to. He is going to win his
appeal. The case against him was flimsy, tainted, and
dubious. What if he fails? He doesn't believe in
"premature planning". "One day at a time is my motto."
- he says smugly - "The world is so unpredictable that it
is by far better to improvise."

He seems disappointed with our first session. When I

ask him what his expectations were, he shrugs:
"Frankly, doctor, talking about scams, I don't believe
in this psycho-babble of yours. But I was hoping to be
able finally communicate my needs and wishes to
someone who would appreciate them and lend me a
hand here." His greatest need, I suggest, is to accept and
admit that he erred and to feel remorse, This strikes him
as very funny and the encounter ends as it had begun:
with him deriding his victims.

Read more about the Antisocial Personality Disorder

(NPD) - click on these links:
 Narcissist vs. Psychopath

The Psychopath, Sociopath, and Antisocial

Return
 Narcissistic Personality Disorder Treatment
Modalities and Therapies

Question:

Is the Narcissistic Personality Disorder (NPD) more

amenable to Cognitive-Behavioural therapies or to
Psychodynamic/Psychoanalytic ones?

Answer:

Narcissism pervades the entire personality. It is all-

pervasive. Being a narcissist is akin to being an
alcoholic but much more so. Alcoholism is an impulsive
behaviour. Narcissists exhibit dozens of similarly
reckless behaviours, some of them uncontrollable (like
their rage, the outcome of their wounded grandiosity).
Narcissism is not a vocation. Narcissism resembles
depression or other disorders and cannot be changed at
will.

Adult pathological narcissism is no more "curable" than

the entirety of one's personality is disposable. The
patient is a narcissist. Narcissism is more akin to the
colour of one's skin rather than to one's choice of
subjects at the university.

Moreover, the Narcissistic Personality Disorder (NPD)

is frequently diagnosed with other, even more
intractable personality disorders, mental illnesses, and
substance abuse.

Cognitive-Behavioral Therapies (CBTs)

The CBTs postulate that insight – even if merely verbal
and intellectual – is sufficient to induce an emotional
outcome. Verbal cues, analyses of mantras we keep
repeating ("I am ugly", "I am afraid no one would like
to be with me"), the itemizing of our inner dialogues
and narratives and of our repeated behavioural patterns
(learned behaviours) coupled with positive (and, rarely,
negative) reinforcements – are used to induce a
cumulative emotional effect tantamount to healing.

Psychodynamic theories reject the notion that cognition

can influence emotion. Healing requires access to and
the study of much deeper strata by both patient and
therapist. The very exposure of these strata to the
therapeutic is considered sufficient to induce a dynamic
of healing.

The therapist's role is either to interpret the material

revealed to the patient (psychoanalysis) by allowing the
patient to transfer past experience and superimpose it on
the therapist – or to provide a safe emotional and
holding environment conducive to changes in the
patient.

The sad fact is that no known therapy is effective with

narcissism itself, though a few therapies are reasonably
successful as far as coping with some of its effects goes
(behavioural modification).

Dynamic Psychotherapy
Or Psychodynamic Therapy, Psychoanalytic
Psychotherapy

This is not psychoanalysis. It is an intensive

psychotherapy based on psychoanalytic theory without
the (very important) element of free association. This is
not to say that free association is not used in these
therapies – only that it is not a pillar of the technique.
Dynamic therapies are usually applied to patients not
considered "suitable" for psychoanalysis (such as those
suffering from personality disorders, except the
Avoidant PD).

Typically, different modes of interpretation are

employed and other techniques borrowed from other
treatments modalities. But the material interpreted is not
necessarily the result of free association or dreams and
the psychotherapist is a lot more active than the
psychoanalyst.

Psychodynamic therapies are open-ended. At the

commencement of the therapy, the therapist (analyst)
makes an agreement (a "pact" or "alliance") with the
analysand (patient or client). The pact says that the
patient undertakes to explore his problems for as long as
may be needed. This is supposed to make the
therapeutic environment much more relaxed because the
patient knows that the analyst is at his/her disposal no
matter how many meetings would be required in order
to broach painful subject matter.

Sometimes, these therapies are divided to expressive

versus supportive, but I regard this division as
misleading.

Expressive means uncovering (making conscious) the

patient's conflicts and studying his or her defences and
resistances. The analyst interprets the conflict in view of
the new knowledge gained and guides the therapy
towards a resolution of the conflict. The conflict, in
other words, is "interpreted away" through insight and
the change in the patient motivated by his/her insights.

The supportive therapies seek to strengthen the Ego.

Their premise is that a strong Ego can cope better (and
later on, alone) with external (situational) or internal
(instinctual, related to drives) pressures. Supportive
therapies seek to increase the patient's ability to
REPRESS conflicts (rather than bring them to the
surface of consciousness).

When the patient's painful conflicts are suppressed, the

attendant dysphorias and symptoms vanish or are
ameliorated. This is somewhat reminiscent of
behaviourism (the main aim is to change behaviour and
to relieve symptoms). It usually makes no use of insight
or interpretation (though there are exceptions).

Group Therapies

Narcissists are notoriously unsuitable for collaborative

efforts of any kind, let alone group therapy. They
immediately size up others as potential Sources of
Narcissistic Supply – or as potential competitors. They
idealise the first (suppliers) and devalue the latter
(competitors). This, obviously, is not very conducive to
group therapy.

Moreover, the dynamic of the group is bound to reflect

the interactions of its members. Narcissists are
individualists. They regard coalitions with disdain and
contempt. The need to resort to team work, to adhere to
group rules, to succumb to a moderator, and to honour
and respect the other members as equals is perceived by
them to be humiliating and degrading (a contemptible
weakness). Thus, a group containing one or more
narcissists is likely to fluctuate between short-term, very
small size, coalitions (based on "superiority" and
contempt) and narcissistic outbreaks (acting outs) of
rage and coercion.

Can Narcissism be Cured?

Adult narcissists can rarely be "cured", though some

scholars think otherwise. Still, the earlier the therapeutic
intervention, the better the prognosis. A correct
diagnosis and a proper mix of treatment modalities in
early adolescence guarantees success without relapse in
anywhere between one third and one half the cases.
Additionally, ageing moderates or even vanquishes
some antisocial behaviours.

In their seminal tome, "Personality Disorders in

Modern Life" (New York, John Wiley & Sons, 2000),
Theodore Millon and Roger Davis write (p. 308):

"Most narcissists strongly resist psychotherapy. For

those who choose to remain in therapy, there are
several pitfalls that are difficult to avoid ...
Interpretation and even general assessment are often
difficult to accomplish..."

The third edition of the "Oxford Textbook of

Psychiatry" (Oxford, Oxford University Press,
reprinted 2000), cautions (p. 128):

"... (P)eople cannot change their natures, but can only

change their situations. There has been some progress
in finding ways of effecting small changes in disorders
of personality, but management still consists largely of
helping the person to find a way of life that conflicts
less with his character ... Whatever treatment is used,
aims should be modest and considerable time should
be allowed to achieve them."

The fourth edition of the authoritative "Review of

General Psychiatry" (London, Prentice-Hall
International, 1995), says (p. 309):

"(People with personality disorders) ... cause

resentment and possibly even alienation and burnout
in the healthcare professionals who treat them ... (p.
318) Long-term psychoanalytic psychotherapy and
psychoanalysis have been attempted with (narcissists),
although their use has been controversial."

The reason narcissism is under-reported and healing

over-stated is that therapists are being fooled by smart
narcissists. Most narcissists are expert manipulators and
consummate actors and they learn how to deceive their
therapists.

Here are some hard facts:

 There are gradations and shades of narcissism.

The differences between two narcissists can be
great. The existence of grandiosity and empathy
or lack thereof are not minor variations. They
are serious predictors of future psychodynamics.
The prognosis is much better if they do exist.

 There are cases of spontaneous healing,

Acquired Situational Narcissism, and of "short-
term NPD" [see Gunderson's and Ronningstam
work, 1996].
  The prognosis for a classical narcissist
(grandiosity, lack of empathy and all) is
decidedly not good as far as long-term, lasting,
and complete healing. Moreover, narcissists are
intensely disliked by therapists.

BUT…

 Side effects, co-morbid disorders (such as

Obsessive-Compulsive behaviors) and some
aspects of NPD (the dysphorias, the persecutory
delusions, the sense of entitlement, the
pathological lying) can be modified (using talk
therapy and, depending on the problem,
medication). These are not long-term or
complete solutions – but some of them do have
long-term effects.

 The DSM is a billing and administration

oriented diagnostic tool. It is intended to "tidy"
up the psychiatrist's desk. The Axis II
Personality Disorders are ill demarcated. The
differential diagnoses are vaguely defined. There
are some cultural biases and judgements [see the
diagnostic criteria of the Schizotypal and
Antisocial PDs]. The result is sizeable confusion
and multiple diagnoses ("co-morbidity"). NPD
was introduced to the DSM in 1980 [DSM-III].
There isn't enough research to substantiate any
view or hypothesis about NPD. Future DSM
editions may abolish it altogether within the
framework of a cluster or a single "personality
disorder" category. When we ask: "Can NPD be
healed?" we need to realise that we don't know
for sure what is NPD and what constitutes long-
 term healing in the case of an NPD. There are
those who seriously claim that NPD is a cultural
disease (culture-bound) with a societal
determinant.

Narcissists in Therapy

In therapy, the general idea is to create the conditions

for the True Self to resume its growth: safety,
predictability, justice, love and acceptance - a mirroring,
re-parenting, and holding environment. Therapy is
supposed to provide these conditions of nurturance and
guidance (through transference, cognitive re-labelling or
other methods). The narcissist must learn that his past
experiences are not laws of nature, that not all adults are
abusive, that relationships can be nurturing and
supportive.

Most therapists try to co-opt the narcissist's inflated ego

(False Self) and defences. They compliment the
narcissist, challenging him to prove his omnipotence by
overcoming his disorder. They appeal to his quest for
perfection, brilliance, and eternal love - and his paranoid
tendencies - in an attempt to get rid of
counterproductive, self-defeating, and dysfunctional
behaviour patterns.

By stroking the narcissist's grandiosity, they hope to

modify or counter cognitive deficits, thinking errors,
and the narcissist's victim-stance. They contract with the
narcissist to alter his conduct. Some even go to the
extent of medicalizing the disorder, attributing it to a
hereditary or biochemical origin and thus "absolving"
the narcissist from his responsibility and freeing his
mental resources to concentrate on the therapy.
Confronting the narcissist head on and engaging in
power politics ("I am cleverer", "My will should
prevail", and so on) is decidedly unhelpful and could
lead to rage attacks and a deepening of the narcissist's
persecutory delusions, bred by his humiliation in the
therapeutic setting.

Successes have been reported by applying 12-step

techniques (as modified for patients suffering from the
Antisocial Personality Disorder), and with treatment
modalities as diverse as NLP (Neurolinguistic
Programming), Schema Therapy, and EMDR (Eye
Movement Desensitization).

But, whatever the type of talk therapy, the narcissist

devalues the therapist. His internal dialogue is: "I know
best, I know it all, the therapist is less intelligent than I,
I can't afford the top level therapists who are the only
ones qualified to treat me (as my equals, needless to
say), I am actually a therapist myself…"

A litany of self-delusion and fantastic grandiosity

(really, defences and resistances) ensues: "He (my
therapist) should be my colleague, in certain respects it
is he who should accept my professional authority, why
won't he be my friend, after all I can use the lingo
(psycho-babble) even better than he does? It's us (him
and me) against a hostile and ignorant world (shared
psychosis, folie a deux)…"

Then there is this internal dialog: "Just who does he

think he is, asking me all these questions? What are his
professional credentials? I am a success and he is a
nobody therapist in a dingy office, he is trying to negate
my uniqueness, he is an authority figure, I hate him, I
will show him, I will humiliate him, prove him ignorant,
have his licence revoked (transference). Actually, he is
pitiable, a zero, a failure…"

And this is only in the first three sessions of the therapy.

This abusive internal exchange becomes more
vituperative and pejorative as therapy progresses.

Narcissists generally are averse to being medicated.

Resorting to medicines is an implied admission that
something is wrong. Narcissists are control freaks and
hate to be "under the influence" of "mind altering" drugs
prescribed to them by others.

Additionally, many of them believe that medication is

the "great equaliser" – it will make them lose their
uniqueness, superiority and so on. That is unless they
can convincingly present the act of taking their
medicines as "heroism", a daring enterprise of self-
exploration, part of a breakthrough clinical trial, and so
on.

They often claim that the medicine affects them

differently than it does other people, or that they have
discovered a new, exciting way of using it, or that they
are part of someone's (usually themselves) learning
curve ("part of a new approach to dosage", "part of a
new cocktail which holds great promise"). Narcissists
must dramatise their lives to feel worthy and special.
Aut nihil aut unique – either be special or don't be at all.
Narcissists are drama queens.

Very much like in the physical world, change is brought

about only through incredible powers of torsion and
breakage. Only when the narcissist's elasticity gives
way, only when he is wounded by his own intransigence
– only then is there hope.

It takes nothing less than a real crisis. Ennui is not

enough.

Also read

The Narcissist in Therapy

Getting Better

Testing the Abuser

Telling Them Apart

Facilitating Narcissism

Your Abuser in Therapy

Self Awareness and Healing

The Reconditioned Narcissist

Can the Narcissist Ever Get Better?

Narcissists and Biochemical Imbalances

Narcissists, Paranoiacs and Psychotherapists

Homosexual Narcissists

The Inverted Narcissist

The Myth of Mental Illness

 Other Personality Disorders

Depression and the Narcissist

The Myth of Mental Illness

The Roots of Pedophilia

The Incest Taboo

In Defense of Psychoanalysis

Narcissism, Psychosis, and Delusions

Narcissistic Personality Disorder at a Glance

Eating Disorders and Personality Disorders

Use and abuse of Differential Diagnoses

Misdiagnosing Narcissism - The Bipolar I Disorder

Misdiagnosing Narcissism - Asperger's Disorder

Misdiagnosing Narcissism - Generalized Anxiety Disorder

Narcissists, Inverted Narcissists and Schizoids

Narcissism, Substance Abuse, and Reckless Behaviours

Return
 Reconditioning the Narcissist

Question:

You seem to be very sceptical that someone with a

Narcissistic Personality Disorder can be treated
successfully.

Answer:

The Narcissistic Personality Disorder has been

recognised as a distinct mental health diagnosis a little
more than two decades ago. There are few who can
honestly claim expertise or even in-depth understanding
of this complex condition.

No one knows whether therapy works. What is known is

that therapists find narcissists repulsive, overbearing
and unnerving. It is also known that narcissists try to co-
opt, idolize, or humiliate the therapist.

But what if the narcissist really wants to improve? Even

if complete healing is out of the question - behaviour
modification is not.

To a narcissist, I would recommend a functional

approach, along the following lines:

a. Know and accept thyself. This is who you are.

You have good traits and bad traits and you are a
narcissist. These are facts. Narcissism is an
adaptive mechanism. It is dysfunctional now,
but, once, it saved you from a lot more
dysfunction or even non-function. Make a list:
 what does it mean to be a narcissist in your
specific case? What are your typical behaviour
patterns? Which types of conduct do you find to
be counterproductive, irritating, self-defeating or
self-destructive? Which are productive,
constructive and should be enhanced despite
their pathological origin?

b. Decide to suppress the first type of behaviours

and to promote the second. Construct lists of
self-punishments, negative feedback and
negative reinforcements. Impose them upon
yourself when you have behaved negatively.
Make a list of prizes, little indulgences, positive
feedbacks and positive reinforcements. Use them
to reward yourself when you adopted a
behaviour of the second kind.

c. Keep doing this with the express intent of

conditioning yourself. Be objective, predictable
and just in the administration of both
punishments and awards, positive and negative
reinforcements and feedback. Learn to trust your
"inner court". Constrain the sadistic, immature
and ideal parts of your personality by applying a
uniform codex, a set of immutable and
invariably applied rules.

d. Once sufficiently conditioned, monitor yourself

incessantly. Narcissism is sneaky and it
possesses all your resources because it is you.
Your disorder is intelligent because you are.
Beware and never lose control. With time this
onerous regime will become a second habit and
 supplant the narcissistic (pathological)
superstructure.

You might have noticed that all the above can be amply
summed by suggesting to you to become your own
parent. This is what parents do and the process is called
"education" or "socialisation". Re-parent yourself. Be
your own parent. If therapy is helpful or needed, go
ahead.

The heart of the beast is the inability of the narcissist to

distinguish true from false, appearances from reality,
posing from being, Narcissistic Supply from genuine
relationships, and compulsive drives from true interests
and avocations. Narcissism is about deceit. It blurs the
distinction between authentic actions, true motives, real
desires, and original emotions – and their malignant
forms.

Narcissists are no longer capable of knowing

themselves. Terrified by their internal apparitions,
paralysed by their lack of authenticity, suppressed by
the weight of their repressed emotions – they occupy a
hall of mirrors. Edvard Munch-like, their elongated
figures stare at them, on the verge of the scream, yet
somehow, soundless.

The narcissist's childlike, curious, vibrant, and

optimistic True Self is dead. His False Self is, well,
false. How can anyone on a permanent diet of echoes
and reflections ever acquaint himself with reality? How
can the narcissist ever love – he, whose essence is to
devour meaningful others?
The answer is: discipline, decisiveness, clear targets,
conditioning, justice. The narcissist is the product of
unjust, capricious and cruel treatment. He is the finished
product off a production line of self-recrimination, guilt
and fear. He needs to take the antidote to counter the
narcissistic poison. Unfortunately, there is no drug
which can ameliorate pathological narcissism.

Confronting one's parents about one's childhood is a

good idea if the narcissist feels that he can take it and
cope with new and painful truths. But the narcissist
must be careful. He is playing with fire. Still, if he feels
confident that he can withstand anything revealed to
him in such a confrontation, it is a good and wise move
in the right direction.

My advice to the narcissist would then be: dedicate a lot

of time to rehearsing this critical encounter and define
well what is it exactly that you want to achieve. Do not
turn this reunion into a monodrama, group therapy, or
trial. Get some answers and get at the truth. Don't try to
prove anything, to vindicate, to take revenge, to win the
argument, or to exculpate. Talk to them, heart to heart,
as you would with yourself. Do not try to sound
professional, mature, intelligent, knowledgeable and
distanced. There is no "problem to solve" – just a
condition to adjust yourself to.

More generally, try to take life and yourself much less

seriously. Being immersed in one's self and in one's
mental health condition is never the recipe to full
functionality, let alone happiness. The world is an
absurd place. It is indeed a theatre to be enjoyed. It is
full of colours and smells and sounds to be treasured
and cherished. It is varied and it accommodates and
tolerates everyone and everything, even narcissists.

You, the narcissist, should try to see the positive aspects

of your disorder. In Chinese, the ideogram for "crisis"
includes a part that stands for "opportunity". Why don't
you transform the curse that is your life into a blessing?
Why don't you tell the world your story, teach people in
your condition and their victims how to avoid the
pitfalls, how to cope with the damage? Why don't you
do all this in a more institutionalised manner?

For instance, you can start a discussion group or put up

a Web site on the internet. You can establish a
"narcissists anonymous" in some community shelter.
You can open a correspondence network, a help centre
for men in your condition, for women abused by
narcissists … the possibilities are endless. And it will
instil in you a regained sense of self-worth, give you a
purpose, endow you with self-confidence and
reassurance. It is only by helping others that we help
ourselves. This is, of course, a suggestion – not a
prescription. But it demonstrates the ways in which you
can derive power from adversity.

It is easy for the narcissist to think about Pathological

Narcissism as the source of all that is evil and wrong in
his life. Narcissism is a catchphrase, a conceptual
scapegoat, an evil seed. It conveniently encapsulates the
predicament of the narcissist. It introduces logic and
causal relations into his baffled, tumultuous world. But
this is a trap.
The human psyche is too complex and the brain too
plastic to be captured by a single, all-encompassing
label, however all-pervasive the disorder is. The road to
self-help and self-betterment passes through numerous
junctions and stations. Except for pathological
narcissism, there are many other elements in the
complex dynamics that is the soul of the narcissist. The
narcissist should take responsibility for his life and not
relegate it to some hitherto rather obscure
psychodynamic concept. This is the first and most
important step towards healing.

Also Read

Can the Narcissist Ever Get Better?

Treatment Modalities and Psychotherapies

Narcissists, Paranoiacs and Psychotherapists

Narcissistic Personality Disorder at a Glance

Self Defeating and Self Destructive Behaviors

Pathological Narcissism - A Dysfunction or a

Blessing?

Return
 Narcissists, Medication, and
Chemical Imbalances

Question:

Can pathological narcissism be induced by substance

abuse or biochemical imbalances in the brain?

Answer:

The narcissist's moods change abruptly in the wake of a

narcissistic injury. One can easily manipulate the moods
of a narcissist by making a disparaging remark, by
disagreeing with him, by criticising him, by doubting
his grandiosity or fantastic claims, etc.

Such REACTIVE mood shifts are not provoked by the

fluctuations in the narcissist's body chemistry (for
instance, his blood sugar levels), or with the presence or
absence of any substance or chemical in his brain. It is
possible to reduce the narcissist to a state of rage and
depression AT ANY MOMENT, simply by employing
the above "technique". He can be elated, even manic –
and in a split second, following a narcissistic injury,
depressed, sulking or raging.

The opposite is also true. The narcissist can be

catapulted from the bleakest despair to utter mania (or at
least to an increased and marked feeling of well-being)
by being provided with the flimsiest Narcissistic Supply
(attention, adulation, etc.).

These swings are totally correlated to external events

(narcissistic injury or Narcissistic Supply) and not to
cycles of hormones, enzymes, neurotransmitters, sugar,
or other substances in the body.

It is conceivable, though, that a third, unrelated problem

causes chemical imbalances in the brain, metabolic
diseases such as diabetes, pathological narcissism, and
other mental health syndromes. There may be a
common cause, a hidden common denominator (perhaps
a group of genes).

Certain medical conditions can activate the narcissistic

defense mechanism. Chronic ailments are likely to lead
to the emergence of narcissistic traits or a narcissistic
personality style. Traumas (such as brain injuries) have
been known to induce states of mind akin to full-blown
personality disorders.

Such "narcissism", though, is reversible and tends to be

ameliorated or disappear altogether when the underlying
medical problem does.

Other disorders, like the Bipolar Disorder (mania-

depression) are characterised by mood swings that are
not brought about by external events (endogenous, not
exogenous). But the narcissist's mood swings are strictly
the results of external events (as he perceives and
interprets them, of course).

Narcissists are absolutely insulated from their emotions.

They are emotionally flat or numb.

The narcissist does not have pendular (cyclical) mood

swings on a regular, almost predictable basis, from
depression to euphoria (mania), as is the case in
biochemically induced mental disorders.

Additionally, the narcissist goes through mega-cycles

which last months or even years. These cannot, of
course, be attributed to blood sugar levels or to
Dopamine and Serotonin secretions in the brain.

The Narcissistic Personality Disorder (NPD) per se is

not treated with medication. The underlying disorder is
treated by one of the long-term psychodynamic or
cognitive-behavioural therapies. Other Personality
Disorders (NPD is usually comorbid - diagnosed with
other PDs) are treated separately and according to their
own characteristics.

But phenomena, which are often associated with NPD,

such as depression or OCD (obsessive-compulsive
disorder), are treated with medication. Rumour has it
that SSRI's (such as Fluoxetine, known as Prozac) might
have adverse effects if the primary disorder is NPD.
They sometimes lead to the Serotonin syndrome, which
includes agitation and exacerbates the rage attacks
typical of a narcissist. The use of SSRI's is associated at
times with delirium and the emergence of a manic phase
and even with psychotic microepisodes.

This is not the case with the heterocyclics, MAO and

mood stabilisers, such as lithium. Blockers and
inhibitors are regularly applied without discernible
adverse side effects (as far as NPD is concerned).

Additionally, cognitive-behavioural therapies are often

used to treat the attendant OCD and depression.
To summarise:

Not enough is known about the biochemistry of NPD.

There seems to be some vague link to Serotonin but no
one knows for sure. There isn't a reliable non-intrusive
method to measure brain and central nervous system
Serotonin levels anyhow, so it is mostly guesswork at
this stage.

Thus, as of now, the typical and recommended

treatment for pathological narcissism and the comorbid
depression and OCD is talk therapy of one kind
(psychodynamic) or another (cognitive-behavioural).

Antidepressants can be used moderately (with SSRI

being currently under critical scrutiny).

Also read

Brain and Personality Disorders

The Narcissistic Mini-Cycle

The Narcissistic Pendulum

Depression and the Narcissist

Do Narcissists Have Emotions?

The Intermittent Explosive Narcissist

Misdiagnosing Narcissism - The Bipolar I Disorder

Misdiagnosing Narcissism - Asperger's Disorder

Return
The Narcissist and Psychopath Getting Better

Question:

Can a narcissist ever get better and, if not, how should

his partner end a relationship with him?

Answer:

The Narcissistic Personality Disorder is a systemic, all-

pervasive condition, very much like pregnancy: either
you have it or you don't. Once you have it, you have it
day and night, it is an inseparable part of the
personality, a recurrent set of behaviour patterns.

Recent research shows that there is a condition, which

might be called "Transient or Temporary or Short-Term
Narcissism" as opposed to the full-fledged Narcissistic
Personality Disorder, (NPD) [Ronningstam, 1996]. The
phenomenon of "reactive narcissistic regression" or
Acquired Situational Narcissism is well known: people
regress to a transient narcissistic phase in reaction to a
major life crisis which threatens their mental
composure.

There are narcissistic touches in every personality and

in this sense, all of us are narcissists to some extent. But
this is a far cry from the NPD pathology.

One bit of good news: no one knows why, but, in

certain cases, though rarely, with age (in one's forties),
the disorder seems to mutate into a subdued version of
its former self. This does not universally occur, though.
Should a partner stay on with a narcissist in the hope
that his disorder will be ameliorated by ripe age? This is
a matter of value judgement, preferences, priorities,
background, emotions and a host of other "non-
scientific" matters. There could be no one "correct"
answer. It would seem that the only valid criterion is the
partner's well-being. If he or she feels bad in a
relationship (and no amount of self-help or of
professional help changes that) – then looking for the
exit door sounds like a viable and healthy strategy.

A relationship with a narcissist consists of dependence,

even symbiosis. Moreover, the narcissist is a superb
emotional manipulator and extortionist. In some cases,
there is real threat to his mental stability. Even
"demonstrative" (failed) suicide cannot be ruled out in
the repertory of narcissistic reactions to abandonment.
And even a modest amount of residual love harboured
by the narcissist's partner makes the separation very
difficult for him or her.

But there is a magic formula.

The narcissist teams up with his partner because he

regards IT as a Source of Narcissistic Supply. He values
the partner as such a source. Put differently: the minute
the partner ceases to supply him with what he needs –
the narcissist loses all interest in IT. (I use IT
judiciously – the narcissist objectifies his partners, he
treats them as he would inanimate objects.)

The transition from over-valuation (bestowed upon

potential and actual Sources of Narcissistic Supply) to
devaluation (reserved for other mortals) is so swift that
it is likely to inflict pain upon the narcissist's partner,
even if she previously prayed for the narcissist to depart
and leave her alone. The partner is the narcissist's
pusher and the drug that she is proffering is stronger
than any other drug because it sustains the narcissist's
very essence (his False Self).

Without Narcissistic Supply the narcissist disintegrates,

crumbles and shrivels – very much as vampires do in
horror movies when exposed to sunlight.

Here lies the partner's salvation. An advice to you: if

you wish to sever your relationship with the narcissist,
stop providing him with what he needs. Do not adore,
admire, approve, applaud, or confirm anything that he
does or says. Disagree with his views, belittle him,
reduce him to size, compare him to others, tell him that
he is not unique, criticise him, make suggestions, offer
help. In short, deprive him of that illusion which holds
his personality together.

The narcissist is a delicately attuned piece of equipment.

At the first sign of danger to his inflated, fantastic and
grandiose self – he will disappear on you.

Question:

I love him. I cannot leave him like that. He is like a

crippled small child. My heart goes out to him. Will he
ever get better? Can he ever get better?

Answer:

The Narcissistic Personality Disorder is a systemic, all-

pervasive condition, very much like pregnancy: either
you have it or you don't. Once you have it, you have it
day and night, it is an inseparable part of the
personality, a recurrent set of behavior patterns.

Recent research shows that there is a condition which

might be called "Transient or Temporary or Short Term
Narcissism" as opposed to the full-fledged Narcissistic
Personality Disorder, (NPD). (Ronningstam, 1996). The
phenomenon of "Reactive Narcissistic Regression" or
"Acquired Situational Narcissism" is well known:
people regress to a transient narcissistic phase in
reaction to a major life crisis which threatens their
mental composure.

There are narcissistic touches in every personality and

in this sense, all of us are narcissists to a certain extent.
But this is a far cry from the NPD pathology.

One bit of good news: no one knows why, but, in

certain, rare, cases, with age (in one's forties), the
disorder - especially its antisocial manifestations -
seems to decay and, finally, stay on in the form of a
subdued mutation of itself. This does not universally
occur, though.

Should a partner stay on with a narcissist in the hope

that his disorder will be ameliorated by ripe old age?

This is a matter of value judgment, preferences,

priorities, background, emotions and a host of other
"non-scientific" matters. There is no one "correct"
answer. It would seem that the only valid criterion is the
partner's well being. If he or she feels bad in a
relationship (and no amount of self-help or of
professional help make a difference) – then looking for
the exit sounds like a viable and healthy strategy.
Having a relationship with a narcissist sometimes
borders on co-dependence, or even symbiosis.
Moreover, the narcissist is a consummate emotional
manipulator and extortionist.

True, in some cases, there is real threat to his mental

stability. Even "demonstrative" (failed) suicide cannot
be ruled out in the repertory of narcissistic reactions to
abandonment. And even a modest amount of residual
love harboured by the narcissist's partner makes the
separation very difficult for him or her.

But there is a magic formula.

The narcissist is with his partner because he regards IT

as a valuable Source of Narcissistic Supply. When the
partner ceases to supply him with what he needs – he
loses all interest in IT. (I use IT judiciously – the
narcissist objectifies his partners, treats them as he
would inanimate objects.)

The transition from over-valuation (reserved for

potential and actual Sources of Narcissistic Supply) to
devaluation (reserved for other mortals) is painfully and
shockingly swift. Even partners who previously prayed
for the narcissist to depart and leave them alone are
anguished. The partner is the narcissist's pusher and the
drug that she is purveying (Narcissistic Supply) is
potent because it sustains the narcissist's very essence
(his False Self).

Without Narcissistic Supply the narcissist disintegrates,

crumbles and shrivels – very much as vampires do in
horror movies when exposed to sunlight.
Here lies the partner's salvation.

An advice: if you wish to sever your relationship with

the Narcissist, stop providing him with what he needs.
Do not adore, admire, approve, applaud, or confirm
anything that he does or says. Pay him no attention - or,
if you do, constantly disagree with his views, reduce
him to size, compare him to others, tell him that he is
not unique, criticize him, make suggestions, offer help.
In short, deprive him of that illusion which holds his
personality together.

The narcissist is a delicately attuned piece of equipment.

At the first sign of danger to his inflated, fantastic and
grandiose self – he will disappear on you.

But can he get better, you insist.

Pathological narcissism is very hard to treat

successfully. NPD has been recognized as a distinct
mental disorder a little more than two decades ago.
There is no one who can honestly claim expertise or
even in-depth understanding of this complex condition.

So, no one knows whether therapy works. What is

known is that therapists find narcissists repulsive,
overbearing and unnerving. It is also known that
narcissists try to co-opt, play-down or even humiliate
the therapist.

To a narcissist, I would recommend a more functional

approach, perhaps along the following lines:

a. Know and accept thyself. This is what you are.

You are highly intelligent. You are very
 inquisitive. You are a narcissist. These are facts.
Narcissism is an adaptive mechanism. It is
dysfunctional – but it saves you from a LOT
MORE dysfunction. Make a list: what does it
mean to be a narcissist in your specific case?
What are your typical behavior patterns? Which
types of behavior are counterproductive,
irritating, self-defeating or self-destructive?
Which are productive, constructive and should
be enhanced, their pathological origin
notwithstanding? Decide to suppress the first
and to promote the latter.

b. Construct lists of self-punishments, negative

feedback and negative reinforcements. Penalize
yourself when you exhibit one of the behaviors
in the first list. Make a list of prizes, little
indulgences, positive feedbacks and positive
reinforcements. Use them to reward yourself
when you display a behavior of the second kind.

c. Keep doing this with the express intent of

conditioning yourself. Try to be objective,
predictable and just in the administration of both
punishments and rewards, positive and negative
reinforcements and feedback. Learn to trust your
"inner court". Constrain the sadistic, immature
and ideal parts of your personality (known as
"Superego" in psychoanalytic parlance) by
applying a uniform and consistent set of rules.

d. Once sufficiently conditioned, monitor yourself

incessantly. Narcissism is sneaky and it
possesses all your resources because it is you.
Your disorder is intelligent because you are.
 Beware and never lose control. With time this
onerous regime will become a second habit and
supplant the narcissistic (pathological)
superstructure.

You might have noticed that all the above can be amply
summed by suggesting to you to become your own
parent. This is what parents do and the process is called
"education" or "socialization".

The heart of the beast is the inability of the narcissist to

distinguish true from false, posing from being,
Narcissistic Supply from genuine relationships and
compulsive drives from true interests and avocations in
his life. Narcissism is about deceit. It blurs the
distinction between authentic actions, true motives, real
desires, original emotions – and the malignant forms
that are the attributes of narcissism.

Narcissists are no longer capable of knowing

themselves. Terrified by their internal apparitions,
paralyzed by their lack of authenticity, suppressed by
the weight of their repressed emotions – they occupy a
hall of mirrors. Their curious, vibrant, optimistic True
Self is dead. The False Self is false, the narcissist's
permanent diet of reflections obscures the real world.

How can the narcissist ever love, he who repeatedly

devours meaningful others and transforms them into
meaningless aliens?

The answer is the relentless but compassionate and just

application of discipline in the service of pursuing clear
and realistic targets.
The narcissist is the product of unjust, capricious and
cruel treatment. He is the finished product off a
production line of self-recrimination, guilt and fear. He
needs to take an antidote to counter the narcissistic
poison. But, unfortunately, there is no drug which
ameliorates pathological narcissism.

So what can be done?

Confronting one's parents and childhood is a good idea

if the narcissist feels that he is ready for it. Can he take
it? Can he cope with rediscovered truths, however
painful? The narcissist must be careful. This is playing
with fire. But if he feels confident that there is nothing
that can be revealed to him in such a confrontation that
he cannot withstand – it is a good and wise move.

My advice to the narcissist would then be: just dedicate

a lot of time to rehearsing the encounter and define well
what is it exactly that you want to ask. Do not turn this
into a monodrama, group dynamics or trial. Ask in order
to be enlightened. Don't try to prove anything, to
vindicate, to take revenge, to win, to exculpate. Talk to
them as you would with yourself. Do not try to sound
professional, mature, intelligent, knowledgeable and
distanced. There is no "problem to solve" – just a
condition to adjust yourself to. Think about it as
diabetes.

At the risk of sounding heartless, I will make three

concluding comments:

1. The narcissist should take life in general and

himself, in particular, much less seriously. Being
immersed in one's self and in one's condition is
 never the right recipe to functionality, let alone
happiness. The world is a comic, absurd place. It
is indeed a theatre to be enjoyed. It is full of
colors and smells and sounds to be treasured and
cherished. It is varied and it accommodates and
tolerates everyone and everything, even
narcissists.

2. The narcissist should regard his condition as an

asset. I am a narcissist, so I write about it. My
advice to the narcissist would be: ask yourself
what can you do with it? In Chinese the
ideogram for "crisis" and "opportunity" is one
and the same. Why don't you transform the curse
in your life – into a blessing in other people's
lives? Why don't you tell them your story, warn
them, teach them how to avoid the same pitfalls,
how to cope with the damage? Why don't you do
all this in a more institutionalized manner? For
instance, you can start a discussion group on the
internet. You can establish "Narcissists
Anonymous" in some community shelter. You
can open a correspondence network, a help
centre for men in your condition, for women
abused by narcissists ... the possibilities are
endless. And it will instill in you a regained
sense of self-worth, a purpose, self-confidence
and reassurance. It is only by helping others that
we can help ourselves.
This is, of course, a suggestion – not a
prescription. But it demonstrates the ways in
which you can derive power from adversity.

3. It is easy for the narcissist to think about

Pathological Narcissism as the source of all that
is evil and wrong in his life. Narcissism is a
catchall phrase, a conceptual scapegoat, an evil
seed. It conveniently encapsulates the
predicament of the narcissist. It introduces logic
and causal relations into his baffled, tumultuous
world. But this is a trap. The human psyche is
too complex to be captured by a single, all-
encompassing explanation, however convincing.
The road to self-help and self-betterment passes
through numerous junctions and stations.
Narcissism is the first and the foremost. But
there are many other elements in the complex
dynamics that is the soul of the narcissist. The
narcissist should take responsibility for his life
and not relegate it to some hitherto rather
obscure psychodynamic concept. This is the first
and most important step on the way to healing.
Can the Narcissist Help Himself?

In the book describing the fabulous tales of Baron

Munchhausen, there is a story about how the legendary
nobleman succeeded to pull himself out of a quicksand
marsh – by his own hair. Such a miracle is not likely to
recur. Narcissists cannot cure themselves any more than
other mental patients do.

Pathological narcissism (the Narcissistic Personality

Disorder - NPD) is not merely an aberrant thought
process which can be controlled cognitively. It is an all-
pervasive emotional, cognitive, and behavioural
impairment. Thus, gaining insight into the disorder is
not tantamount to healing.

It is not a question of determination or resilience. It is

not a function of the time invested by the narcissist, the
effort expended by him, the lengths to which he is
willing to go, the depth of his commitment and his
professional knowledge. All these are very important
precursors and good predictors of the success of an
eventual therapy. However, they are no substitute for
one.

The best – really, the only way – a narcissist can help

himself is by resorting to a mental health professional.
Even then, sadly, the prognosis (the healing prospects)
are dim. It seems that only time can bring on a limited
remission (or, at times, aggravation of the condition).

Therapy can tackle the more pernicious aspects of this

disorder. It can help the patient adapt to his condition,
accept it and learn to conduct a more functional life.
Learning to live with one's disorder – is a great
achievement and the narcissist should be happy that
even this modicum of success is, in principle, possible.

But just to get the narcissist to see a therapist is difficult.

The therapeutic situation implies a superior-inferior
relationship. The therapist is supposed to help him –
and, to the narcissist, this means that he is not as
omnipotent as he imagines himself to be. The therapist
is supposed to know more (in his field) than the
narcissist – a presumption which seems to undermine
the second pillar of narcissism, that of omniscience.

Going to a therapy (of whatever nature) implies both

imperfection (something is wrong) and need (read:
weakness, inferiority). The therapeutic setting (the client
visits the therapist, has to be punctual and to pay for the
service) – implies subservience. The process itself is
also threatening: it involves transformation, losing one's
identity (read: uniqueness), one's long cultivated
defences.

The narcissist must shed his False Self and face the
world naked, defenceless, and (to his mind) pitiful. He
is inadequately equipped to deal with his old hurts,
traumas and unresolved conflicts. His True Self is
infantile, mentally immature, frozen, incapable of
confronting the almighty Superego (the narcissist's
inner, chastising, voices). The narcissist knows this –
and recoils. Therapy demands of him to finally place
full, unmitigated, trust in another human being.

Moreover, the transaction implicitly offered to him is

the most unappealing imaginable. He is to give up
decades of emotional investment in an elaborate,
adaptive and, mostly, functioning, mental hyper
structure. In return, he stands to become "normal" – an
anathema to a narcissist. Being normal, to him, means,
being average, not unique, non-existent. Why should the
narcissist commit himself to such a move when it
doesn't even guarantee him happiness (he sees many
unhappy "normal" people around)?

But is there anything the narcissist can do by himself,

"in the meantime", until he reaches a final decision
whether to attend therapy or not?

The first step involves self-awareness. The narcissist

often notices that something is wrong with him and with
his life – but he never own up to his role and
responsibility in his misfortune and discomfort. He
prefers to come up with elaborate rationalizations as to
why that which is wrong with him – is really quite OK!

Cognitive dissonance, rationalisation or

intellectualisation are the narcissist's allies in insulating
him from reality. The narcissist consistently convinces
himself that everyone else is wrong, deficient, lacking,
and incapable (alloplastic defences and outside locus of
control). He tells himself that he is exceptional and
made to suffer for it – not that he is in the wrong. On the
contrary, history will surely prove him right as it has
done so many other towering figures.

This is the first and, by far, the most critical step on the
way to coping with the disorder: will the narcissist
admit, be forced, or convinced to concede that he is
absolutely and unconditionally wrong, that something is
very amiss in his life, that he is in need of urgent,
professional, help and that, in the absence of such help,
things will only get worse? Having crossed this
Rubicon, the narcissist is more open and amenable to
constructive suggestions and assistance.

The second important leap forward is when the

narcissist begins to confront a more REALISTIC
version of himself. A good friend, a spouse, a therapist,
a parent, or a combination of these people can decide
not to collaborate with the narcissist's confabulations
anymore, to stop fearing the narcissist and not to
acquiesce in his folly any longer.

When they confront the narcissist with the truth about

himself, they help demolish the grandiose phantom that
"runs" the narcissist. They no longer succumb to his
whims or accord him a special treatment. They
reprimand him when needed. They disagree with him
and show him why and where he is mistaken. In short:
they deprive him of many of his sources of Narcissistic
Supply. They refuse to take part in the elaborate game
that is the narcissist. They rebel.

The third Do It Yourself element involves the decision

to commit to a regime of therapy. This is a tough one.
The narcissist must not decide to embark on therapy
only because he is (currently) feeling bad (mostly, due
to a life crisis), or because he is subjected to pressure by
family or peers, or because he wants to get rid of a few
disturbing issues while preserving the awesome totality.

His attitude towards the therapist must not be

judgemental, cynical, critical, disparaging, competitive,
or superior. He must not view the therapy as a contest or
a tournament. There are many winners in therapy – but
only one loser if it fails. He must decide not to try to co-
opt the therapist, not to threaten him, or humiliate him.

In short: he must adopt a humble frame of mind, open to

the new experience of encountering one's self. Finally,
he must resolve to be constructively and productively
active in his own therapy, to assist the therapist without
condescending, to provide information without
distorting, to try to change without consciously
resisting.

The end of therapy is really only the beginning of a

new, more vulnerable life. This terrifies the narcissist.
He knows that maybe he can get better, but he can
rarely get well ("heal"). The reason is the narcissist's
enormous life-long, irreplaceable and indispensable
emotional investment in his disorder.

The narcissist's disorder serves two critical functions,

which together maintain the precariously balanced
house of cards that is his personality. His disorder
endows the narcissist with a sense of uniqueness, of
"being special" – and it provides him with a rational
explanation of his behaviour (an "alibi").

Most narcissists reject the notion or diagnosis that they

are mentally disturbed. Absent powers of introspection
and a total lack of self-awareness are part and parcel of
the disorder. Pathological narcissism is founded on
alloplastic defences – the firm conviction that the world
or others are to blame for one's behaviour.

The narcissist simply "knows" that his closest, nearest

and dearest should be held responsible for his reactions
because they have triggered them. With such an
entrenched state of mind, the narcissist is
constitutionally incapable of admitting that something is
wrong with HIM.

But that is not to say that the narcissist does not

experience the pernicious outcomes of his disorder. He
does. But he re-interprets this experience. He regards his
dysfunctional behaviours – social, sexual, emotional,
mental – as conclusive and irrefutable proof of his
superiority, brilliance, distinction, prowess, might, or
success.

Rudeness to others and bullying are reinterpreted as

efficiency. Abusive behaviours are cast as educational.
Sexual absence as proof of preoccupation with higher
functions. His rage is always justified and a reaction to
injustice or to being misunderstood by intellectual
dwarves.

Thus, paradoxically, the disorder becomes an integral

and inseparable part of the narcissist's inflated self-
esteem and vacuous grandiose fantasies.

His False Self (the pivot of his pathological narcissism)

is a self-reinforcing mechanism. The narcissist believes
that he is unique BECAUSE he has a False Self. His
False Self IS the centre of his "specialness". Any
therapeutic "attack" on the integrity and functioning of
the False Self constitutes a threat to the narcissist's
ability to regulate his wildly fluctuating sense of self-
worth and an effort to "reduce" him to other people's
mundane and mediocre existence.

The few narcissists that are willing to admit that

something is terribly wrong with them, displace their
alloplastic defences. Instead of blaming the world, other
people, or circumstances beyond their control – they
now blame their "disease". Their disorder becomes a
catch-all, universal explanation for everything that is
wrong in their lives and every derided, indefensible and
inexcusable behaviour. Their narcissism becomes a
"licence to kill", a liberating force which sets them
outside and above human rules and codes of conduct.
Such freedom is so intoxicating and empowering that it
is difficult to give up.

The narcissist is emotionally attached to only one thing:

his disorder. The narcissist loves his disorder, desires it
passionately, cultivates it tenderly, is proud of its
"achievements" (and in my case, I make a living off it).
His emotions are misdirected. Where normal people
love others and empathise with them, the narcissist
loves his False Self and identifies with it to the
exclusion of all else – including his True Self.

Also Read

Narcissists and Introspection

Self Awareness and Healing

Return
 Misdiagnosing the Narcissistic
Personality Disorder

Eating Disorders

The Eating Disordered Patient

Eating disorders - notably Anorexia Nervosa and

Bulimia Nervosa - are complex phenomena. The patient
with eating disorder maintains a distorted view of her
body as too fat or as somehow defective (she may
have a body dysmorphic disorder). Many patients with
eating disorders are found in professions where body
form and image are emphasized (e.g., ballet students,
fashion models, actors).

The Diagnostic and Statistical Manual (DSM) IV-TR

(2000) (pp. 584-5):

"(Patients with personality disorders exhibit) feelings

of ineffectiveness, a strong need to control one's
environment, inflexible thinking, limited social
spontaneity, perfectionism, and overly restrained
initiative and emotional expression ... (Bulimics show
a greater tendency to have) impulse-control problems,
abuse alcohol or other drugs, exhibit mood lability,
(have) a greater frequency of suicide attempts."

Eating Disorders and Self-control

The current view of orthodoxy is that the eating

disordered patient is attempting to reassert control over
her life by ritually regulating her food intake and her
body weight. In this respect, eating disorders resemble
obsessive-compulsive disorders.

One of the first scholars to have studied eating

disorders, Bruch, described the patient's state of mind as
"a struggle for control, for a sense of identity and
effectiveness." (1962, 1974).

In Bulimia Nervosa, protracted episodes of fasting and

purging (induced vomiting and the abuse of laxatives
and diuretics) are precipitated by stress (usually fear of
social situations akin to Social Phobia) and the
breakdown of self-imposed dietary rules. Thus, eating
disorders seem to be life-long attempts to relieve
anxiety. Ironically, binging and purging render the
patient even more anxious and provoke in
her overwhelming self-loathing and guilt.

Eating disorders involve masochism. The patient

tortures herself and inflicts on her body great harm by
ascetically abstaining from food or by purging. Many
patients cook elaborate meals for others and then refrain
from consuming the dishes they had just prepared,
perhaps as a sort of "self-punishment" or "spiritual
purging."

The Diagnostic and Statistical Manual (DSM) IV-TR

(2000) (p. 584) comments on the inner mental landscape
of patients with eating disorders:

"Weight loss is viewed as an impressive achievement,

a sign of extraordinary self-discipline, whereas weight
gain is perceived as an unacceptable failure of self-
control."
But the "eating disorder as an exercise in self-control"
hypothesis may be overstated. If it were true, we would
have expected eating disorders to be prevalent among
minorities and the lower classes - people whose lives
are controlled by others. Yet, the clinical picture is
reversed: the vast majority of patients with eating
disorders (90-95%) are white, young (mostly
adolescent) women from the middle and upper classes.
Eating disorders are rare among the lower and working
classes, and among minorities, and non-Western
societies and cultures.

Refusing to Grow Up

Other scholars believe that the patient with eating

disorder refuses to grow up. By changing her body and
stopping her menstruation (a condition known as
amenorrhea), the patient regresses to childhood and
avoids the challenges of adulthood (loneliness,
interpersonal relationships, sex, holding a job, and
childrearing).

Similarities with Personality Disorders

Patients with eating disorders maintain great secrecy

about their condition, not unlike narcissists or
paranoids, for instance. When they do attend
psychotherapy it is usually owing to tangential
problems: having been caught stealing food and other
forms of antisocial behavior, such as rage
attacks. Clinicians who are not trained to diagnose the
subtle and deceptive signs and symptoms of eating
disorders often misdiagnose them as personality
disorders or as mood or affective or anxiety disorders.
Patients with eating disorders are emotionally labile,
frequently suffer from depression, are socially
withdrawn, lack sexual interest, and are irritable. Their
self-esteem is low, their sense of self-worth fluctuating,
they are perfectionists. The patient with eating disorder
derives narcissistic supply from the praise she garners
for having gone down in weight and the way she looks
post-dieting. Small wonder eating disorders are often
misdiagnosed as personality disorders: Borderline,
Schizoid, Avoidant, Antisocial or Narcissistic.

Patients with eating disorders also resemble subjects

with personality disorders in that they have primitive
defense mechanisms, most notably splitting.

The Review of General Psychiatry (p. 356):

"Individuals with Anorexia Nervosa tend to view

themselves in terms of absolute and polar opposites.
Behavior is either all good or all bad; a decision is
either completely right or completely wrong; one is
either absolutely in control or totally out of control."

They are unable to differentiate their feelings and needs

from those of others, adds the author.

To add confusion, both types of patients - with eating

disorders and personality disorders - share an identically
dysfunctional family background. Munchin et al.
described it thus (1978): "enmeshment, over-
protectiveness, rigidity, lack of conflict resolution."
Both types of patients are reluctant to seek help.

The Diagnostic and Statistical Manual (DSM) IV-TR

(2000) (pp. 584-5):

"Individuals with Anorexia Nervosa frequently lack

insight into or have considerable denial of the problem
... A substantial portion of individuals with Anorexia
Nervosa have a personality disturbance that meets
criteria for at least one Personality Disorder."

In clinical practice, co-morbidity of an eating disorder

and a personality disorder is a common occurrence.
About 20% of all Anorexia Nervosa patients are
diagnosed with one or more personality disorders
(mainly Cluster C - Avoidant, Dependent, Compulsive-
Obsessive - but also Cluster A - Schizoid and
Paranoid).

A whopping 40% of Anorexia Nervosa/Bulimia

Nervosa patients have co-morbid personality disorders
(mostly Cluster B - Narcissistic, Histrionic, Antisocial,
Borderline). Pure bulimics tend to have Borderline
Personality Disorder. Binge eating is included in the
impulsive behavior criterion for Borderline Personality
Disorder.

Such rampant comorbidity raises the question whether

eating disorders are not actually behavioral
manifestations of underlying personality disorders.
Additional resources

Diagnostic and Statistical Manual of Mental

Disorders, fourth edition, Text Revision (DSM-IV-
TR) - Washington DC, The American Psychiatric
Association, 2000

Goldman, Howard G. – Review of General Psychiatry,

4th ed. – London, Prentice-Hall International, 1995

Gelder, Michael et al., eds. – Oxford Textbook of

Psychiatry, 3rd ed. – London, Oxford University Press,
2000

Vaknin, Sam – Malignant Self Love – Narcissism

Revisited, 8th revised impression – Skopje and Prague,
Narcissus Publications, 2006

Bipolar I Disorder

(The use of gender pronouns in this article reflects the

clinical facts: most narcissists are men.)

The manic phase of Bipolar I Disorder is often

misdiagnosed as Narcissistic Personality Disorder
(NPD).

Bipolar patients in the manic phase exhibit many of the

signs and symptoms of pathological narcissism -
hyperactivity, self-centeredness, lack of empathy, and
control freakery. During this recurring chapter of the
disease, the patient is euphoric, has grandiose fantasies,
spins unrealistic schemes, and has frequent rage attacks
(is irritable) if her or his wishes and plans are
(inevitably) frustrated.

The manic phases of the bipolar disorder, however, are

limited in time - NPD is not. Furthermore, the mania is
followed by - usually protracted - depressive episodes.
The narcissist is also frequently dysphoric. But whereas
the bipolar sinks into deep self-deprecation, self-
devaluation, unbounded pessimism, all-pervasive guilt
and anhedonia - the narcissist, even when depressed,
never forgoes his narcissism: his grandiosity, sense of
entitlement, haughtiness, and lack of empathy.

Narcissistic dysphorias are much shorter and reactive -

they constitute a response to the Grandiosity Gap. In
plain words, the narcissist is dejected when confronted
with the abyss between his inflated self-image and
grandiose fantasies - and the drab reality of his life: his
failures, lack of accomplishments, disintegrating
interpersonal relationships, and low status. Yet, one
dose of Narcissistic Supply is enough to elevate the
narcissists from the depth of misery to the heights of
manic euphoria.

Not so with the bipolar. The source of her or his mood

swings is assumed to be brain biochemistry - not the
availability of Narcissistic Supply. Whereas the
narcissist is in full control of his faculties, even when
maximally agitated, the bipolar often feels that s/he has
lost control of his/her brain ("flight of ideas"), his/her
speech, his/her attention span (distractibility), and
his/her motor functions.
The bipolar is prone to reckless behaviors and substance
abuse only during the manic phase. The narcissist does
drugs, drinks, gambles, shops on credit, indulges in
unsafe sex or in other compulsive behaviors both when
elated and when deflated.

As a rule, the bipolar's manic phase interferes with

his/her social and occupational functioning. Many
narcissists, in contrast, reach the highest rungs of their
community, church, firm, or voluntary organization.
Most of the time, they function flawlessly - though the
inevitable blowups and the grating extortion of
Narcissistic Supply usually put an end to the narcissist's
career and social liaisons.

The manic phase of bipolar sometimes requires

hospitalization and - more frequently than admitted -
involves psychotic features. Narcissists are never
hospitalized as the risk for self-harm is minute.
Moreover, psychotic microepisodes in narcissism are
decompensatory in nature and appear only under
unendurable stress (e.g., in intensive therapy).

The bipolar's mania provokes discomfort in both

strangers and in the patient's nearest and dearest. His/her
constant cheer and compulsive insistence on
interpersonal, sexual, and occupational, or professional
interactions engenders unease and repulsion. Her/his
lability of mood - rapid shifts between uncontrollable
rage and unnatural good spirits - is downright
intimidating. The narcissist's gregariousness, by
comparison, is calculated, "cold", controlled, and goal-
orientated (the extraction of Narcissistic Supply). His
cycles of mood and affect are far less pronounced and
less rapid.
The bipolar's swollen self-esteem, overstated self-
confidence, obvious grandiosity, and delusional
fantasies are akin to the narcissist's and are the source of
the diagnostic confusion. Both types of patients purport
to give advice, carry out an assignment, accomplish a
mission, or embark on an enterprise for which they are
uniquely unqualified and lack the talents, skills,
knowledge, or experience required.

But the bipolar's bombast is far more delusional than the

narcissist's. Ideas of reference and magical thinking are
common and, in this sense, the bipolar is closer to the
schizotypal than to the narcissistic.

There are other differentiating symptoms:

Sleep disorders - notably acute insomnia - are common

in the manic phase of bipolar and uncommon in
narcissism. So is "manic speech" - pressured,
uninterruptible, loud, rapid, dramatic (includes singing
and humorous asides), sometimes incomprehensible,
incoherent, chaotic, and lasts for hours. It reflects the
bipolar's inner turmoil and his/her inability to control
his/her racing and kaleidoscopic thoughts.

As opposed to narcissists, bipolar in the manic phase are

often distracted by the slightest stimuli, are unable to
focus on relevant data, or to maintain the thread of
conversation. They are "all over the place" -
simultaneously initiating numerous business ventures,
joining a myriad organization, writing umpteen letters,
contacting hundreds of friends and perfect strangers,
acting in a domineering, demanding, and intrusive
manner, totally disregarding the needs and emotions of
the unfortunate recipients of their unwanted attentions.
They rarely follow up on their projects.

The transformation is so marked that the bipolar is often

described by his/her closest as "not himself/herself".
Indeed, some bipolars relocate, change name and
appearance, and lose contact with their "former life".
Antisocial or even criminal behavior is not uncommon
and aggression is marked, directed at both others
(assault) and oneself (suicide). Some biploars describe
an acuteness of the senses, akin to experiences
recounted by drug users: smells, sounds, and sights are
accentuated and attain an unearthly quality.

As opposed to narcissists, bipolars regret their misdeeds

following the manic phase and try to atone for their
actions. They realize and accept that "something is
wrong with them" and seek help. During the depressive
phase they are ego-dystonic and their defenses are
autoplastic (they blame themselves for their defeats,
failures, and mishaps).

Finally, pathological narcissism is already discernible in

early adolescence. The full-fledged bipolar disorder -
including a manic phase - rarely occurs before the age
of 20. The narcissist is consistent in his pathology - not
so the bipolar. The onset of the manic episode is fast
and furious and results in a conspicuous metamorphosis
of the patient.

More about this topic here:

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

Vaknin, Sam – Malignant Self Love – Narcissism

Revisited, 8th revised impression – Skopje and Prague,
Narcissus Publications, 2006

Asperger's Disorder

(The use of gender pronouns in this article reflects the

clinical facts: most narcissists and most Asperger's
patients are male.)

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).

In both cases, the patient is self-centered and engrossed

in a narrow range of interests and activities. Social and
occupational interactions are severely hampered and
conversational skills (the give and take of verbal
intercourse) are primitive. The Asperger's patient body
language - eye to eye gaze, body posture, facial
expressions - is constricted and artificial, akin to the
narcissist's. Nonverbal cues are virtually absent and
their interpretation in others lacking.

Yet, the gulf between Asperger's and pathological

narcissism is vast.
The narcissist switches between social agility and social
impairment voluntarily. His social dysfunctioning is the
outcome of conscious haughtiness and the reluctance to
invest scarce mental energy in cultivating relationships
with inferior and unworthy others. When confronted
with potential Sources of Narcissistic Supply, however,
the narcissist easily regains his social skills, his charm,
and his gregariousness.

Many narcissists reach the highest rungs of their

community, church, firm, or voluntary organization.
Most of the time, they function flawlessly - though the
inevitable blowups and the grating extortion of
Narcissistic Supply usually put an end to the narcissist's
career and social liaisons.

The Asperger's patient often wants to be accepted

socially, to have friends, to marry, to be sexually active,
and to sire offspring. He just doesn't have a clue how to
go about it. His affect is limited. His initiative - for
instance, to share his experiences with nearest and
dearest or to engage in foreplay - is thwarted. His ability
to divulge his emotions stilted. He is incapable or
reciprocating and is largely unaware of the wishes,
needs, and feelings of his interlocutors or
counterparties.

Inevitably, Asperger's patients are perceived by others

to be cold, eccentric, insensitive, indifferent, repulsive,
exploitative or emotionally-absent. To avoid the pain of
rejection, they confine themselves to solitary activities -
but, unlike the schizoid, not by choice. They limit their
world to a single topic, hobby, or person and dive in
with the greatest, all-consuming intensity, excluding all
other matters and everyone else. It is a form of hurt-
control and pain regulation.

Thus, while the narcissist avoids pain by excluding,

devaluing, and discarding others - the Asperger's patient
achieves the same result by withdrawing and by
passionately incorporating in his universe only one or
two people and one or two subjects of interest. Both
narcissists and Asperger's patients are prone to react
with depression to perceived slights and injuries - but
Asperger's patients are far more at risk of self-harm and
suicide.

The use of language is another differentiating factor.

The narcissist is a skilled communicator. He uses

language as an instrument to obtain Narcissistic Supply
or as a weapon to obliterate his "enemies" and discarded
sources with. Cerebral narcissists derive Narcissistic
Supply from the consummate use they make of their
innate verbosity.

Not so the Asperger's patient. He is equally verbose at

times (and taciturn on other occasions) but his topics are
few and, thus, tediously repetitive. He is unlikely to
obey conversational rules and etiquette (for instance, to
let others speak in turn). Nor is the Asperger's patient
able to decipher nonverbal cues and gestures or to
monitor his own misbehavior on such occasions.
Narcissists are similarly inconsiderate - but only
towards those who cannot possibly serve as Sources of
Narcissistic Supply.

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

Vaknin, Sam – Malignant Self Love – Narcissism

Revisited, 8th revised impression – Skopje and Prague,
Narcissus Publications, 2006

Generalised Anxiety Disorder (GAD)

(The use of gender pronouns in this article reflects the

clinical facts: most narcissists are men.)

Anxiety Disorders – and especially Generalised Anxiety

Disorder (GAD) – are often misdiagnosed as
Narcissistic Personality Disorder (NPD).

Anxiety is uncontrollable and excessive apprehension.

Anxiety disorders usually come replete with obsessive
thoughts, compulsive and ritualistic acts, restlessness,
fatigue, irritability, difficulty concentrating, and somatic
manifestations (such as an increased heart rate,
sweating, or, in Panic Attacks, chest pains).
By definition, narcissists are anxious for social approval
or attention (Narcissistic Supply). The narcissist cannot
control this need and the attendant anxiety because he
requires external feedback to regulate his labile sense of
self-worth. This dependence makes most narcissists
irritable. They fly into rages and have a very low
threshold of frustration.

Like patients who suffer from Panic Attacks and Social

Phobia (another anxiety disorder), narcissists are
terrified of being embarrassed or criticised in public.
Consequently, most narcissists fail to function well in
various settings (social, occupational, romantic, etc.).

Many narcissists develop obsessions and compulsions.

Like sufferers of GAD, narcissists are perfectionists and
preoccupied with the quality of their performance and
the level of their competence. As the Diagnostic and
Statistical Manual (DSM-IV-TR, p. 473) puts it, GAD
patients (especially children):

"… (A)re typically overzealous in seeking approval

and require excessive reassurance about their
performance and their other worries."

This could apply equally well to narcissists. Both

classes of patients are paralysed by the fear of being
judged as imperfect or lacking. Narcissists as well as
patients with anxiety disorders constantly fail to
measure up to an inner, harsh, and sadistic critic and a
grandiose, inflated self-image.

The narcissistic solution is to avoid comparison and

competition altogether and to demand special treatment.
The narcissist's sense of entitlement is incommensurate
with the narcissist's true accomplishments. He
withdraws from the rat race because he does not deem
his opponents, colleagues, or peers worthy of his efforts.

As opposed to narcissists, patients with Anxiety

Disorders are invested in their work and their
profession. To be exact, they are over-invested. Their
preoccupation with perfection is counter-productive
and, ironically, renders them underachievers.

It is easy to mistake the presenting symptoms of certain

anxiety disorders with pathological narcissism. Both
types of patients are worried about social approbation
and seek it actively. Both present a haughty or
impervious facade to the world. Both are dysfunctional
and weighed down by a history of personal failure on
the job and in the family. But the narcissist is ego-
syntonic: he is proud and happy of who he is. The
anxious patient is distressed and is looking for help and
a way out of his or her predicament. Hence the
differential diagnosis.

Bibliography

Goldman, Howard G. – Review of General Psychiatry,

4th ed. – London, Prentice-Hall International, 1995 –
pp. 279-282

Gelder, Michael et al., eds. – Oxford Textbook of

Psychiatry, 3rd ed. – London, Oxford University Press,
2000 – pp. 160-169

Klein, Melanie – The Writings of Melanie Klein – Ed.

Roger Money-Kyrle – 4 vols. – New York, Free Press –
1964-75
Kernberg O. – Borderline Conditions and Pathological
Narcissism – New York, Jason Aronson, 1975

Millon, Theodore (and Roger D. Davis, contributor) –

Disorders of Personality: DSM IV and Beyond – 2nd
ed. – New York, John Wiley and Sons, 1995

Millon, Theodore – Personality Disorders in Modern

Life – New York, John Wiley and Sons, 2000

Schwartz, Lester – Narcissistic Personality Disorders –

A Clinical Discussion – Journal of Am.
Psychoanalytic Association – 22 (1974): 292-305

Vaknin, Sam – Malignant Self Love – Narcissism

Revisited, 8th revised impression – Skopje and Prague,
Narcissus Publications, 2006

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 Is the Narcissist Legally Insane?

Narcissists are not prone to "irresistible impulses" and

dissociation (blanking out certain stressful events and
actions). They more or less fully control their behavior
and acts at all times. But exerting control over one's
conduct requires the investment of resources, both
mental and physical. Narcissists regard this as a waste
of their precious time, or a humiliating chore. Lacking
empathy, they don't care about other people's feelings,
needs, priorities, wishes, preferences, and
boundaries. As a result, narcissists are awkward,
tactless, painful, taciturn, abrasive and insensitive.

The narcissist often has rage attacks and grandiose

fantasies. Most narcissists are also mildly obsessive-
compulsive. Yet, all narcissists should be held
accountable to the vast and overwhelming
majority of their actions.

At all times, even during the worst explosive episode,

the narcissist can tell right from wrong and reign in their
impulses. The narcissist's impulse control is unimpaired,
though he may pretend otherwise in order to terrorize,
manipulate and coerce his human environment into
compliance.

The only things the narcissist cannot "control" are his

grandiose fantasies. All the same, he knows that lying
and confabulating are morally wrong and can choose to
refrain from doing so.

The narcissist is perfectly capable of anticipating

the consequences of his actions and their influence on
others. Actually, narcissists are "X-ray" machines: they
are very perceptive and sensitive to the subtlest nuances.
But the narcissist does not care. For him, humans are
dispensable, rechargeable, reusable. They are there to
fulfil a function: to supply him with Narcissistic Supply
(adoration, admiration, approval, affirmation, etc.) They
do not have an existence apart from carrying out their
"duties".

Still, it is far from a clear-cut case.

Some scholars note, correctly, that many

narcissists have no criminal intent (“mens rea”) even
when they commit criminal acts (“acti rei”). The
narcissist may victimise, plunder, intimidate and abuse
others - but not in the cold, calculating manner of the
psychopath. The narcissist hurts people offhandedly,
carelessly, and absentmindedly. The narcissist is more
like a force of nature or a beast of prey - dangerous but
not purposeful or evil.

Moreover, many narcissists don't feel responsible for

their actions. They believe that they are victims of
injustice, bias, prejudice, and discrimination. This is
because they are shape-shifters and actors. The
narcissist is not one person - but two. The True Self is
as good as dead and buried. The False Self changes so
often in reaction to life's circumstances that the
narcissist has no sense of personal continuity.

From my book "Malignant Self Love - Narcissism

Revisited":

"The narcissist's perception of his life and his

existence is discontinuous. The narcissist is a walking
compilation of "personalities", each with its own
personal history. The narcissist does not feel that he is,
in any way, related to his former "selves". He,
therefore, does not understand why he has to be
punished for "someone else's" actions or inaction.
This "injustice" surprises, hurts, and enrages him."

Click on these links to learn more:

Narcissists and Evil

The Intermittent Explosive Narcissist

Warped Reality and Retroactive Emotional Content

Narcissists and Crime

Narcissistic Immunity

The Accountable Narcissist

The Compulsive Acts of the Narcissist

The Myth of Mental Illness

Return
APPENDICES
 The Myth of Mental Illness

"You can know the name of a bird in all the languages

of the world, but when you're finished, you'll know
absolutely nothing whatever about the bird… So let's
look at the bird and see what it's doing – that's what
counts. I learned very early the difference between
knowing the name of something and knowing
something."

Richard Feynman, Physicist and 1965 Nobel Prize

laureate (1918-1988)

"You have all I dare say heard of the animal spirits

and how they are transfused from father to son
etcetera etcetera – well you may take my word that
nine parts in ten of a man's sense or his nonsense, his
successes and miscarriages in this world depend on
their motions and activities, and the different tracks
and trains you put them into, so that when they are
once set a-going, whether right or wrong, away they go
cluttering like hey-go-mad."

Lawrence Sterne (1713-1758), "The Life and Opinions

of Tristram Shandy, Gentleman" (1759)

I. Overview

Someone is considered mentally "ill" if:

1. His conduct rigidly and consistently deviates

from the typical, average behaviour of all other
 people in his culture and society that fit his
profile (whether this conventional behaviour is
moral or rational is immaterial), or
2. His judgment and grasp of objective, physical
reality is impaired, and
3. His conduct is not a matter of choice but is
innate and irresistible, and
4. His behavior causes him or others discomfort,
and is
5. Dysfunctional, self-defeating, and self-
destructive even by his own yardsticks.

Descriptive criteria aside, what is the essence of mental

disorders? Are they merely physiological disorders of
the brain, or, more precisely of its chemistry? If so, can
they be cured by restoring the balance of substances and
secretions in that mysterious organ? And, once
equilibrium is reinstated – is the illness "gone" or is it
still lurking there, "under wraps", waiting to erupt? Are
psychiatric problems inherited, rooted in faulty genes
(though amplified by environmental factors) – or
brought on by abusive or wrong nurturance?

These questions are the domain of the "medical" school

of mental health.

Others cling to the spiritual view of the human psyche.

They believe that mental ailments amount to the
metaphysical discomposure of an unknown medium –
the soul. Theirs is a holistic approach, taking in the
patient in his or her entirety, as well as his milieu.

The members of the functional school regard mental

health disorders as perturbations in the proper,
statistically "normal", behaviours and manifestations of
"healthy" individuals, or as dysfunctions. The "sick"
individual – ill at ease with himself (ego-dystonic) or
making others unhappy (deviant) – is "mended" when
rendered functional again by the prevailing standards of
his social and cultural frame of reference.

In a way, the three schools are akin to the trio of blind

men who render disparate descriptions of the very same
elephant. Still, they share not only their subject matter –
but, to a counter intuitively large degree, a faulty
methodology.

As the renowned anti-psychiatrist, Thomas Szasz, of the

State University of New York, notes in his article "The
Lying Truths of Psychiatry", mental health scholars,
regardless of academic predilection, infer the etiology of
mental disorders from the success or failure of treatment
modalities.

This form of "reverse engineering" of scientific models

is not unknown in other fields of science, nor is it
unacceptable if the experiments meet the criteria of the
scientific method. The theory must be all-inclusive
(anamnetic), consistent, falsifiable, logically
compatible, monovalent, and parsimonious.
Psychological "theories" – even the "medical" ones (the
role of serotonin and dopamine in mood disorders, for
instance) – are usually none of these things.

The outcome is a bewildering array of ever-shifting

mental health "diagnoses" expressly centred around
Western civilisation and its standards (example: the
ethical objection to suicide). Neurosis, a historically
fundamental "condition" vanished after 1980.
Homosexuality, according to the American Psychiatric
Association, was a pathology prior to 1973. Seven years
later, narcissism was declared a "personality disorder",
almost seven decades after it was first described by
Freud. Prominent psychiatrists have taken to accusing
the committee that is busy writing the next, fifth edition
of the DSM (to be published in 2013) of pathologizing
large swathes of the population:

“Two eminent retired psychiatrists are warning that

the revision process is fatally flawed. They say the new
manual, to be known as DSM-V, will extend
definitions of mental illnesses so broadly that tens of
millions of people will be given unnecessary and risky
drugs. Leaders of the American Psychiatric
Association (APA), which publishes the manual, have
shot back, accusing the pair of being motivated by
their own financial interests - a charge they deny.”
(New Scientist, “Psychiatry’s Civil War”, December
2009).

II. Personality Disorders

Indeed, personality disorders are an excellent example

of the kaleidoscopic landscape of "objective"
psychiatry.

The classification of Axis II personality disorders –

deeply ingrained, maladaptive, lifelong behavior
patterns – in the Diagnostic and Statistical Manual,
fourth edition, text revision [American Psychiatric
Association. DSM-IV-TR, Washington, 2000] – or the
DSM-IV-TR for short – has come under sustained and
serious criticism from its inception in 1952, in the first
edition of the DSM.
The DSM IV-TR adopts a categorical approach,
postulating that personality disorders are "qualitatively
distinct clinical syndromes" (p. 689). This is widely
doubted. Even the distinction made between "normal"
and "disordered" personalities is increasingly being
rejected. The "diagnostic thresholds" between normal
and abnormal are either absent or weakly supported.

The polythetic form of the DSM's Diagnostic Criteria –

only a subset of the criteria is adequate grounds for a
diagnosis – generates unacceptable diagnostic
heterogeneity. In other words, people diagnosed with
the same personality disorder may share only one
criterion or none.

The DSM fails to clarify the exact relationship between

Axis II and Axis I disorders and the way chronic
childhood and developmental problems interact with
personality disorders.

The differential diagnoses are vague and the personality

disorders are insufficiently demarcated. The result is
excessive co-morbidity (multiple Axis II diagnoses).

The DSM contains little discussion of what

distinguishes normal character (personality), personality
traits, or personality style (Millon) – from personality
disorders.

A dearth of documented clinical experience regarding

both the disorders themselves and the utility of various
treatment modalities.
Numerous personality disorders are "not otherwise
specified" – a catchall, basket "category".

Cultural bias is evident in certain disorders (such as the

Antisocial and the Schizotypal).

The emergence of dimensional alternatives to the

categorical approach is acknowledged in the DSM-IV-
TR itself:

“An alternative to the categorical approach is the

dimensional perspective that Personality Disorders
represent maladaptive variants of personality traits
that merge imperceptibly into normality and into one
another” (p.689)

The following issues – long neglected in the DSM – are

likely to be tackled in future editions as well as in
current research. But their omission from official
discourse hitherto is both startling and telling:

 The longitudinal course of the disorder(s) and

their temporal stability from early childhood
onwards;
 The genetic and biological underpinnings of
personality disorder(s);
 The development of personality
psychopathology during childhood and its
emergence in adolescence;
 The interactions between physical health and
disease and personality disorders;
 The effectiveness of various treatments – talk
therapies as well as psychopharmacology.

III. The Biochemistry and Genetics of Mental Health

Certain mental health afflictions are either correlated
with a statistically abnormal biochemical activity in the
brain – or are ameliorated with medication. Yet the two
facts are not ineludibly facets of the same underlying
phenomenon. In other words, that a given medicine
reduces or abolishes certain symptoms does not
necessarily mean they were caused by the processes or
substances affected by the drug administered. Causation
is only one of many possible connections and chains of
events.

To designate a pattern of behaviour as a mental health

disorder is a value judgment, or at best a statistical
observation. Such designation is effected regardless of
the facts of brain science. Moreover, correlation is not
causation. Deviant brain or body biochemistry (once
called "polluted animal spirits") do exist – but are they
truly the roots of mental perversion? Nor is it clear
which triggers what: do the aberrant neurochemistry or
biochemistry cause mental illness – or the other way
around?

That psychoactive medication alters behaviour and

mood is indisputable. So do illicit and legal drugs,
certain foods, and all interpersonal interactions. That the
changes brought about by prescription are desirable – is
debatable and involves tautological thinking. If a certain
pattern of behaviour is described as (socially)
"dysfunctional" or (psychologically) "sick" – clearly,
every change would be welcomed as "healing" and
every agent of transformation would be called a "cure".

The same applies to the alleged heredity of mental

illness. Single genes or gene complexes are frequently
"associated" with mental health diagnoses, personality
traits, or behaviour patterns. But too little is known to
establish irrefutable sequences of causes-and-effects.
Even less is proven about the interaction of nature and
nurture, genotype and phenotype, the plasticity of the
brain and the psychological impact of trauma, abuse,
upbringing, role models, peers, and other environmental
elements.

Nor is the distinction between psychotropic substances

and talk therapy that clear-cut. Words and the
interaction with the therapist also affect the brain, its
processes and chemistry - albeit more slowly and,
perhaps, more profoundly and irreversibly. Medicines –
as David Kaiser reminds us in "Against Biologic
Psychiatry" (Psychiatric Times, Volume XIII, Issue 12,
December 1996) – treat symptoms, not the underlying
processes that yield them.

IV. The Variance of Mental Disease

If mental illnesses are bodily and empirical, they should

be invariant both temporally and spatially, across
cultures and societies. This, to some degree, is, indeed,
the case. Psychological diseases are not context
dependent – but the pathologizing of certain behaviours
is. Suicide, substance abuse, narcissism, eating
disorders, antisocial ways, schizotypal symptoms,
depression, even psychosis are considered sick by some
cultures – and utterly normative or advantageous in
others.

This was to be expected. The human mind and its

dysfunctions are alike around the world. But values
differ from time to time and from one place to another.
Hence, disagreements about the propriety and
desirability of human actions and inaction are bound to
arise in a symptom-based diagnostic system.

As long as the pseudo-medical definitions of mental

health disorders continue to rely exclusively on signs
and symptoms – i.e., mostly on observed or reported
behaviours – they remain vulnerable to such discord and
devoid of much-sought universality and rigor.

V. Mental Disorders and the Social Order

The mentally sick receive the same treatment as carriers

of AIDS or SARS or the Ebola virus or smallpox. They
are sometimes quarantined against their will and
coerced into involuntary treatment by medication,
psychosurgery, or electroconvulsive therapy. This is
done in the name of the greater good, largely as a
preventive policy.

Conspiracy theories notwithstanding, it is impossible to

ignore the enormous interests vested in psychiatry and
psychopharmacology. The multibillion dollar industries
involving drug companies, hospitals, managed
healthcare, private clinics, academic departments, and
law enforcement agencies rely, for their continued and
exponential growth, on the propagation of the concept
of "mental illness" and its corollaries: treatment and
research.

“The wording used in the DSM has a significance that

goes far beyond questions of semantics. The diagnoses
it enshrines affect what treatments people receive, and
whether health insurers will fund them. They can also
exacerbate social stigmas and may even be used to
deem an individual such a grave danger to society that
they are locked up ... Some of the most acrimonious
arguments stem from worries about the
pharmaceutical industry's influence over psychiatry.
This has led to the spotlight being turned on the
financial ties of those in charge of revising the
manual, and has made any diagnostic changes that
could expand the use of drugs especially
controversial.” (New Scientist, “Psychiatry’s Civil
War”, December 2009).

VI. Mental Ailment as a Useful Metaphor

Abstract concepts form the core of all branches of

human knowledge. No one has ever seen a quark, or
untangled a chemical bond, or surfed an electromagnetic
wave, or visited the unconscious. These are useful
metaphors, theoretical entities with explanatory or
descriptive power.

"Mental health disorders" are no different. They are

shorthand for capturing the unsettling quiddity of "the
Other". Useful as taxonomies, they are also tools of
social coercion and conformity, as Michel Foucault and
Louis Althusser observed. Relegating both the
dangerous and the idiosyncratic to the collective fringes
is a vital technique of social engineering.

The aim is progress through social cohesion and the

regulation of innovation and creative destruction.
Psychiatry, therefore, is reifies society's preference of
evolution to revolution, or, worse still, to mayhem. As is
often the case with human endeavour, it is a noble
cause, unscrupulously and dogmatically pursued.
VII. The Insanity Defense

"It is an ill thing to knock against a deaf-mute, an

imbecile, or a minor. He that wounds them is culpable,
but if they wound him they are not culpable."
(Mishna, Babylonian Talmud)

If mental illness is culture-dependent and mostly serves

as an organizing social principle - what should we make
of the insanity defense (NGRI- Not Guilty by Reason of
Insanity)?

A person is held not responsible for his criminal actions

if s/he cannot tell right from wrong ("lacks substantial
capacity either to appreciate the criminality
(wrongfulness) of his conduct" - diminished capacity),
did not intend to act the way he did (absent "mens rea")
and/or could not control his behavior ("irresistible
impulse"). These handicaps are often associated with
"mental disease or defect" or "mental retardation".

Mental health professionals prefer to talk about an

impairment of a "person's perception or understanding
of reality". They hold a "guilty but mentally ill" verdict
to be contradiction in terms. All "mentally-ill" people
operate within a (usually coherent) worldview, with
consistent internal logic, and rules of right and wrong
(ethics). Yet, these rarely conform to the way most
people perceive the world. The mentally-ill, therefore,
cannot be guilty because s/he has a tenuous grasp on
reality.

Yet, experience teaches us that a criminal maybe

mentally ill even as s/he maintains a perfect reality test
and thus is held criminally responsible (Jeffrey Dahmer
comes to mind). The "perception and understanding of
reality", in other words, can and does co-exist even with
the severest forms of mental illness.

This makes it even more difficult to comprehend what is

meant by "mental disease". If some mentally ill
maintain a grasp on reality, know right from wrong, can
anticipate the outcomes of their actions, are not subject
to irresistible impulses (the official position of the
American Psychiatric Association) - in what way do
they differ from us, "normal" folks?

This is why the insanity defense often sits ill with

mental health pathologies deemed socially "acceptable"
and "normal" - such as religion or love.

Consider the following case:

A mother bashes the skulls of her three sons. Two of

them die. She claims to have acted on instructions she
had received from God. She is found not guilty by
reason of insanity. The jury determined that she "did not
know right from wrong during the killings."

But why exactly was she judged insane?

Her belief in the existence of God - a being with

inordinate and inhuman attributes - may be irrational.

But it does not constitute insanity in the strictest sense

because it conforms to social and cultural creeds and
codes of conduct in her milieu. Billions of people
faithfully subscribe to the same ideas, adhere to the
same transcendental rules, observe the same mystical
rituals, and claim to go through the same experiences.
This shared psychosis is so widespread that it can no
longer be deemed pathological, statistically speaking.

She claimed that God has spoken to her.

As do numerous other people. Behavior that is

considered psychotic (paranoid-schizophrenic) in other
contexts is lauded and admired in religious circles.
Hearing voices and seeing visions - auditory and visual
delusions - are considered rank manifestations of
righteousness and sanctity.

Perhaps it was the content of her hallucinations that

proved her insane?

She claimed that God had instructed her to kill her

boys. Surely, God would not ordain such evil?

Alas, the Old and New Testaments both contain

examples of God's appetite for human sacrifice.
Abraham was ordered by God to sacrifice Isaac, his
beloved son (though this savage command was
rescinded at the last moment). Jesus, the son of God
himself, was crucified to atone for the sins of humanity.

A divine injunction to slay one's offspring would sit

well with the Holy Scriptures and the Apocrypha as
well as with millennia-old Judeo-Christian traditions of
martyrdom and sacrifice.

Her actions were wrong and incommensurate with

both human and divine (or natural) laws.

Yes, but they were perfectly in accord with a literal

interpretation of certain divinely-inspired texts,
millennial scriptures, apocalyptic thought systems, and
fundamentalist religious ideologies (such as the ones
espousing the imminence of "rupture"). Unless one
declares these doctrines and writings insane, her actions
are not.

we are forced to the conclusion that the murderous

mother is perfectly sane. Her frame of reference is
different to ours. Hence, her definitions of right and
wrong are idiosyncratic. To her, killing her babies was
the right thing to do and in conformity with valued
teachings and her own epiphany. Her grasp of reality -
the immediate and later consequences of her actions -
was never impaired.

It would seem that sanity and insanity are relative terms,

dependent on frames of cultural and social reference,
and statistically defined. There isn't - and, in principle,
can never emerge - an "objective", medical, scientific
test to determine mental health or disease
unequivocally.

VIII. Adaptation and Insanity - (correspondence with

Paul Shirley, MSW)

"Normal" people adapt to their environment - both

human and natural.

"Abnormal" ones try to adapt their environment - both

human and natural - to their idiosyncratic needs/profile.

If they succeed, their environment, both human

(society) and natural is pathologized.
Note on the Medicalization of Sin and Wrongdoing

With Freud and his disciples started the medicalization

of what was hitherto known as "sin", or wrongdoing. As
the vocabulary of public discourse shifted from
religious terms to scientific ones, offensive behaviors
that constituted transgressions against the divine or
social orders have been relabelled. Self-centredness and
dysempathic egocentricity have now come to be known
as "pathological narcissism"; criminals have been
transformed into psychopaths, their behavior, though
still described as anti-social, the almost deterministic
outcome of a deprived childhood or a genetic
predisposition to a brain biochemistry gone awry -
casting in doubt the very existence of free will and free
choice between good and evil. The contemporary
"science" of psychopathology now amounts to a godless
variant of Calvinism, a kind of predestination by nature
or by nurture.

Also Read

On Disease

The Insanity of the Defense

In Defense of Psychoanalysis

he Metaphors of the Mind - Part I (The Brain)

The Metaphors of the Mind - Part II (Psychotherapy)

The Metaphors of the Mind - Part III (Dreams)

 The Use and Abuse of Differential Diagnoses

Althusser, Competing Interpellations and the Third Text

Return
 Psychology and Psychotherapy

Storytelling has been with us since the days of campfire

and besieging wild animals. It served a number of
important functions: amelioration of fears,
communication of vital information (regarding survival
tactics and the characteristics of animals, for instance),
the satisfaction of a sense of order (justice), the
development of the ability to hypothesize, predict and
introduce theories and so on.

We are all endowed with a sense of wonder. The world

around us in inexplicable, baffling in its diversity and
myriad forms. We experience an urge to organize it, to
"explain the wonder away", to order it in order to know
what to expect next (predict). These are the essentials of
survival. But while we have been successful at imposing
our mind's structures on the outside world – we have
been much less successful when we tried to cope with
our internal universe.

The relationship between the structure and functioning

of our (ephemeral) mind, the structure and modes of
operation of our (physical) brain and the structure and
conduct of the outside world have been the matter of
heated debate for millennia. Broadly speaking, there
were (and still are) two ways of treating it:

There were those who, for all practical purposes,

identified the origin (brain) with its product (mind).
Some of them postulated the existence of a lattice of
preconceived, born categorical knowledge about the
universe – the vessels into which we pour our
experience and which mould it. Others have regarded
the mind as a black box. While it was possible in
principle to know its input and output, it was
impossible, again in principle, to understand its internal
functioning and management of information. Pavlov
coined the word "conditioning", Watson adopted it and
invented "behaviourism", Skinner came up with
"reinforcement". The school of epiphenomenologists
(emergent phenomena) regarded the mind as the by
product of the brain's "hardware" and "wiring"
complexity. But all ignored the psychophysical
question: what IS the mind and HOW is it linked to the
brain?

The other camp was more "scientific" and "positivist". It

speculated that the mind (whether a physical entity, an
epiphenomenon, a non-physical principle of
organization, or the result of introspection) – had a
structure and a limited set of functions. They argued that
a "user's manual" could be composed, replete with
engineering and maintenance instructions. The most
prominent of these "psychodynamists" was, of course,
Freud. Though his disciples (Adler, Horney, the object-
relations lot) diverged wildly from his initial theories –
they all shared his belief in the need to "scientify" and
objectify psychology. Freud – a medical doctor by
profession (Neurologist) and Josef Breuer before him –
came with a theory regarding the structure of the mind
and its mechanics: (suppressed) energies and (reactive)
forces. Flow charts were provided together with a
method of analysis, a mathematical physics of the mind.

But this was a mirage. An essential part was missing:

the ability to test the hypotheses, which derived from
these "theories". They were all very convincing, though,
and, surprisingly, had great explanatory power. But -
non-verifiable and non-falsifiable as they were – they
could not be deemed to possess the redeeming features
of a scientific theory.

Deciding between the two camps was and is a crucial

matter. Consider the clash - however repressed -
between psychiatry and psychology. The former regards
"mental disorders" as euphemisms - it acknowledges
only the reality of brain dysfunctions (such as
biochemical or electric imbalances) and of hereditary
factors. The latter (psychology) implicitly assumes that
something exists (the "mind", the "psyche") which
cannot be reduced to hardware or to wiring diagrams.
Talk therapy is aimed at that something and supposedly
interacts with it.

But perhaps the distinction is artificial. Perhaps the

mind is simply the way we experience our brains.
Endowed with the gift (or curse) of introspection, we
experience a duality, a split, constantly being both
observer and observed. Moreover, talk therapy involves
TALKING - which is the transfer of energy from one
brain to another through the air. This is directed,
specifically formed energy, intended to trigger certain
circuits in the recipient brain. It should come as no
surprise if it were to be discovered that talk therapy has
clear physiological effects upon the brain of the patient
(blood volume, electrical activity, discharge and
absorption of hormones, etc.).

All this would be doubly true if the mind was, indeed,

only an emergent phenomenon of the complex brain -
two sides of the same coin.
Psychological theories of the mind are metaphors of the
mind. They are fables and myths, narratives, stories,
hypotheses, conjunctures. They play (exceedingly)
important roles in the psychotherapeutic setting – but
not in the laboratory. Their form is artistic, not rigorous,
not testable, less structured than theories in the natural
sciences. The language used is polyvalent, rich,
effusive, and fuzzy – in short, metaphorical. They are
suffused with value judgements, preferences, fears, post
facto and ad hoc constructions. None of this has
methodological, systematic, analytic and predictive
merits.

Still, the theories in psychology are powerful

instruments, admirable constructs of the mind. As such,
they are bound to satisfy some needs. Their very
existence proves it.

The attainment of peace of mind is a need, which was

neglected by Maslow in his famous rendition. People
will sacrifice material wealth and welfare, will forgo
temptations, will ignore opportunities, and will put their
lives in danger – just to reach this bliss of wholeness
and completeness. There is, in other words, a preference
of inner equilibrium over homeostasis. It is the
fulfilment of this overriding need that psychological
theories set out to cater to. In this, they are no different
than other collective narratives (myths, for instance).

In some respects, though, there are striking differences:

Psychology is desperately trying to link up to reality and

to scientific discipline by employing observation and
measurement and by organizing the results and
presenting them using the language of mathematics.
This does not atone for its primordial sin: that its subject
matter is ethereal and inaccessible. Still, it lends an air
of credibility and rigorousness to it.

The second difference is that while historical narratives

are "blanket" narratives – psychology is "tailored",
"customized". A unique narrative is invented for every
listener (patient, client) and he is incorporated in it as
the main hero (or anti-hero). This flexible "production
line" seems to be the result of an age of increasing
individualism. True, the "language units" (large chunks
of denotates and connotates) are one and the same for
every "user". In psychoanalysis, the therapist is likely to
always employ the tripartite structure (Id, Ego,
Superego). But these are language elements and need
not be confused with the plots. Each client, each person,
and his own, unique, irreplicable, plot.

To qualify as a "psychological" plot, it must be:

a. All-inclusive (anamnetic) – It must encompass,

integrate and incorporate all the facts known
about the protagonist.

b. Coherent – It must be chronological, structured

and causal.

c. Consistent – Self-consistent (its subplots cannot

contradict one another or go against the grain of
the main plot) and consistent with the observed
phenomena (both those related to the protagonist
and those pertaining to the rest of the universe).

d. Logically compatible – It must not violate the

laws of logic both internally (the plot must abide
 by some internally imposed logic) and externally
(the Aristotelian logic which is applicable to the
observable world).

e. Insightful (diagnostic) – It must inspire in the

client a sense of awe and astonishment which is
the result of seeing something familiar in a new
light or the result of seeing a pattern emerging
out of a big body of data. The insights must be
the logical conclusion of the logic, the language
and of the development of the plot.

f. Aesthetic – The plot must be both plausible and

"right", beautiful, not cumbersome, not
awkward, not discontinuous, smooth and so on.

g. Parsimonious – The plot must employ the

minimum numbers of assumptions and entities
in order to satisfy all the above conditions.

h. Explanatory – The plot must explain the

behaviour of other characters in the plot, the
hero's decisions and behaviour, why events
developed the way that they did.

i. Predictive (prognostic) – The plot must possess

the ability to predict future events, the future
behaviour of the hero and of other meaningful
figures and the inner emotional and cognitive
dynamics.

j. Therapeutic – With the power to induce change

(whether it is for the better, is a matter of
contemporary value judgements and fashions).
 k. Imposing – The plot must be regarded by the
client as the preferable organizing principle of
his life's events and the torch to guide him in the
darkness to come.

l. Elastic – The plot must possess the intrinsic

abilities to self organize, reorganize, give room
to emerging order, accommodate new data
comfortably, avoid rigidity in its modes of
reaction to attacks from within and from
without.

In all these respects, a psychological plot is a theory in

disguise. Scientific theories should satisfy most of the
same conditions. But the equation is flawed. The
important elements of testability, verifiability,
refutability, falsifiability, and repeatability – are all
missing. No experiment could be designed to test the
statements within the plot, to establish their truth-value
and, thus, to convert them to theorems.

There are four reasons to account for this shortcoming:

1. Ethical – Experiments would have to be

conducted, involving the hero and other humans.
To achieve the necessary result, the subjects will
have to be ignorant of the reasons for the
experiments and their aims. Sometimes even the
very performance of an experiment will have to
remain a secret (double blind experiments).
Some experiments may involve unpleasant
experiences. This is ethically unacceptable.

2. The Psychological Uncertainty Principle – The

current position of a human subject can be fully
 known. But both treatment and experimentation
influence the subject and void this knowledge.
The very processes of measurement and
observation influence the subject and change
him.

3. Uniqueness – Psychological experiments are,

therefore, bound to be unique, unrepeatable,
cannot be replicated elsewhere and at other
times even if they deal with the SAME subjects.
The subjects are never the same due to the
psychological uncertainty principle. Repeating
the experiments with other subjects adversely
affects the scientific value of the results.

4. The undergeneration of testable hypotheses –

Psychology does not generate a sufficient
number of hypotheses, which can be subjected to
scientific testing. This has to do with the
fabulous (=storytelling) nature of psychology. In
a way, psychology has affinity with some private
languages. It is a form of art and, as such, is self-
sufficient. If structural, internal constraints and
requirements are met – a statement is deemed
true even if it does not satisfy external scientific
requirements.

So, what are plots good for? They are the instruments
used in the procedures, which induce peace of mind
(even happiness) in the client. This is done with the help
of a few embedded mechanisms:

a. The Organizing Principle – Psychological plots

offer the client an organizing principle, a sense
of order and ensuing justice, of an inexorable
 drive toward well defined (though, perhaps,
hidden) goals, the ubiquity of meaning, being
part of a whole. It strives to answer the "why’s"
and "how’s". It is dialogic. The client asks: "why
am I (here follows a syndrome)". Then, the plot
is spun: "you are like this not because the world
is whimsically cruel but because your parents
mistreated you when you were very young, or
because a person important to you died, or was
taken away from you when you were still
impressionable, or because you were sexually
abused and so on". The client is calmed by the
very fact that there is an explanation to that
which until now monstrously taunted and
haunted him, that he is not the plaything of
vicious Gods, that there is who to blame
(focussing diffused anger is a very important
result) and, that, therefore, his belief in order,
justice and their administration by some
supreme, transcendental principle is restored.
This sense of "law and order" is further
enhanced when the plot yields predictions which
come true (either because they are self-fulfilling
or because some real "law" has been
discovered).

b. The Integrative Principle – The client is

offered, through the plot, access to the
innermost, hitherto inaccessible, recesses of his
mind. He feels that he is being reintegrated, that
"things fall into place". In psychodynamic terms,
the energy is released to do productive and
positive work, rather than to induce distorted and
destructive forces.
 c. The Purgatory Principle – In most cases, the
client feels sinful, debased, inhuman, decrepit,
corrupting, guilty, punishable, hateful, alienated,
strange, mocked and so on. The plot offers him
absolution. Like the highly symbolic figure of
the Saviour before him – the client's sufferings
expurgate, cleanse, absolve, and atone for his
sins and handicaps. A feeling of hard won
achievement accompanies a successful plot. The
client sheds layers of functional, adaptive
clothing. This is inordinately painful. The client
feels dangerously naked, precariously exposed.
He then assimilates the plot offered to him, thus
enjoying the benefits emanating from the
previous two principles and only then does he
develop new mechanisms of coping. Therapy is
a mental crucifixion and resurrection and
atonement for the sins. It is highly religious with
the plot in the role of the scriptures from which
solace and consolation can be always gleaned.

Return
 Guide to Coping with
Narcissists and Psychopaths

Save for later reference! Forward to interested parties and relevant

discussion and mailing groups!

Click with your mouse on the links (the blue text).

Coping with Narcissistic and Psychopathic Abusers

http://samvak.tripod.com/faq4.html
http://samvak.tripod.com/abusefamily19.html
http://samvak.tripod.com/abusefamily20.html
http://samvak.tripod.com/npdtips.html
http://samvak.tripod.com/5.html
http://samvak.tripod.com/faq80.html
http://samvak.tripod.com/4.html
http://samvak.tripod.com/faq75.html
http://samvak.tripod.com/journal56.html
http://samvak.tripod.com/journal68.html
Strategies for Coping with Abusers (General)

http://samvak.tripod.com/abuse.html
http://samvak.tripod.com/abuse3.html
http://samvak.tripod.com/abuse17.html
http://samvak.tripod.com/abuse19.html
http://samvak.tripod.com/abuse20.html
http://samvak.tripod.com/abuse21.html
http://samvak.tripod.com/abuse21a.html
http://samvak.tripod.com/abuse21b.html
http://samvak.tripod.com/abuse12.html
http://samvak.tripod.com/abuse13.html
http://samvak.tripod.com/abuse5.html
http://samvak.tripod.com/abuse6.html
http://samvak.tripod.com/abusefamily13.html
http://samvak.tripod.com/abusefamily5.html
http://samvak.tripod.com/abusefamily6.html
http://samvak.tripod.com/abusefamily8.html

Working with the System and with Professionals

http://samvak.tripod.com/abusefamily10.html
http://samvak.tripod.com/abusefamily11.html
http://samvak.tripod.com/abusefamily12.html
How to Cope with Stalkers and Paranoids

http://samvak.tripod.com/abuse21a.html
http://samvak.tripod.com/abuse21b.html
http://samvak.tripod.com/abuse18.html
http://samvak.tripod.com/abuse15.html
http://samvak.tripod.com/abuse16.html
http://samvak.tripod.com/abusefamily14.html
http://samvak.tripod.com/abusefamily16.html
http://samvak.tripod.com/abusefamily17.html
http://samvak.tripod.com/abusefamily18.html

Return
Narcissistic abuse in the workplace and
Narcissism of authority figures

Click on the links:

http://malignantselflove.tripod.com/faq81.html

http://malignantselflove.tripod.com/journal79.html

http://malignantselflove.tripod.com/faq11.html

http://malignantselflove.tripod.com/15.html

http://malignantselflove.tripod.com/faq19.html

http://malignantselflove.tripod.com/journal73.html

http://malignantselflove.tripod.com/faq47.html

http://malignantselflove.tripod.com/journal70.html

http://malignantselflove.tripod.com/journal52.html

http://malignantselflove.tripod.com/journal48.html

http://malignantselflove.tripod.com/corporatenarcissism
.html

http://www.healthyplace.com/personality-
disorders/transcripts/narcissism-in-the-workplace/menu-id-62/

http://malignantselflove.tripod.com/pp114.html
http://www.tipsofallsorts.com/bully.html

http://open-
site.org/Society/Issues/Violence_and_Abuse/Workplace/

http://www.nypress.com/16/7/news&columns/feature.cfm

http://www.bullyonline.org/workbully/npd.htm

http://www.freepint.com/issues/240703.htm

http://malignantselflove.tripod.com/journal45.html

http://www.abc.net.au/rn/talks/bbing/stories/s1158704.h
tm

http://www.freepint.com/issues/260505.htm

http://alaskaclubs.fitdv.com/new/articles/article.html?artid=640

Return
 THE AUTHOR

Shmuel (Sam) Vaknin

Curriculum Vitae

Born in 1961 in Qiryat-Yam, Israel.

Served in the Israeli Defence Force (1979-1982) in

training and education units.

Education

1970-1978: Completed nine semesters in the Technion –

Israel Institute of Technology, Haifa.

1982-3: Ph.D. in Philosophy (dissertation: "Time

Asymmetry Revisited") – Pacific Western University,
California, USA.

1982-5: Graduate of numerous courses in Finance

Theory and International Trading in the UK and USA.

Certified E-Commerce Concepts Analyst by

Brainbench.

Certified in Psychological Counselling Techniques by

Brainbench.
Certified Financial Analyst by Brainbench.

Full proficiency in Hebrew and in English.

Business Experience

1980 to 1983

Founder and co-owner of a chain of computerised

information kiosks in Tel-Aviv, Israel.

1982 to 1985

Senior positions with the Nessim D. Gaon Group of

Companies in Geneva, Paris and New-York (NOGA
and APROFIM SA):

– Chief Analyst of Edible Commodities in the Group's

Headquarters in Switzerland
– Manager of the Research and Analysis Division
– Manager of the Data Processing Division
– Project Manager of the Nigerian Computerised
Census
– Vice President in charge of RND and Advanced
Technologies
– Vice President in charge of Sovereign Debt Financing

1985 to 1986

Represented Canadian Venture Capital Funds in Israel.

1986 to 1987

General Manager of IPE Ltd. in London. The firm

financed international multi-lateral countertrade and
leasing transactions.

1988 to 1990

Co-founder and Director of "Mikbats-Tesuah", a

portfolio management firm based in Tel-Aviv.
Activities included large-scale portfolio management,
underwriting, forex trading and general financial
advisory services.

1990 to Present

Freelance consultant to many of Israel's Blue-Chip

firms, mainly on issues related to the capital markets in
Israel, Canada, the UK and the USA.

Consultant to foreign RND ventures and to

Governments on macro-economic matters.

Freelance journalist in various media in the United

States.

1990 to 1995

President of the Israel chapter of the Professors World

Peace Academy (PWPA) and (briefly) Israel
representative of the "Washington Times".
1993 to 1994

Co-owner and Director of many business enterprises:

– The Omega and Energy Air-Conditioning Concern

– AVP Financial Consultants
– Handiman Legal Services
Total annual turnover of the group: 10 million USD.

Co-owner, Director and Finance Manager of COSTI

Ltd. – Israel's largest computerised information vendor
and developer. Raised funds through a series of private
placements locally in the USA, Canada and London.

1993 to 1996

Publisher and Editor of a Capital Markets Newsletter

distributed by subscription only to dozens of subscribers
countrywide.

In a legal precedent in 1995 – studied in business

schools and law faculties across Israel – was tried for
his role in an attempted takeover of Israel's Agriculture
Bank.

Was interned in the State School of Prison Wardens.

Managed the Central School Library, wrote, published

and lectured on various occasions.

Managed the Internet and International News

Department of an Israeli mass media group, "Ha-
Tikshoret and Namer".
Assistant in the Law Faculty in Tel-Aviv University (to
Prof. S.G. Shoham).

1996 to 1999

Financial consultant to leading businesses in

Macedonia, Russia and the Czech Republic.

Economic commentator in "Nova Makedonija",

"Dnevnik", "Makedonija Denes", "Izvestia",
"Argumenti i Fakti", "The Middle East Times", "The
New Presence", "Central Europe Review", and other
periodicals, and in the economic programs on various
channels of Macedonian Television.

Chief Lecturer in courses in Macedonia organised by

the Agency of Privatization, by the Stock Exchange, and
by the Ministry of Trade.

1999 to 2002

Economic Advisor to the Government of the Republic

of Macedonia and to the Ministry of Finance.

2001 to 2003

Senior Business Correspondent for United Press

International (UPI).

2007 -

Associate Editor, Global Politician

Founding Analyst, The Analyst Network

Contributing Writer, The American Chronicle Media
Group

Expert, Self-growth.com

2007-2008

Columnist and analyst in "Nova Makedonija", "Fokus",

and "Kapital" (Macedonian papers and newsweeklies).

2008-

Member of the Steering Committee for the

Advancement of Healthcare in the Republic of
Macedonia

Advisor to the Minister of Health of Macedonia

Seminars and lectures on economic issues in various

forums in Macedonia.

Web and Journalistic Activities

Author of extensive Web sites in:

– Psychology ("Malignant Self Love") - An Open

Directory Cool Site for 8 years.

– Philosophy ("Philosophical Musings"),

– Economics and Geopolitics ("World in Conflict and

Transition").
Owner of the Narcissistic Abuse Study Lists and the
Abusive Relationships Newsletter (more than 6,000
members).

Owner of the Economies in Conflict and Transition

Study List , the Toxic Relationships Study List, and the
Links and Factoid Study List.

Editor of mental health disorders and Central and

Eastern Europe categories in various Web directories
(Open Directory, Search Europe, Mentalhelp.net).

Editor of the Personality Disorders, Narcissistic

Personality Disorder, the Verbal and Emotional Abuse,
and the Spousal (Domestic) Abuse and Violence topics
on Suite 101 and Bellaonline.

Columnist and commentator in "The New Presence",

United Press International (UPI), InternetContent,
eBookWeb, PopMatters, Global Politician, The Analyst
Network, Conservative Voice, The American Chronicle
Media Group, eBookNet.org, and "Central Europe
Review".

Publications and Awards

"Managing Investment Portfolios in States of

Uncertainty", Limon Publishers, Tel-Aviv, 1988

"The Gambling Industry", Limon Publishers, Tel-Aviv,

1990

"Requesting My Loved One – Short Stories", Yedioth

Aharonot, Tel-Aviv, 1997
"The Suffering of Being Kafka" (electronic book of
Hebrew and English Short Fiction), Prague, 1998-2004

"The Macedonian Economy at a Crossroads – On the

Way to a Healthier Economy" (dialogues with Nikola
Gruevski), Skopje, 1998

"The Exporters' Pocketbook", Ministry of Trade,

Republic of Macedonia, Skopje, 1999

"Malignant Self Love – Narcissism Revisited",

Narcissus Publications, Prague, 1999-2007 (Read
excerpts - click here)

The Narcissism, Psychopathy, and Abuse in

Relationships Series
(E-books regarding relationships with abusive
narcissists and psychopaths), Prague, 1999-2010

Personality Disorders Revisited (e-book about

personality disorders), Prague, 2007

"After the Rain – How the West Lost the East",

Narcissus Publications in association with Central
Europe Review/CEENMI, Prague and Skopje, 2000

Winner of numerous awards, among them Israel's

Council of Culture and Art Prize for Maiden Prose
(1997), The Rotary Club Award for Social Studies
(1976), and the Bilateral Relations Studies Award of the
American Embassy in Israel (1978).

Hundreds of professional articles in all fields of finance

and economics, and numerous articles dealing with
geopolitical and political economic issues published in
both print and Web periodicals in many countries.

Many appearances in the electronic media on subjects in

philosophy and the sciences, and concerning economic
matters.

Write to Me:
palma@unet.com.mk
narcissisticabuse-owner@yahoogroups.com

My Web Sites:
Economy/Politics:
http://ceeandbalkan.tripod.com/
Psychology:
http://www.narcissistic-abuse.com/
Philosophy:
http://philosophos.tripod.com/
Poetry:
http://samvak.tripod.com/contents.html
Fiction:
http://samvak.tripod.com/sipurim.html

Return
 Abused? Stalked? Harassed? Bullied? Victimized?
Afraid? Confused? Need HELP? DO SOMETHING ABOUT IT!

Had a Narcissistic Parent?

Married to a Narcissist – or Divorcing One?
Afraid your children will turn out the same?
Want to cope with this pernicious, baffling condition?
OR
Are You a Narcissist – or suspect that You are one…
This book will teach you how to…
Cope, Survive, and Protect Your Loved Ones!
You should read…

"Malignant Self Love – Narcissism Revisited"

The EIGHTH, REVISED PRINTING (January 2007) is now available!

Nine additional e-books, All NEW Editions, JUST RELEASED!!!

Malignant Self Love, Toxic Relationships,
Pathological Narcissism, Coping with Divorce,
The Narcissist and Psychopath in the Workplace – and MORE!!!

Click on this link to purchase the PRINT BOOK and/or

the NINE E-BOOKS
http://www.narcissistic-abuse.com/thebook.html

Sam Vaknin published the EIGHTH, REVISED IMPRESSION of his book

about relationships with abusive narcissists, "Malignant Self Love –
Narcissism Revisited".
The book deals with the Narcissistic Personality Disorder and its
effects on the narcissist and his nearest and dearest – in 102
frequently asked questions and two essays – a total of 600 pages!
 Print Edition from BARNES AND NOBLE and AMAZON

Barnes and Noble – "Malignant Self Love – Narcissism Revisited"

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Print Edition from the PUBLISHER

The previous revised impression of Sam Vaknin's "Malignant Self –

Love – Narcissism Revisited".
Comes with an exclusive BONUS PACK (not available through
Barnes and Noble or Amazon).
Contains the entire text: essays, frequently asked questions and
appendices regarding pathological narcissism and the Narcissistic
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The publisher charges the full list price – but throws into the
bargain a bonus pack with hundreds of additional pages and seven
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Click on this link:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_MSL
Free excerpts from the EIGHTH, Revised Impression of "Malignant
Self Love – Narcissism Revisited" are available as well as a free
NEW EDITION of the Narcissism Book of Quotes
Click on this link to download the files:
http://www.narcissistic-abuse.com/freebooks.html

"After the Rain – How the West Lost the East"

The history, cultures, societies, and economies of countries in
transition in the Balkans.
Click on this link to purchase this print book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_ATR

Electronic Books (e-books) from the Publisher

An electronic book is a computer file, sent to you as an attachment to an

e-mail message. Just save it to your hard disk and click on the file to open,
read, and learn!

1. "Malignant Self Love – Narcissism Revisited"

Eighth, Revised Edition (January 2007)
The e-book version of Sam Vaknin's "Malignant Self – Love –
Narcissism Revisited". Contains the entire text: essays, frequently
asked questions (FAQs) and appendices regarding pathological
narcissism and the Narcissistic Personality Disorder (NPD).
Click on this link to purchase the e-book:
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2. "The Narcissism, Psychopathy, and Abuse in Relationships

Series" Eighth, Revised Edition (July 2010)
NINE e-books (more than 3000 pages), including the full text of
"Malignant Self Love – Narcissism Revisited", regarding Pathological
Narcissism, relationships with abusive narcissists and psychopaths,
and the Narcissistic Personality Disorder (NPD).
Click on this link to purchase the EIGHT e-books:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_SERIES
3. "Toxic Relationships – Abuse and its Aftermath"
Fourth Edition (February 2006)
How to identify abuse, cope with it, survive it, and deal with your
abuser and with the system in divorce and custody issues.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_ABUSE

4. "The Narcissist and Psychopath in the Workplace"

(September 2006)
Identify abusers, bullies, and stalkers in the workplace (bosses,
colleagues, suppliers, and authority figures) and learn how to cope
with them effectively.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_WORKPLACE

5. "Abusive Relationships Workbook" (February 2006)

Self-assessment questionnaires, tips, and tests for victims of
abusers, batterers, and stalkers in various types of relationships.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_WORKBOOK

6. "Pathological Narcissism FAQs"

Eighth, Revised Edition (January 2007)
Dozens of Frequently Asked Questions regarding Pathological
Narcissism, relationships with abusive narcissists, and the
Narcissistic Personality Disorder.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_FAQS

7. "The World of the Narcissist"

Eighth, Revised Edition (January 2007)
A book-length psychodynamic study of pathological narcissism,
relationships with abusive narcissists, and the Narcissistic
Personality Disorder, using a new vocabulary.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_ESSAY
8. "Excerpts from the Archives of the Narcissism List"
Hundreds of excerpts from the archives of the Narcissistic Abuse
Study List regarding Pathological Narcissism, relationships with
abusive narcissists, and the Narcissistic Personality Disorder (NPD).
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_EXCERPTS

9. "Diary of a Narcissist" (November 2005)

The anatomy of one man's mental illness – its origins, its unfolding,
its outcomes.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_JOURNAL

10. "After the Rain – How the West Lost the East"
The history, cultures, societies, and economies of countries in
transition in the Balkans.
Click on this link to purchase the e-book:
http://www.ccnow.com/cgi-local/cart.cgi?vaksam_ATR-EBOOK

Download Free Electronic Books

Click on this link:
http://www.narcissistic-abuse.com/freebooks.html

More about the Books and Additional Resources

The Eighth, Revised Impression (January 2007) of the Print Edition

of "Malignant Self Love – Narcissism Revisited" includes:
• The full text of "Malignant Self Love – Narcissism Revisited"
• The full text of 102 Frequently Asked Questions and Answers
• Covering all the dimensions of Pathological Narcissism and Abuse
in Relationships
• An Essay – The Narcissist's point of view
• Bibliography
• 600 printed pages in a quality paper book
• Digital Bonus Pack! (available only when you purchase the
previous edition from the Publisher) – Bibliography, three e-
 books, additional FAQs, appendices and more – hundreds of
additional pages!

Testimonials and Additional Resources

You can read Readers' Reviews at the Barnes and Noble Web page
dedicated to "Malignant Self Love" – HERE:
http://search.barnesandnoble.com/bookSearch/isbnInquiry.asp?r=
1&ISBN=9788023833843

Dozens of Links and Resources

Click on these links:
The Narcissistic Abuse Study List
http://groups.yahoo.com/group/narcissisticabuse
The Toxic Relationships Study List
http://groups.yahoo.com/group/toxicrelationships
Abusive Relationships Newsletter
http://groups.google.com/group/narcissisticabuse

Participate in Discussions about Abusive Relationships - click on

these links:

http://narcissisticabuse.ning.com/

http://www.runboard.com/bnarcissisticabuserecovery

http://thepsychopath.freeforums.org/

The Narcissistic Abuse Study List

http://health.groups.yahoo.com/group/narcissisticabuse/

The Toxic Relationships Study List

http://groups.yahoo.com/group/toxicrelationships

Abusive Relationships Newsletter

http://groups.google.com/group/narcissisticabuse/
Archived discussion threads - click on these links:

http://personalitydisorders.suite101.com/discussions.cfm

http://www.suite101.com/discussions.cfm/verbal_emotional_abu
se

http://www.suite101.com/discussuions.cfm/spousal_domestic_ab
use

Links to Therapist Directories, Psychological Tests, NPD

Resources, Support Groups for Narcissists and Their Victims,
and Tutorials

http://health.groups.yahoo.com/group/narcissisticabuse/message/5458

Support Groups for Victims of Narcissists and Narcissists

http://dmoz.org/Health/Mental_Health/Disorders/Personality/Narcissistic

BE WELL, SAFE AND WARM WHEREVER YOU ARE!

Sam Vaknin
 Malignant Self Love
Narcissism Revisited

The Book
"Narcissists live in a state of constant rage, repressed
aggression, envy and hatred. They firmly believe that
everyone is like them. As a result, they are paranoid,
aggressive, haughty and erratic. Narcissists are
forever in pursuit of Narcissistic Supply.
They know no past or future, are not constrained by any
behavioural consistency, 'rules' of conduct or moral
considerations. You signal to a narcissist that you are a willing
source – and he is bound to extract his supply from you.
This is a reflex.
He would have reacted absolutely the same to any other
source. If what is needed to obtain supply from you is
intimations of intimacy – he will supply them liberally."
This book is comprised of two parts.
The first part contains 102 Frequently Asked Questions
related to the various aspects of pathological narcissism,
relationships with abusive narcissists, and the
Narcissistic Personality Disorder (NPD).
The second part is an exposition of the various psychodynamic
theories regarding pathological narcissism and
a proposed new vocabulary.

The Author
Sam Vaknin was born in Israel in 1961. A financial consultant
and columnist, he lived (and published) in 12 countries.
He is a published and awarded author of short fiction and
reference and an editor of mental health categories in various
Web directories. This is his twelfth book.