Psychopathy and the neighbours of narcissism
Part A
A psychopath, a narcissist and a man with complex post-traumatic stress disorder walk into a bar on a quiet afternoon. And you are the lone bar tender. In this formulaic joke world, they are each wearing badges displaying a diagnosis they have been given. What comes into your mind imagining each of these people? Is one of them quite different to the others?
So far in this blog, after introducing a theory of narcissism, I have looked at the lives of Marilyn Monroe, John Lennon, Charles Chaplin and Michael Jackson – people who have earned iconic sustained fame. I have done this looking for illustrations of two things that narcissism theory predicts: firstly, the kinds of strategies they use for managing their moods, emotions and relationships – narcissistic strategies. And secondly, the kinds of experiences they have had growing up – that might shape these strategies.
I have described narcissism as the use of performance, admiration, shaming, emotional distance and power in order to avoid the felt experience of vulnerability, shame or humiliation. But there are a few other concepts that appear similar to or overlap with narcissism. Sometimes these labels get used when narcissism would be a better fit. Here I will compare narcissism with narcissistic personality disorder, psychopathy, emotionally unstable personality disorder (AKA borderline personality disorder, or complex emotional needs) and ‘complex PTSD’ (post-traumatic stress disorder). Here, I don’t want to endorse these concepts or their names as such – I just want to compare them.
It is sometimes easy to blame confusion in ourselves on a lack of knowledge about the differences between these concepts. We can assume that psychiatry, psychology and psychoanalysis have come to understand and agree. Sadly though, this is not the case. The waters here run muddy and deep.
In part B of this post, I will be arguing that the group labelled as ‘psychopaths’ demonstrate a severe form of narcissism mixed with traits of other personality disorders. So here, I will list the main key features of narcissism to compare with psychopathy later on:
The main features of narcissism are:
Seeking idealisation, admiration and power
Reliance on charisma and performance
Overuse of intellectual performance (thinking) as opposed to experiences and communication of the emotional mind (feelings)
Lacking emotional empathy and capacity for emotional connection (but empathy for other’s thoughts and perspectives may be good)
Highly avoidant of experiencing shame, humiliation or blame in even small doses
Poor connection with one’s own vulnerable emotions (sometimes finding vulnerability in others as a way to be ‘less’ vulnerable themselves).
A tendency to judge, shame or put down others.
What is a ‘personality disorder’?
Personality disorders are problems that affect the way the person manages their emotions and relationships – affecting the way they think, feel and behave. Personality disorders are long term and develop quite early on in life. One way to view personality disorder is as a narrow set of personality traits that express themselves in an extreme way that cause problems. Often, these traits can be understood as ways of adapting to adverse situations in childhood.
With all personality disorder diagnoses, there are two or three conversations that can sound like they are referring to the same thing but are often not. Firstly, there is psychology and psychoanalysis’s description of personality traits and defences or strategies and their roots in earlier experiences (for example, ‘narcissistic defences’).
Secondly, there is a medical approach to classifying symptoms of mental ill health – this system is intended to help doctors assess and decide on treatment. Narcissistic personality disorder is such a diagnosis. The medical definitions of personality disorders are dominated by two international publications: The Diagnostic and Statistical Manual of Mental Disorders1 (DSM, published by the American Psychiatric Association) and the International Classification of Diseases2 (ICD, World Health Organisation). Whilst some schools of psychology contradict each other, whilst appearing to talk about the same thing, these two psychiatric manuals, in contrast, retain a tight control over how these diagnoses are defined – for better or worse. each has its own checklist of criteria.
In the last few years there has been a large-scale argument about the concept of personality disorders and how we divide these into categories (or not). In short, there is acceptance about the various personality traits being important and that there are different levels of severity. But the idea of discreet categories of disorder like those described here, is being questioned. Taking a physical health example, people with hepatitis will rarely have a kidney infection. They are different kinds of problem affecting different organs. But people with BPD will often also have narcissistic or antisocial traits. The dividing lines can help decide on what treatment will help, so it is not pointless, but it is also artificial. The DSM manual has three ‘clusters’ of personality disorder types. Narcissistic personality disorder, borderline personality disorder and antisocial personality disorder are together in ‘cluster B’ because they share more dramatic or volatile features.
Thirdly, mainstream media adopt the same language - terms like ‘narcissist’ or ‘psychopath’ - to judge or characterise people in a certain way (for example, Sherlock Holmes played by Benedict Cumberbatch is described as a “psychopath” by his partner Watson).
Narcissistic personality disorder (NPD)
“NPD comprises of a persistent manner of grandiosity, a continuous desire for admiration, along with a lack of empathy”1.
Narcissistic personality disorder (NPD) is a psychiatric (medical) diagnosis. NPD affects around 1% of the general population3. NPD as a mental health diagnosis is more specific and often more severe than narcissism as a personality trait more broadly.
NPD is in some ways the logical conclusion of narcissistic strategies becoming more fixed or severe. As with all personality disorders, the difference between someone with ‘NPD’ and someone with ‘narcissistic personality traits’, is only a matter of degree. How much distress does it cause? How much does it impact on their relationships? How inflexible is it as a set of strategies? Increase in severity comes with increased aggression, envy and more law-breaking and abuse of others4.
Historically, dating back to Freud, there are two schools of thought in psychology about narcissism. The first is more concerned with the drives, conflicts and desires of the individual and the other is concerned with early nurturing relationships that have failed to provide what was needed5. More recently, theory and research about attachment and trauma and the emotional needs of infants and children, have added detail to the second of these – the more ‘relational’ school of thought. In this blog I have brought together some ideas from both but mainly focus on attachment trauma and other traumatic experiences, I have described this understanding of narcissism in the theory post.
NPD is not a diagnosis that is used as much as BPD or EUPD. The first reasons for this, is that narcissism is less associated with asking for help. These people suffer a kind of phobia of putting themselves in a position of vulnerability. So, psychiatrists are less often asked by those with narcissism for a diagnosis. Secondly, even if they have asked to be assessed, patients rarely thank a psychiatrist for diagnosing them with narcissistic PD. Who would? But they are also hypersensitive to critical assessment even if the assessment is offered with the helpful intention.
As the bar tender in my opening scenario, which person would you feel most empathy for? As society we often have more sympathy towards some personality disorders or diagnoses than others. The person with BPD or C-PTSD might make us fear for their safety and health and our response is more often to try to protect or even rescue. But with NPD and ASPD in particular, we are more likely to meet them as a prison psychologist. They may affect others’ safety more than their own. They may be labelled as an ‘offender’ before receiving a diagnosis of a mental health problem. If narcissistic, they will also be quick to present a high functioning intellectual façade that looks quite different to ‘illness’. Here, psychiatry and psychology have to tread a different path. The person is not only ‘suffering’ from a health problem. They are also causing suffering to others. And being given a personality disorder diagnosis or one of psychopathy, does not take away responsibility for their behaviour.
Antisocial personality disorder (ASPD)
We don’t hear about ASPD so much. According to the American Psychiatric Association,
“ASPD is a diagnosis assigned to individuals who habitually and pervasively disregard or violate the rights and considerations of others without remorse”1
Compared with NPD, ASPD is marked by more impulsivity (action without thinking that causes problems), more violence and lower general success in life. Antisocial personality disorder does overlap with EUPD and NPD and it is not uncommon to find traits of all three in one person in more severe cases.
ASPD tends to be compared and contrasted most with EUPD. ASPD is seen as the more ‘male’ disorder, associated with aggression and exploitation compared with the self-harm and dependence of EUPD. The other big difference is that people with EUPD usually know they have a problem and try to get help. The difference between having some ‘antisocial personality traits’ and having ‘ASPD’ is a matter of how much stress and general impact it has and how fixed and rigid the strategies are. Whilst narcissism is referred to as a set of traits or strategies quite a lot in mainstream media to characterise people, the idea that someone is a bit ‘antisocial’ is less popular.
Emotionally unstable personality disorder (EUPD) or borderline personality disorder (BPD)
Over the past 30 years there has been a developing argument that EUPD/BPD* should be named differently – perhaps as complex PTSD or as ‘complex emotional needs’ (CEN). There are questions about both the ‘borderline’ and the ‘personality disorder’ terms. Many with this diagnosis struggle with what they see as the implied judgment of the individual without acknowledging the trauma that is usually found beneath. There is plenty of evidence that EUPD is a kind of complex post traumatic syndrome – especially when we take into account emotional neglect and abuse. The DSM defines BPD as:
“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts.”1
As the bar tender, we might experience those with EUPD, C-PTSD, ASPD and NPD differently, because they are distinguished by different strategies and styles – especially in interpersonal situations. NPD is defined by grandiosity and emotional distance, BPD by changeability, impulsivity and mood instability. And the person with EUPD is more likely to ask for help. This is mainly to do with the contrasting strategies used in order to manage emotions, states of mind and interactions6. Many theories of personality-based problems identify them as related– having overlapping difficulties behind the different strategies. The different strategies are important. People with EUPD are not known for their aggression or exploitation of others. Most theories of NPD and ASPD indicate childhood adversity, trauma or abuse as important causes4 and problems with relationships and emotional management as underlying problems.
Otto Kernberg4, an authority on both narcissism and ‘borderline PD’, describes borderline personality as an underlying “organisation” of how a person manages themselves and relationships. Kernberg paints NPD and ASPD as more severe and more fixed than borderline PD and as some kind of extension of “borderline personality organisation”4. I think this is compatible with a strategies approach I have described in the theory post along with the map of narcissism7.
Complex post-traumatic stress disorder (C-PTSD)
Recently, the concept of complex PTSD has gained increasing recognition and it is now included in the ICD-11. It is complex mainly because it is caused by repeated adverse experiences that tend to be relational. The overlaps between what this looks like and what EUPD looks like are substantial. Fewer authors have written about the overlaps between C-PTSD and narcissism or NPD– which is, according to many theorists caused by relational and repeated trauma (as illustrated in posts in Narcissism, influence and celebrity).
One thing that muddies the water here, is that C-PTSD is a concept defined by trauma. There has to be reported trauma to meet the criteria for this diagnosis. NPD, which is also a response to trauma, is not defined at all with reference to trauma in the psychiatric manuals – just patterns of behaviour thoughts and feeling. Neither are any of the other PDs, including EUPD, defined with reference to trauma. So, are they different ‘things’ or similar things being measured using different measuring devices? How much is this like having a 10cm carrot and the 4-inch carrot and saying they are different kinds of carrot? In this blog, I have in the theory post described a theory of narcissism rooted in complex relational trauma.
In part B, I will turn to psychopathy. The ‘psychopath’ is often portrayed as having a very different kind of mental health condition compared with not only narcissism but also other personality disorders. I will look at how the concept of psychopathy developed, and how many of the ‘symptoms’ of psychopathy are actually (though no one really admits it) extreme narcissism.
References
1. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Washington, DC: American Psychiatric Publishing.
2. World Health Organisation (2019). ICD-11: International classification of diseases (11th Revision)
3. Trull, T.J., Jahng, S., Tomko, R.L., Wood, P.K. & Sher, K.J. (2010). Revised NESARC personality disorder diagnoses; Gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders, 24(4), 412-426.
4. Diamond, D., Yeomans, F.E., Stern, B.L. & Kernberg, O.F. (2022) Treating Pathological Narcissism with Transference Focussed Therapy. Guildford.
5. Mitchell, S.A. (1986). The wings of icarus. Contemporary Psychoanalysis, 22: 107-132.
6. Jellema, A. (2000). Insecure attachment states: Their relationship to borderline and narcissistic personality disorders and treatment process in cognitive analytic therapy. Clinical Psychology and Psychotherapy Clinical Psychology and Psychotherapy. 7, 138–154.
7. Ryle, A. & Kerr, I.B. (2002). Introducing Cognitive Analytic Therapy. Wiley.
*BPD is the DSM term whilst EUPD is the ICD term. I will generally use EUPD.
Disclaimer: All views expressed are my own unless otherwise stated, and do not necessarily reflect the views of any institution I have been employed by. The content here is for information and should not be interpreted as advice.
Thank you so much for this interesting and enlightening article. It’s really cleared up a few questions I had about how the personality disorders overlap.