The signs and symptoms of bipolar mania mimic those of certain personality disorders,potentially leading to a misdiagnosis.

The manic phase of the Bipolar I Disorder is often misdiagnosed as a Personality Disorder.

In the manic phase of Bipolar Disorder, patients exhibit many of the signs and symptoms of certain personality disorders, such as the Narcissistic, Borderline, Histrionic, or even Schizotypal Personality Disorders: they are hyperactive, self-centered, lack empathy, and are control freaks. The manic patient is euphoric, delusional, has grandiose fantasies, spins unrealistic schemes, and has frequent rage attacks (is irritable) if her or his wishes and plans are (inevitably) frustrated.

Bipolar Disorder got its name because the mania is followed by - usually protracted - depressive attacks. A similar pattern of mood shifts and dysphorias occurs in many personality disorders such as the Borderline, Narcissistic, Paranoid, and Masochistic. But whereas the bipolar patient sinks into deep self-deprecation, self-devaluation, unbounded pessimism, all-pervasive guilt and anhedonia - patients with personality disorders, even when depressed, never lose the underlying and overarching structure of their primary mental health problem. The narcissist, for instance, never foregoes his narcissism, even when down and blue: his grandiosity, sense of entitlement, haughtiness, and lack of empathy remain intact.

From my book "Malignant Self Love - Narcissism Revisited":

"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."

The etiologies (the causes) of the Bipolar Disorder and of personality disorders differ. These disparities explain the different manifestations of mood swings. The source of the Bipolar's mood shifts is assumed to be brain biochemistry. The source of the transitions from euphoric mania to depression and dysphorias in the Cluster B personality disorders (Narcissistic, Histrionic, Borderline) is the fluctuations in 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. In contrast, people with personality disorders do drugs, drink, gamble, shop on credit, indulge 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 or her social and occupational functioning. Many patients with personality disorders, in contrast, reach the highest rungs of their community, church, firm, or voluntary organization and function reasonably well most of the time. The manic phase of Bipolar sometimes requires hospitalization and involves psychotic features. Patients with personality disorders are rarely if ever hospitalized. Moreover, psychotic microepisodes in certain personality disorders (e.g., the Borderline, Paranoid, Narcissistic, Schizotypal) are decompensatory in nature and appear only under unendurable stress (e.g., in intensive therapy).

The bipolar patient's nearest and dearest as well as perfect strangers react to his mania with marked discomfort. The constant, unwarranted cheer, the emphasized and compulsive insistence on interpersonal, sexual, and occupational, or professional interactions engenders unease and repulsion. The patient's lability of mood - rapid shifts between uncontrollable rage and unnatural good spirits - is downright intimidating.

Similarly, people with personality disorders also garner unease and hostility from their human environment - but their conduct is more often considered to be manipulative, cold, and calculating, rarely out of control. The narcissist's gregariousness, for example, is goal-orientated (the extraction of Narcissistic Supply). His cycles of mood and affect are far less pronounced and less rapid.

From my book "Malignant Self Love - Narcissism Revisited":

"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."

---

---

---

Sleep disorders - notably acute insomnia - are common in the manic phase of bipolar and uncommon among patients with personality disorders. So is "manic speech" which is 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 subjects with personality disorders, bipolars 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 or her closest as "not being himself of herself". Indeed, some bipolars relocate, change name and appearance, and lose contact with their "former life". Like in psychopathy, 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.

People with personality disorders are mostly ego-syntonic (the patient feels good with himself, with his life in general, and with the way he acts). In contrast, 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, personality disorders are usually diagnosed in early adolescence. Full-fledged bipolar disorder rarely occurs before the age of 20. The pathology of the bipolar is inconsistent. The onset of the manic episode is fast and furious and results in a conspicuous metamorphosis of the patient. With the exception of the Borderline patient, this is not the case in personality disorders.

More about this topic here:

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

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

Vaknin, Sam - Malignant Self Love - Narcissism Revisited - Skopje and Prague, Narcissus Publications, 1999-2006

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

---

---

next:   Misdiagnosing Personality Disorders as Asperger's Disorder

Patients with late stage syphilis are sometimes misdiagnosed with Bipolar Disorder, Narcissistic and Paranoid Personality Disorders. Here's why.

• Watch the video on The Role of Syphilis and the Narcissist 

It is common knowledge that brain disorders, injuries, and traumas are sometimes misdiagnosed as mental health problems. But what about "run of the mill" organic medical conditions? Syphilis provides a fascinating glimpse into the convoluted world of differential diagnoses: the art of telling one form of illness from another.

Syphilis is a venereal (sexually transmitted) disease. It has a few stages and involves unpleasant phenomena such as lesions and skin eruptions. Syphilis can go dormant (latent) for years or even decades before it affects the brain in a condition known as general paresis. Brain tissue is gradually destroyed by the tiny organisms that cause syphilis, the spirochetes. This progressive devastation causes mania, dementia, megalomania (delusions of grandeur), and paranoia.

Even when its existence is suspected, syphilis is difficult to diagnose. Most mental health clinicians are unlikely to try to rule it out. Syphilis in its tertiary (brain consuming) phase produces symptoms that are easily misdiagnosed as Bipolar Disorder combined with the Narcissistic and the Paranoid Personality Disorders.

Syphilitic patients in the tertiary stage are often described as brutal, suspicious, delusional, moody, irritable, raging, lacking empathy, grandiose, and demanding. They are indecisive and absorbed in irrelevant detail one moment and irresponsibly and manically impulsive the next. They exhibit disorganized thinking, transient false beliefs, mental rigidity, and obsessive-compulsive repetitive behaviors.

Fritz Redlich, retired Dean of the Yale Department of Psychiatry published "Hitler: Diagnosis of a Destructive Prophet" in 1998. In it, he describes the final stages of general neurosyphilitic paresis:

 

"... (S)igns and symptoms (include) rapid mental deterioration, psychotic and usually absurdly grandiose behavior..." (p. 231)

Misdiagnosing the Bipolar Disorder as Narcissistic Personality Disorder - click on this link

Misdiagnosing Asperger's Disorder as Narcissistic Personality Disorder - click on this link

Misdiagnosing General Anxiety Disorder (GAD) as Narcissistic Personality Disorder - click on this link

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

 

---

---

next: Misdiagnosing Personality Disorders as Bipolar I Disorder

To figure out if an abuser has a personality disorder, he/she needs to be tested before psychological treatment can begin.

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 the following tests to provide a complete picture of his personality and the roots of his unbridled aggression.

In the court-mandated evaluation phase, you should insist to first find out whether your abuser suffers from mental health disorders. These may well be the - sometimes treatable - roots of his abusive conduct. A qualified mental health diagnostician can determine whether someone suffers from a personality disorder only following lengthy tests and personal interviews.

The predictive power of these tests - often based on literature and scales of traits constructed by scholars - has been hotly disputed. Still, they are far preferable to subjective impressions of the diagnostician which are often amenable to manipulation.

By far the most authoritative and widely used instrument is the Millon Clinical Multiaxial Inventory-III (MCMI-III) - a potent test for personality disorders and attendant anxiety and depression. The third edition was formulated in 1996 by Theodore Millon and Roger Davis and includes 175 items. As many abusers show narcissistic traits, it is advisable to universally administer to them the Narcissistic Personality Inventory (NPI) as well.

Many abusers have a borderline (primitive) organization of personality. It is, therefore, diagnostically helpful to subject them to the Borderline Personality Organization Scale (BPO). Designed in 1985, it sorts the responses of respondents into 30 relevant scales. It indicates the existence of identity diffusion, primitive defenses, and deficient reality testing.

To these one may add 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 whether your abuser suffers from a personality impairment, it is mandatory to understand the way he functions in relationships, copes with intimacy, and responds with abuse to triggers.

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 - especially abusive stratagems - used by members of a dyad (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 and their personality disorders. Offenders are uncanny in their ability to deceive their evaluators.

This is the topic of our next article.

---

---

next: Conning the System

Theoretical description of the sadistic personality. Read sample therapy notes from a man diagnosed with Sadistic Personality Disorder.

Disclaimer

The Sadistic personality disorder was included in the DSM III-TR but removed from the DSM IV and from its text revision, the DSM IV-TR. This was criticized by some scholars, notably Theodore Millon.

Notes of first therapy session with Jared, male, 43, diagnosed with Sadistic Personality Disorder

"A little discipline never hurt nobody." - repeats Jared, clearly amused. Beating a three year old and letting her freeze to near death on your doorstep in subzero temperatures, is this his idea of discipline? "It's one way or getting the message across" - Jared laughs heartily and then composes himself: "Listen, Doc, I am as merciful and compassionate as they come, believe you me. But what I can't stand is cry-babies, weaklings, and whining bitches. Besides, it's fun to see how a little ice does wonders to their sirens."

Why did he force the mother to dump her by now limp and profusely bleeding infant daughter outside the door? If she were a proper caretaker none of this would have happened. He wanted to show her wretched family who is the only boss in the household. "They were getting on my nerves, her mother and sister. They needed some re-education, like in them Chinese camps."- he chuckles. They all claim to be terrified of him and intimidated by his capricious and violent behavior. "I sure hope so!" - he smirks.

The kid says that you pinched her repeatedly and that's why she cried. "I was just kidding with her." Pinching hurts. "Sure does!" - he roars and slaps my shoulder across the desk - "I like you, Doc!" The slap hurt, too. Could he please refrain from doing it in the future? "Whatever turns you own, ma'shrink" - he accepts my interdict jovially.

The mother says that about a year ago you beat the same child and caused her grave injuries because she wouldn't cry when you pinched her and kicked her around. You kept yelling "cry, you bitch, cry." Then you mauled her because she wouldn't cry and now you spanked her because she did cry. "She has to make up her mind and stick to it. I respect that. But she can't change her behavior every time I pinch her. That's why I disciplined her. I want her to have a spine." It seems to me that he is the one who keeps changing the rules. his face darken and he leans forward, whispering hoarsely:

"I like you, Doc, and all - but don't cross the line here or you may get a taste of the same medicine yourself." Is this a threat? He merely glowers at me malevolently. Doesn't he like me any more? "(Expletive deleted) off."

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

---

---

next: The Masochistic Patient ~ back to: Case Studies: Table of Contents

Read about the signs, symptoms and characteristics of Schizotypal Personality Disorder.

Do you believe in UFOs and alien abductions? You may be suffering from the Schizotypal Personality Disorder. Do you believe in the immaculate conception of the Virgin Mary and in the resurrection of her son? Then you are merely a religious person.

In other words, it is OK to believe in certain "supernatural" phenomena just because such beliefs are socially acceptable and widespread. The Schizotypal Personality Disorder is one of the most culture-bound mental health diagnoses in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). Many of the diagnostic criteria of this "personality disorder" refer to behaviors which some say are utterly normative in certain cultures or sub-cultures.

But possessing an idiosyncratic belief system is not enough. The schizotypal must also be a "strange bird". He or she must dress uniquely, and have uncommon thought and speech patterns. Finally, to "qualify" as a schizotypal, one must act bizarre. Critics argue that such lifestyle choices should not constitute a mental illness.

The DSM says that Schizotypals frequently develop ideas of reference. They are erroneously convinced that, behind their back, they are a constant topic of derision, mockery, criticism, or gossip. But this often is the case! Owing to their peculiarities, schizotypals are invariably the butt of jokes, the targets of derision and mockery, and the focus of malicious gossip. In other words, their "ideas of reference" are reality-based, not imaginary and paranoid.

If you ask her nearest and dearest to describe the schizotypal, they would say that she dresses oddly, behaves eccentrically, and appears to be weird. These recurrent encounters with social censure and ridicule cause most schizotypals to become suspicious and even paranoid and to develop persecutory ideation. Consequently, schizotypals may be mistrustful and interact only with first-degree relatives. Schizotypals are more immune to criticism than narcissists or schizoids, but they do tend to avoid social settings, convinced that everyone is "out to get them".

The schizotypal is certain that the world is a hostile and unpredictable place and, thus, best avoided. Same as paranoids, schizotypals do hold and adopt unusual beliefs, "theories", convictions, "scenarios", superstitions, and conspiracies.

I described this facet of the disorder in the Open Site Encyclopedia:

"Although generally not prone to delusions, the schizotypal is steeped in the occult and the esoteric to the exclusion of rational thinking and to the detriment of proper daily functioning.

Some schizotypals report 'supernatural' experiences, including perceptual distortions - such as "out of body" voyages, remote viewing, clairvoyance, telepathy, or recurrent coincidences. They report these events in a private language which is difficult to fathom due to its excessive use of metaphors, vagueness, circumspection, complexity, or stereotypes. The schizotypal's thinking is similarly convoluted and hermetic."

Some schizotypals share traits with narcissists: they believe themselves to be omnipotent and omniscient, for instance. They have magical thinking and ideas of reference and, often, they feel immune to the consequences of their actions (though, unlike the psychopathic narcissist, they do not lack either empathy or conscience). But, unlike the narcissist and more like the paranoid, the schizotypal's reality test is completely impaired.

Read Notes from the therapy of a Schizotypal Patient

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

---

---

next: Five Factor Personality Model

What's it like living with Borderline Personality Disorder? Read therapy notes of female diagnosed with Borderline Personality Disorder, BPD.

• Watch the video on Therapy notes of a Borderline Patient 

Notes of first therapy session with T. Dal, female, 26, diagnosed with Borderline Personality Disorder (BPD)

Dal is an attractive young woman but seems to be unable to maintain a stable sense of self-worth and self-esteem. Her confidence in her ability to "hold on to men" is at a low ebb, having just parted ways with "the love of her life". In the last year alone she confesses to having had six "serious relationships".

Why did they end? "Irreconcilable differences". The commencement of each affair was "a dream come true" and the men were all and one "Prince Charming". But then she invariably found herself in the stormy throes of violent fights over seeming trifles. She tried to "hang on there", but the more she invested in the relationships, the more distant and "vicious" her partners became. Finally, they abandoned her, claiming that they are being "suffocated by her clinging and drama queen antics."

Is she truly a drama queen?

She shrugs and then becomes visibly irritated, her speech slurred and her posture almost violent:

"No one f***s with me. I stand my ground, you get my meaning?" She admits that she physically assaulted three of her last six paramours, hurled things at them, and, amidst uncontrollable rage attacks and temper tantrums, even threatened to kill them. What made her so angry? She can't remember now, but it must have been something really big because, by nature, she is calm and composed.

As she recounts these sad exploits, she alternates between boastful swagger and self-chastising, biting criticism of her own traits and conduct. Her affect swings wildly, in the confines of a single therapy session, between exuberant and fantastic optimism and unbridled gloom.

 

One minute she can conquer the world, careless and "free at last" ("It's their loss. I would have made the perfect wife had they known how to treat me right") - the next instant, she hyperventilates with unsuppressed anxiety, bordering on a panic attack ("I am not getting younger, you know - who would want me when I am forty and penniless?")

Dal likes to "live dangerously, on the edge." She does drugs occasionally - "not a habit, just for recreation", she assures me. She is a shopaholic and often finds herself mired in debts. She went through three personal bankruptcies in her short life and blames the credit card companies for doling out their wares "like so many pushers." She also binges on food, especially when she is stressed or depressed which seems to occur quite often.

She sought therapy because she is having intrusive thoughts about killing herself. Her suicidal ideation often manifests in minor acts of self-injury and self-mutilation (she shows me a pair of pale, patched wrists, more scratched than slashed). Prior to such self-destructive acts, she sometimes hears derisive and contemptuous voices but she know that "they are not real", just reactions to the stress of being the target of persecution and vilification by her former mates.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

 

---

---

next: Adolescent Narcissist ~ back to: Case Studies: Table of Contents

• Watch the video on Abusers: Conning the System

Abusers, people who physically, psychologically, emotionally and sexually abuse others, are notorious con artists who easily deceive mental health professionals. Learn why this happens.

Even a complete battery of tests, administered by experienced professionals sometimes fails to identify abusers and their personality disorders. Offenders are uncanny in their ability to deceive their evaluators. They often succeed in transforming therapists and diagnosticians into four types of collaborators: the adulators, the blissfully ignorant, the self-deceiving, and those deceived by the batterer's conduct or statements.

Abusers co-opt mental health and social welfare workers and compromise them - even when the diagnosis is unequivocal - by flattering them, by emphasizing common traits or a common background, by forming a joint front against the victim of abuse ("shared psychosis"), or by emotionally bribing them. Abusers are master manipulators and exploit the vulnerabilities, traumas, prejudices, and fears of the practitioners to "convert" them to the offender's cause.

I. The Adulators

The adulators are fully aware of the nefarious and damaging aspects of the abuser's behavior but believe that they are more than balanced by his positive traits. In a curious inversion of judgment, they cast the perpetrator as the victim of a smear campaign orchestrated by the abused or attribute the offender's predicament to bigotry.

They mobilize to help the abuser, promote his agenda, shield him from harm, connect him with like-minded people, do his chores for him and, in general, create the conditions and the environment for his ultimate success.

 

II. The Ignorant

As I wrote in "The Guilt of the Abused", it is telling that precious few psychology and psychopathology textbooks dedicate an entire chapter to abuse and violence. Even the most egregious manifestations - such as child sexual abuse - merit a fleeting mention, usually as a sub-chapter in a larger section dedicated to paraphilias or personality disorders.

Abusive behavior did not make it into the diagnostic criteria of mental health disorders, nor were its psychodynamic, cultural and social roots explored in depth. As a result of this deficient education and lacking awareness, most law enforcement officers, judges, counselors, guardians, and mediators are worryingly ignorant about the phenomenon.

Only 4% of hospital emergency room admissions of women in the United States are attributed by staff to domestic violence. The true figure, according to the FBI, is more like 50%. One in three murdered women was done in by her spouse, current or former.

The blissfully ignorant mental health professionals are simply unaware of the "bad sides" of the abuser - and make sure they remain oblivious to them. They look the other way, or pretend that the abuser's behavior is normative, or turn a blind eye to his egregious conduct.

Even therapists sometimes deny a painful reality that contravenes their bias. Some of them maintain a generally rosy outlook premised on the alleged inbred benevolence of Mankind. Others simply cannot tolerate dissonance and discord. They prefer to live in a fantastic world where everything is harmonious and smooth and evil is banished. They react with discomfort or even rage to any information to the contrary and block it out instantly.

Once they form an opinion that the accusations against the abusers are overblown, malicious, and false - it becomes immutable. "I have made up my mind - they seem to be broadcasting - "Now don't confuse me with the facts."

 

III. The Self-Deceivers

The self-deceivers are fully aware of the abuser's transgressions and malice, his indifference, exploitativeness, lack of empathy, and rampant grandiosity - but they prefer to displace the causes, or the effects of such misconduct. They attribute it to externalities ("a rough patch"), or judge it to be temporary. They even go as far as accusing the victim for the offender's lapses, or for defending herself ("she provoked him").

---

---

---

In a feat of cognitive dissonance, they deny any connection between the acts of the abuser and their consequences ("his wife abandoned him because she was promiscuous, not because of anything he did to her"). They are swayed by the batterer's undeniable charm, intelligence, or attractiveness. But the abuser needs not invest resources in converting them to his cause - he does not deceive them. They are self-propelled.

IV. The Deceived

The deceived are deliberately taken for a premeditated ride by the abuser. He feeds them false information, manipulates their judgment, proffers plausible scenarios to account for his indiscretions, soils the opposition, charms them, appeals to their reason, or to their emotions, and promises the moon.

Again, the abuser's incontrovertible powers of persuasion and his impressive personality play a part in this predatory ritual. The deceived are especially hard to deprogram. They are often themselves encumbered with the abuser's traits and find it impossible to admit a mistake, or to atone.

From "The Guilt of the Abused":

Therapists, marriage counselors, mediators, court-appointed guardians, police officers, and judges are human. Some of them are social reactionaries, others are abusers, and a few are themselves spouse abusers. Many things work against the victim facing the justice system and the psychological profession.

Start with denial. Abuse is such a horrid phenomenon that society and its delegates often choose to ignore it or to convert it into a more benign manifestation, typically by pathologizing the situation or the victim - rather than the perpetrator.

A man's home is still his castle and the authorities are loath to intrude.

Most abusers are men and most victims are women. Even the most advanced communities in the world are largely patriarchal. Misogynistic gender stereotypes, superstitions, and prejudices are strong.

Therapists are not immune to these ubiquitous and age-old influences and biases.

They are amenable to the considerable charm, persuasiveness, and manipulativeness of the abuser and to his impressive thespian skills. The abuser offers a plausible rendition of the events and interprets them to his favor. The therapist rarely has a chance to witness an abusive exchange first hand and at close quarters. In contrast, the abused are often on the verge of a nervous breakdown: harassed, unkempt, irritable, impatient, abrasive, and hysterical.

Confronted with this contrast between a polished, self-controlled, and suave abuser and his harried casualties - it is easy to reach the conclusion that the real victim is the abuser, or that both parties abuse each other equally. The prey's acts of self-defense, assertiveness, or insistence on her rights are interpreted as aggression, lability, or a mental health problem.

The profession's propensity to pathologize extends to the wrongdoers as well. Alas, few therapists are equipped to do proper clinical work, including diagnosis.

Abusers are thought by practitioners of psychology to be emotionally disturbed, the twisted outcomes of a history of familial violence and childhood traumas. They are typically diagnosed as suffering from a personality disorder, an inordinately low self-esteem, or codependence coupled with an all-devouring fear of abandonment. Consummate abusers use the right vocabulary and feign the appropriate "emotions" and affect and, thus, sway the evaluator's judgment.

But while the victim's "pathology" works against her - especially in custody battles - the culprit's "illness" works for him, as a mitigating circumstance, especially in criminal proceedings.

---

---

---

In his seminal essay, "Understanding the Batterer in Visitation and Custody Disputes", Lundy Bancroft sums up the asymmetry in favor of the offender:

"Batterers ... adopt the role of a hurt, sensitive man who doesn't understand how things got so bad and just wants to work it all out 'for the good of the children'. He may cry ... and use language that demonstrates considerable insight into his own feelings. He is likely to be skilled at explaining how other people have turned the victim against him, and how she is denying him access to the children as a form of revenge ... He commonly accuses her of having mental health problems, and may state that her family and friends agree with him ... that she is hysterical and that she is promiscuous. The abuser tends to be comfortable lying, having years of practice, and so can sound believable when making baseless statements. The abuser benefits ... when professionals believe that they can "just tell" who is lying and who is telling the truth, and so fail to adequately investigate.

Because of the effects of trauma, the victim of battering will often seem hostile, disjointed, and agitated, while the abuser appears friendly, articulate, and calm. Evaluators are thus tempted to conclude that the victim is the source of the problems in the relationship."

There is little the victim can do to "educate" the therapist or "prove" to him who is the guilty party. Mental health professionals are as ego-centered as the next person. They are emotionally invested in opinions they form or in their interpretation of the abusive relationship. They perceive every disagreement as a challenge to their authority and are likely to pathologize such behavior, labeling it "resistance" (or worse).

In the process of mediation, marital therapy, or evaluation, counselors frequently propose various techniques to ameliorate the abuse or bring it under control. Woe betides the party that dares object or turn these "recommendations" down. Thus, an abuse victim who declines to have any further contact with her batterer - is bound to be chastised by her therapist for obstinately refusing to constructively communicate with her violent spouse.

Better to play ball and adopt the sleek mannerisms of your abuser. Sadly, sometimes the only way to convince your therapist that it is not all in your head and that you are a victim - is by being insincere and by staging a well-calibrated performance, replete with the correct vocabulary. Therapists have Pavlovian reactions to certain phrases and theories and to certain "presenting signs and symptoms" (behaviors during the first few sessions). Learn these - and use them to your advantage. It is your only chance.

This is the topic of our next article.

Note - The Risks of Self-diagnosis and Labeling

The Narcissistic Personality Disorder (NPD) is a disease. It is defined only by and in the Diagnostic and Statistical Manual (DSM). All other "definitions" and compilations of "criteria" are irrelevant and very misleading.

People go around putting together lists of traits and behaviors (usually based on their experience with one person who was never officially diagnosed as a narcissist) and deciding that these lists constitute the essence or definition of narcissism.

People are erroneously using the term "narcissist" to describe every type of abuser or obnoxious and uncouth person. That is wrong. Not all abusers are narcissists.

Only a qualified mental health diagnostician can determine whether someone suffers from Narcissistic Personality Disorder (NPD) and this, following lengthy tests and personal interviews.

It is true that narcissists can mislead even the most experienced professional (see the article above). But this does not mean that laymen possess the ability to diagnose mental health disorders. The same signs and symptoms apply to many psychological problems and differentiating between them takes years of learning and training.

---

---

next: Befriending the System

What defines someone as having Paranoid Personality Disorder? Take a look at the signs, symptoms and traits of the paranoid.

The paranoid's world is hostile, arbitrary, malicious, and unpredictable. Consequently, he or she distrusts others and suspects them. No good deed goes unpunished. Every gesture of goodwill is surely fuelled by ulterior, self-interested and uncharitable motives. Paranoids are firmly convinced that people are out to exploit, harm, get, or deceive them, sometimes just for the fun of it. Evil needs no pretext or context, it is just out there without good or sufficient cause.

These nagging doubts about the loyalty or trustworthiness of others gnaw at the paranoid's mind ceaselessly. No one is spared his constant brooding. His hypervigilance extends to family members, friends, co-workers, and neighbors. Persecutory delusions are common: most paranoids believe that they are at the epicenter of conspiracies and collusions, big and small, quotidian and earth-shattering.

The paranoid's conviction that he is the target of the unwelcome and frightful attentions of unnamed and occult structures and people serves well his grandiosity. Like narcissists, paranoids need to be at the center of attention. They must prove to themselves on an hourly basis that they are of sufficient importance and interest to warrant such persecution.

No wonder that patients with PPD (paranoid personality disorder) are typically socially isolated and considered eccentric.

I describe their existence thus in the Open Site Encyclopedia:

"They may cower at home, planning a defense against perceived attacks, yet may reject any attempts by others to communicate with them. They may become reclusive, maintaining suspicions that others may use information against them. From others, even the most benign gestures, comments, or events, assume threatening proportions, nefarious meanings or malicious intent. Even benign encounters may be misinterpreted as threats.

Paranoid persons may dwell on the trivial. They may be hypersensitive, bear grudges and be unforgiving. Remarks by others may be immediately interpreted as an insult, injury, attack, or slight directed at their personality or reputation, and may provoke aggressive responses. They may eventually be shunned because of their eccentric behavior; moreover, this may include close family members, as well as friends."

Read Notes from the therapy of a Paranoid Patient

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

---

---

next: Schizotypal Personality Disorder

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, and reusable. They are there to fulfill 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 victimize, 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::

"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."

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

Are personality disorders true mental illnesses and  should a person with a personality disorder be entitled to  use the insanity defense after committing a crime?

"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)

Some personality disorders are culture-bound. Critics charge that these "mental illnesses" mostly serve as an organizing social principle and are tools for societal control and coercion. But if personality disorders are not objective clinical entities - what should we make of the insanity defense (NGRI- Not Guilty by Reason of Insanity)?

The insanity defense (when a person is held not responsible for his criminal actions) rests on two pillars of evidence:

1. That the accused was unable to tell right from wrong ("lacked substantial capacity either to appreciate the criminality (wrongfulness) of his conduct" - diminished capacity).

2. That the accused 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".

Still, the "guilty but mentally ill" verdict appears to be a contradiction in terms. All "mentally-ill" people operate within a (usually coherent) worldview, with consistent internal logic, and rules of right and wrong (ethics). The problem is that these private constructs 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. Mental health professionals prefer to talk about an impairment of a "person's perception or understanding of reality".

Reality, however, is a lot more shaded and complex that the rules that purport to apply to it. Some criminals are undoubtedly mentally ill but still maintain a perfect grasp on reality ("reality test"). They are, thus, 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. It is, therefore, not very helpful in distinguishing the criminally insane from the merely insane.

This makes it even more difficult to comprehend what is meant by "mental disease". If some mentally ill patients maintain a grasp on reality, know right from wrong, and can anticipate the outcomes of their actions, are not subject to irresistible impulses (the tests set forth by the American Psychiatric Association) - in what way do they differ from us, "normal" folks? Are personality disorders mental illnesses? Can someone with the Narcissistic Personality Disorder (a narcissist) successfully claim the insanity defense? Are narcissists insane?

This is the topic of our next article.

Click on these links to learn more:

The Myth of Mental Illness

The Insanity Defense

Crime and the Never repenting Narcissist

Serial Killers

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

---

---

next: Is the Narcissist Legally Insane?