Bipolar You

The young adult's guide to bipolar depression.

The Relationship Between Narcissism and Bipolar Disorder

Distinctions, similarity and synergy between narcissism and bipolar grandiosity

Someone who presents with narcissistic personality traits can be difficult to distinguish from someone who is experiencing mild to moderate hypomania (bipolar mood elevation less acute than full mania) with grandiose perceptions of self. And while the two may look alike, it’s essential to be able to make a clear distinction between the two. Let's examine these two phenomena more closely.

Narcissism

The term narcissism has unfortunately evolved into a socially pejorative description of personality traits consistent with such adjectives as arrogant, egotistic, insensitive and self-absorbed. The problem with this is that the real clinical implications of narcissism have little to do with negative social traits. The narcissist is just displaying a broad range of adaptations that at one time felt necessary for his or her psychological survival

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Personality is something we all have. It's that unique organization of one's strengths and capabilities, psychological defenses, developmental adaptations, styles of coping as well as genetic predispositions. It's that cluster of characteristics we meet the world with. And it shows amazing endurance and relative stability over time. If someone knew you seven years ago and then met you again today, he or she would notice some physical changes but “how you are” would not likely have undergone much transformation. Your “youness” tends to endure over time.

Some configurations of personality occur in forms that we identify with clinical terms that convey clusters of traits, attitudes and behaviors. Their utility is that they become a kind of clinical shorthand. A lot can be conveyed in a word or two. Maladaptive personality traits cluster in ways that are identifiable and recurrent. The lexicon of personality includes familiar terms such as sociopathy, passive-aggressive, borderline, masochistic and narcissistic, to name a few.

Consider the notion of personality as being like a specific color. Some people may be green; others blue, red or yellow. Some days an individual may be more intensely blue or red, but they don't change from being red to yellow nor can they decide to have a day where they turn off their personality and become monochromatic gray or white.

In its milder form, narcissism is simply a set of one’s personality dynamics that shape how an individual is organized. It's not a "diagnosis" of what's wrong. It's more a description of how someone works. If you consider the narcissist’s emphasis on strengths and social image, it's no surprise that many who display the narcissistic color are people who are highly successful. They are leaders, CEO's, academicians, physicians, actors, lawyers, etc. They lead with their strengths and they don't do well with aspects of weakness or vulnerability. And yet we wouldn’t necessarily say that their narcissistic organization reflects psychopathology. Essentially their life works despite their particular color. But when the coloration is highly saturated; when their personality style truly gets in their way and creates repeated and pervasive interpersonal problems, then their narcissistic organization may cross over into the realm of what's referred to as narcissistic personality disorder. As with most of psychopathology, the behaviors, thoughts, feelings and attitudes reflective of narcissism all exists on a broad continuum of experience.

The real challenge with getting a hold on how one's personality works is that for most individuals the synthesis of all the contributing pieces lies outside of conscious awareness. We don't decide to come forth with all the feelings, perceptions, attitudes and behaviors that fit a particular personality style. The interplay of the many different aspects of our psyche has been finely tuned over many years’ time. Much of how we are just happens automatically.  We might say that over time, the personality cluster has become functionally autonomous.

But how do we become blue, purple, yellow or narcissistic?

The developmental origins of a specific personality organization are not algorithmic. It's not like all people with strong narcissistic traits have been subjected to the same developmental influences. However, there is enough consistency in its pathogenesis to say it does frequently entail an individual's early needs to be developmentally more advanced than one's age, a sense of insufficiency, lack of adequate attunement from primary parental figures and an experience of the developing self that’s diffuse and not well-formed. And yet despite the experience of deficit, the narcissistically organized individual has learned to draw on specific strengths and capacities in order to distance from felt vulnerabilities or weaknesses. If you think about it, it’s actually a remarkable early developmental adaptation.

Narcissistic individuals have developed the capacity to inflate, expand upon and intensify their strengths. They learn to lead with them in such manner that their experience of feeling small or vulnerable is masked by the presentation of just the opposite. The implication here is not that the narcissist's strengths are a sham; but more, that the narcissist is strongly invested in his or her strengths because they are employed in the service of protecting or buttressing the self against the experience of insufficiency. Temporarily, all are fooled by this compensatory counterbalance, including the individual behind the narcissistic mask.

An additional aspect of narcissistic self-perception entails the concept of grandiosity. According to Wikipedia - "Grandiosity refers to an unrealistic sense of superiority - a sustained view of oneself as better than others." Miriam Webster defines grandiosity as "the quality or state of appearing or trying to appear more important or valuable than is the case." These definitions are consistent with what's previously been said about narcissistic flight or avoidance of inadequacy. The avoidance itself is achieved through investment in the grandiose image which offers comforting distance from its opposing reality.

What's so wrong with this picture? Wouldn't we all prefer to feel big rather than little, powerful rather than vulnerable, masterful instead of inept? Yes, of course. But the dilemma is that the narcissist must intensely invest in the defense because any crack in the armor can lead to a precipitous collapse into realms of the self that are intolerable. The personality structure lacks adequate flexibility and the individual is prone to feel rapid onset of acute pain when his or her narcissistic style doesn't work well enough to acquire the love, admiration, power or control the individual was seeking. This pain, brought about by the rapid collapse of defenses, is what we refer to as narcissistic injury.

The unfortunate consequence of the narcissistic style is that people generally like and appreciate individuals who can incorporate vulnerability into their persona. Individuals who consistently need praise and adulation to buttress their esteem and thus avoid feelings of inadequacy can also be interpersonally alienating, and this is where they lose. It's sad that the very strategy employed to elevate others' opinions creates an unintentional disconnect rather than bringing others closer with interest and engagement. If others' could only understand that narcissistic inflation really reflects the extent to which an individual is scared of feeling small and insufficient, then we all might better appreciate the plight the narcissist is faced with.

One other point, and this will help us to better discern narcissism from bipolar symptoms - the narcissistic personality doesn't typically go into remission. We may see variable levels of intensity in the individual's personality style, but as previously mentioned, narcissism is an enduring character style. With enough insight, motivation and self-awareness, it can become modified, usually through psychotherapy, but it doesn't typically resolve, remain absent and then reemerge at some later point in time. This is important when considering the distinctions between narcissism and bipolar disorder.

The therapeutic work with a narcissistically organized individual entails assisting him or her to gradually become more open to the experience of insufficiency that has been historically distanced from. This is no small order. You see, the pathogenesis of pathological personality characteristics is about how individuals have survived their own pain. For many, the potential of relinquishing or mildly altering their way of being is truly frightening because of the degree of emotional pain that needs to be kept at bay. Once the individual learns to accept and experience disowned and painful aspects of self, they can then gradually become integrated into one's experience. If successful with this endeavor, then the individual no longer needs to sustain his or her compensatory behaviors.

The good news here is that the individual's strengths and capabilities do not need to be relinquished. In fact, just the opposite is true. When they no longer serve the function of defense, the strengths and capacities are freed up because they are no longer tied to a compensatory agenda. The individual's rigidity can begin to soften. One can begin to accept that he/she won't always succeed at being superman or superwoman. Once that reality is no longer frightening then the individual becomes freed up to accept themes of vulnerability or weakness which are common to all of us.

Bipolar Grandiosity

Bipolar grandiosity can sometimes masquerade as a representation of narcissism. It can look the same externally and even feel the same from the inside. Such can also lead to misdiagnosis. Even more confounding is the reality that bipolar grandiosity can co-occur along with narcissism and when this is the case then the two symptom sets are prone to synergistically potentiate each other. It's important to distinguish between the two in order to avoid misdiagnosis and identify specific treatment approaches required for each.

Let's start by clarifying bipolar grandiosity. We typically see its presence during the hypomania and/or mania associated with bipolar mood elevation. When individuals with bipolar disorder experience elevated mood, they may have experiences of well-being which include euphoric mood, elevated energy, highly optimistic outlook, accelerated thought processes and increased creativity. In many respects they feel a bit super-human in that the combination of symptoms during mood elevation may enable the bipolar individuals to function above their baseline in certain realms. When thoughts are moving faster some cognitive connections happen more readily. When creativity is intensified because of enhanced cognition and flood of emotion that accompanies hypomania, the outcome can lead to very unique creative processes. There's also the irony that sometimes the end product is not at all unique or special, but the experience of mood elevation may sufficiently alter self-perception such that the individual thinks he or she is producing something truly unique, specialized and even superior. Taken to the extreme as with instances of manic psychosis, these grandiose self-perceptions may become delusional in nature. The individual truly believes he or she is the messiah, the next contemporary Einstein or perhaps a reincarnated Leonardo da Vinci.

The point is whether mood elevation yields enhanced mental and creative processes or whether it simply yields the perception that such is occurring, the bipolar individual in the midst of mood elevation often perceives that he or she is capable of unique greatness. This is the transient grandiosity that we see in bipolar disorder.

Differentiating Bipolar Grandiosity from Narcissistic Grandiosity

Bipolar grandiosity occurs in conjunction with multiple other symptoms that accompany hypomania and/or mania. What's important is that hypomanic and/or manic symptoms, including grandiosity, are all mood-phase specific. As such they do not endure over time and they certainly are not present during bipolar depression where low self-esteem tends to be the dominant filter through which most self-appraisal occurs.

Conversely, the narcissist's grandiose self-perception is more enduring. The experience of superiority is called into play with enough frequency that it's an integral aspect of the individual's self-perception. Consider interacting with two different individuals: one with bipolar hypomanic grandiosity and the other with narcissistic grandiosity. The interactions may actually have a similar feel to them. Perhaps the one identifiable distinction is that the bipolar individual is usually experiencing strongly elevated energy along with elevated mood whereas the grandiose narcissist will experience their inflation on a psychic level, but he or she may not feel like they have three times their normal amount of physical energy.

One last key distinction: unless there is a co-morbid psychosis or delusional disorder, the narcissist's grandiosity does not usually reflect delusional properties. The messianic, Eisnsteinian, reincarnational manifestations of grandiosity mostly occur during manic psychosis and are not present in typical narcissism. And if, in unusual circumstances, the narcissist does experience delusional self-perceptions, then he or she lives at the more extreme end of the narcissistic personality continuum.

Comorbidity of Narcissism and Bipolar Disorder

It is estimated that approximately 5% of those with bipolar disorder (BD) also have co-morbid narcissistic personality disorder (NPD). That is roughly one out of every 20 bipolar individuals also has NPD.

When this occurs, the two disorders can potentiate each other. Imagine the bipolar disordered narcissist who begins to experience an upswing in mood. Mental processes begin to move faster, energy is up and emotions progress towards euphoria and strong optimism. The narcissistic aspects of the personality absolutely welcome this kind of elevation because it provides the inflation and/or elevation that fuels core aspects of the narcissistic personality. Essentially narcissistic grandiosity is fed by bipolar elevation and vice versa.

So what's problematic about this?  The person with bipolar disorder has to learn how to recognize the onset of hypomania. When this occurs the possibility then exists for the individual to try to limit or level out the upward progression of mood and energy. Typically this will occur through medication adjustments, regulating sleep and refraining from choices that further contribute to the mental and physical activation of mood elevation. BUT ... this requires the bipolar individual to perceive that the progression of positive mood is not necessarily a positive thing! When we add narcissism to the mix, the individual's ability to recognize what’s adaptive vs. maladaptive becomes even more difficult as the action of narcissistic defenses neatly fits much of what occurs during bipolar mood elevation and makes self-observation with accuracy nearly impossible.

Managing these issues in treatment really is the purview of psychotherapy. Medication may be necessary to help level things out but it's not going to help you understand how the issues of mood and personality converge within one's psyche. Approaching narcissism in psychotherapy is a complex endeavor with a large range of variables that make the process different for each individual.

If your own experience resonates with any of the preceding content then I strongly encourage you to explore the issues further with a mental health professional who is well versed in the intersect between mood disorders and personality.

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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com

Russ Federman, Ph.D., A.B.P.P. is in private practice in Charlottesville, VA specializing in psychotherapy with individuals having bipolar disorder.

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