Wikimedia Commons by Caravaggio.
Source: Wikimedia Commons by Caravaggio.

Narcissistic Personality Disorder (NPD) and Antisocial Personality Disorder (APD) are two distinct mental disorders and traditionally not typically diagnosed in tandem by clinicians. However, it is clear to many mental health professionals today that APD can include narcissistic traits and that NPD can sometimes include antisocial or sociopathic traits. Such individuals might commonly be described diagnostically as suffering from Antisocial Personality Disorder with Narcissistic Traits, or Narcissistic Personality Disorder with Antisocial Traits. And the occurrence of this combination seems to be on the rise. For this reason, I have proposed the creation of a new hybrid diagnosis of Antisocial/Narcissistic Personality in which, while the criteria for neither one may be completely met, this confluence of symptoms and behaviors together comprise a deceptively destructive, dangerous, and sometimes even deadly character disorder. I refer to this morbid condition as psychopathic narcissism (see my prior posts) to connote the nexus between pathological narcissism and sociopathy. But what is the true nature and etiology of this treacherous intersection between NPD and APD?

To begin with, we would do well to remember that Narcissistic Personality Disorder, like any other mental disorder or specific psychopathology, must, by definition, be a) statistically deviant from the norm, and b) associated with clinically significant distress, impairment or disability or with significant risk of negative consequences to self and/or others. Unlike other mental disorders involving depression or anxiety, for instance, personality disorders such as NPD (or Antisocial Personality Disorder) are less characterized by egodystonic subjective suffering than by suffering inflicted upon others, in the form of cruelty, verbal abusiveness, manipulation, deception, and, in more extreme cases, physical violence. (In my clinical experience, the narcissist does unconsciously suffer from his or her childhood wounds, and, ultimately, from the negative effects on interpersonal relationships engendered by his or her narcissistic defenses. It is commonly only at that critical point that the pathological narcissist is most likely to seek therapy.) 

Having said that, the fact is that narcissism is a pervasive, endemic aspect of contemporary life, and exists to varying degrees in each and every one of us. We all need some measure of healthy narcissism to get on in the world, which is related to self-esteem, confidence, sense of significance, etc. And most of us suffer to some extent from some measure of pathological or neurotic narcissism as well. For example, a great deal of the destructive anger, rage and violence, the animosity between the sexes, and the hypersensitivity to any and all perceived political incorrectness besetting the collective American psyche, springs from pathological narcissism. We live increasingly, as sociologist Christopher Lasch claimed four decades ago, in a "culture of narcissism," one in which narcissism is idealized, worshiped, emulated and rewarded, whether in the world of business, the entertainment industry, or the political arena. Because of this and other reasons, not the least of which is a growing narcissistic tendency in parenting, narcissism has sadly been increasingly normalized in American culture in recent decades. Children of narcissistic parents are prone to become narcissistic themselves: not necessarily due to inherited genetic predisposition, though this may play some part, but primarily because of narcissistic parenting style. 

Psychoanalyst Heinz Kohut, who modified and expanded Freud's original ideas on narcissism, suggests that pathological narcissism is an arrest or distortion of normal, pre-Oedipal development, during which the infant's natural, healthy, primitive or "primary narcissism" is deficiently dealt with or unempathically "mirrored" by the primary caretakers--in most cases, the parents, but particularly, the mother. This so-called "narcissistic wounding" or frustration results in the neurotic perseveration of unresolved infantile narcissism into childhood, adolescence and adulthood. Thus, narcissism in adults may represent a form of "healthy" narcissism either never allowed adequate expression or gratification during childhood or overindulged and insufficiently moderated and socialized, and hence, never outgrown. It is in this sense that the pathologically narcissistic person's often petulant behavior is akin to that of a spoiled or rejected little boy or girl who insists upon having everything their own way, even if that means intimidating, lying and cheating to get it. Or to the profound dread of being hurt, rejected or abandoned again. Indeed, the fatal self-absorption of the mythic young man Narcissus, from whom the clinical term narcissism was derived, is designed to fend off potential rejection via the hostile or aggressive rejection of others. Such neurotic narcissism may manifest somewhat differently in men and women.

It is near impossible to speak meaningfully about pathological narcissism without acknowledging and discussing its close connection with the conscious or unconscious striving for power. (We all seek some sense of power and control in life, but the narcissistic personality is consumed, possessed and driven by this excessive need.) As is so commonly seen in APD, people who suffer (or more aptly, make others suffer) from NPD seek to assert power and control over others, albeit in somewhat more subtle ways. Nonetheless, this power drive can be quite compulsive and unrelenting, motivated by an unquenchable need to overcome profound feelings of powerlessness, stemming usually from childhood. This pathological pursuit of power can be expressed in a broad spectrum of behaviors: from cruelly teasing or bullying a younger sibling, to inflicting physical suffering on insects or family pets, to the abduction, torture, sexual abuse, and sometimes horrific killing of innocent victims by psychopaths. When such individuals seek and successfully attain to positions of power in industry, academia or politics, the results can be catastrophic, since it is especially in the pathologically narcissistic and power-hungry person that "absolute power corrupts absolutely." But this same ruthlessness, sadism, cruelty, and unbridled will to power is played out in the daily lives of petty psychopathic narcissists, wreaking havoc and causing suffering to all those within their smaller sphere of influence. 

Presumably, most individuals who seek to lead others and to partake in the power and status of doing so, much like cult leaders, CEOs, and politicians, are at least partly motivated, often unconsciously, by their immense need for so-called "narcissistic supplies." For attention. For admiration. For adoration. For respect. For love. We all need some of this. But for the narcissist, this incessant need and the drive to satisfy it is never-ending, insatiable and constant. He or she can never get enough, and is therefore, always seeking more compliments, publicity, adoration, power and recognition. Indeed, when this profound need is chronically frustrated, as in the case of most perpetrators of mass shootings, bombings, terrorism and other types of violent attacks on the public, it becomes what I refer to (see my prior posts) as a "wicked rage for recognition." For such individuals, unable to find positive ways to obtain narcissistic supply, there is no limit to what they are willing to do in order to gain that sense of recognition and significance in the eyes of the world. Unable to successfully meet their neurotic needs constructively by becoming famous, they settle for the facile yet nonetheless gratifying goal of infamy. 

Diagnosing well-known politicians like Adolf Hitler or Joseph Stalin (see my prior post), celebrities such as O.J. Simpson, cult leaders like Jim Jones or David Koresh, or infamous criminals like Charles Manson from a distance is a difficult and dubious business, even for experts. Obviously, analyzing or profiling the personality of such a shadowy, enigmatic and elusive figure as Osama bin Laden (now deceased), for example, is an equally difficult task. Nevertheless, in a paper presented at the 25th Annual Scientific Meeting of the International Society of Political Psychology in 2002, Dr. Aubrey Immelman, associate professor of psychology at Minnesota's St. John's University, did just that. Plugging bin Laden's known biographical data into a personality profile using the second edition of the Millon Inventory of Diagnostic Criteria (MIDC), Immelman concluded that "Bin Laden's blend of Ambitious and Dauntless personality patterns suggests the presence of Millon's ‘unprincipled narcissist' syndrome. This composite character complex combines the narcissist's arrogant sense of self-worth, exploitative indifference to the welfare of others, and grandiose expectation of special recognition with the antisocial personality's self-aggrandizement, deficient social conscience, and disregard for the rights of others." Elsewhere, Immelman diagnosed Osama bin Laden--as did psychiatrist Dr. Jerrold Post, the renowned CIA political profiler-- a "malignant narcissist" : a term based on psychoanalyst Otto Kernberg's (1992) conception of malignant narcissism, the core components of which are pathological narcissism, antisocial features, paranoid traits, and destructive aggression. 

At what point, then, does pathological narcissism become not only malignant, but sociopathic? By definition, sociopathy or Antisocial Personality Disorder is a pervasive, pronounced pattern of disregard for and deliberate violation of the rights of others occurring regularly since at least the age of fifteen (DSM-5). Moreover, current diagnostic criteria includes "failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest," "deceitfulness," "reckless disregard for safety of self or others," and, maybe most tellingly, "lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another." A strong sense of conscience is missing. Moreover, as stated in the diagnostic manual of the American Psychiatric Association, the sociopath or psychopath can be disarmingly charming, "excessively opinionated, self-assured, or cocky." There is often a marked history of irritability, anger, rebelliousness, and verbal or physical aggressiveness. (In children and adolescents, this problematic pattern of behavior can be clearly evidenced in Conduct Disorder, the presence of which is a prerequisite for diagnosing APD beyond the age of 18.) Whenever we see some chronic pattern of illegal or destructive behaviors combined with the absence of remorse and appropriate affect, we are likely witnessing, at the very least, what we professionals refer to as "antisocial traits."

Antisocial Personality Disorder--also referred to as sociopathy, psychopathy or dyssocial personality --generally involves, since childhood, a chronic and pathological anger, rage and resentment toward others. As I have suggested elsewhere (see previous post), antisocial personality disorder is, at its core, an anger disorder. Sociopathy centers around a deep-seated hostility toward family, culture, world, destiny, fate, God, reality, and indeed, toward life itself. But the dyssocial personality is highly proficient at masking this underlying and largely unconscious hostility and hatred. They are masterful actors, having honed and practiced their skills since early childhood. Like the narcissistic personality disorder, they have learned to conceal their deeply wounded true selves behind what Winnicott called a "false self." What the world sees in such badly damaged and dangerous individuals is an extremely rigid defensive persona, to employ Jung's pragmatic term, which originates from the dramatic masks worn by stage actors in the ancient Greek theatre. A carefully constructed and meticulously maintained false self, behind which the raging, wounded, depressed true self hides.

It has long been assumed that the antisocial personality--the psychopath--subsequent to having committed a crime, has no real sense of conscience or guilt, owing perhaps to some genetic anomalie or insufficient superego. But I would suggest that the sociopathic conscience is--like the deeper feelings belonging to their long-denied and dissociated true self--still present, but frozen deep beneath the thick, cold ice of the defensive false self. This is why some defendants seem so unperturbed about their evil deeds and the disastrous negative consequences. It is precisely what makes them such charming, charismatic and diabolically convincing con artists, manipulators and liars. And, in some cases, cold-blooded killers.

The primary difference between narcissistic and antisocial personality disorder is always one of degree. Pathological narcissism often includes antisocial proclivities. Sociopathy typically demonstrates narcissistic tendencies. The diagnostic boundary between these two contiguous personality disorders is blurry at best. It has been suggested and substantiated by research that those suffering from antisocial personality disorder--particularly what is called "primary psychopathy"--seek extraordinary levels of stimulation and seem not to learn from experience. It is as if they are addicted to adrenaline, possibly to counteract an underlying chronic depression or to feel anything at all, and so out of touch with their emotions that even normally painful experiences, such as prison time, seem not to deter their bad behavior.

Antisocial personality disorder represents pathological narcissism in its most extreme and destructive form. A sense of narcissistic entitlement is characteristic of both narcissistic and antisocial personality disorder. In the case of antisocial personality disorder, deceitful, manipulative, destructive and aggressive behavior serves the subconscious purpose of causing others to experience the same feelings of fear, rejection, victimization, hurt, terror, abandonment and betrayal as did the perpetrator during his or her own childhood. The rapist, stalker, serial killer: Judging by their behavior, each of these criminals ostensibly shares a conscious belief that they have the absolute right to thrust themselves uninvited into peoples lives and to selfishly exploit others for their own narcissistic ends. But, in reality, this perception presumes a degree of conscious awareness which in most cases is simply not present. They do, however, share in common a distinct lack of empathy with their fellow man, being unwilling or unable to feel compassion toward, nor identify with, the emotions and needs of others. Such grossly inhumane, even monstrous attitudes and actions stem mainly from a combination of compensatory grandiosity and a schizoid-like detachment from their own feelings.

Indeed, a sense of "narcissistic entitlement" is characteristic of both narcissistic and antisocial personality disorder, albeit perhaps for slightly different reasons: for the sociopath, such as Charles Manson, the sense of entitlement stems from feeling that the world owes them for having been so rejecting, whereas the narcissist's sense of entitlement stems mainly from compensatory feelings of grandiosity, superiority and specialness. A feeling of guilt and conscience is typically lacking, especially in sociopathy. And both share in common a distinct lack of empathy with their fellow man, being unwilling or unable to feel compassion toward, nor identify with, the emotions and needs of others, beyond a relatively superficial level of relating. The immense narcissism of criminal defendants like Jodi Arias, Joran van der Sloot, O.J. Simpson, Drew Peterson, and so many others, convinces them that they possess superior intelligence and, therefore, can ultimately outsmart the system. This narcissistic grandiosity regarding their intelligence (which, in my experience, is overestimated and not necessarily commensurate with standardized intelligence testing) can be seen in Jodi's seemingly arrogant and haughty pre-trial proclamation that "no jury will ever convict me." In the same way that van der Sloot's reported compulsive gambling reflected a grandiose, narcissistic overconfidence that he could single-handedly beat the casino system.

Face-saving is one central aspect of pathological narcissism: the concerted, sometimes frantic or desperate effort to preserve and protect one's public persona at all costs. As C.G. Jung observed, we all need a persona, but problems occur when we become overidentified with our persona, when it becomes too one-sided, imbalanced and rigid. In pathological narcissism, this is precisely what has happened: the persona--which has to do not only with what we try to project outwardly to the world but, even more fundamentally, with how we wish to see ourselves--has become a shallow "false self," one which conceals and compensates for what Jung called the shadow. (See my prior post.) We all have a shadow, a dark, unconscious side consisting of those "negative" (or sometimes even repressed positive) parts of our personality we reject, disown, and deem socially or morally unacceptable, reprehensible, evil or dangerous: sexuality, aggression, inferiority feelings, vulnerability, love, healthy narcissism, and the desire for power, for example. In pathological narcissism, this grandiose persona compensates for repressed feelings of inferiority, vulnerability, weakness, smallness, neediness, and must be maintained, preserved and vigorously defended against all challenges. 

Such compulsive face-saving commonly takes the form of exaggeration, obfuscation, manipulation, or careful parsing of the truth, fibbing, fabrication, prevarication, or outright lying when the narcissistic persona is somehow threatened from without or within. In some cases, such elaborate fabrication, lying, and self-deception can attain almost delusional, and, therefore, semi-psychotic proportions, with the person being utterly convinced of the veracity and reality of his or her self-serving falsification. (See my prior post.)  In those individuals whose severe pathological or psychopathic narcissism eventually leads to engaging in immoral, unethical, inappropriate or criminal behavior, the lying becomes at least as much about avoiding assuming responsibility and evading the legal or negative consequences for their evil deeds, considering themselves smarter than or "above the law." In psychopathic narcissism, pathological narcissism crosses the line into antisocial behavior or sociopathy.

Paranoia is another common core component of both narcissism and sociopathy, though it is not considered a requisite diagnostic criterion. Nonetheless, the individual suffering from psychopathic narcissism feels (sometimes due to pervasive childhood trauma) victimized by society and authority, and angrily lashes out against the world which he or she still believes to be "out to get me." Though this underlying paranoia can be subtle, and is not necessarily delusional, and therefore technically psychotic, as in the case of Delusional Disorder or Paranoid Schizophrenia, it can become a pervasive, systematized, rigid and chronic part of the personality, at times of severe stress, sometimes reaching psychotic proportions. A paranoid delusion is, by definition, a psychotic symptom: a fixed, false, irrational conviction not comporting with objective consensual reality but clung to vehemently nonetheless. It is the ultimate form of self-deception, and, can sometimes be adopted by those extremely close to and subservient to the paranoid person in a kind of collective psychosis.

From a diagnostic and evaluative perspective, the crucial question we must ask is always one of degree: Is someone's narcissism pathological, and, if so, to what extent? Does it veer over into the realm of the sociopath? Or possibly even the psychotic? Does his or her narcissistic vulnerability, hypersensitivity and resulting reactive narcissistic rage tend to drive the person to impulsive, self-defeating, vindictive, petty, retaliative speech or acts? Or to suffer (and force others to suffer) from a fundamental lack of empathy? An unwillingness or inability to recognize or identify with the feelings or reality of others? Is he or she overly arrogant, grandiose, self-centered, or interpersonally exploitative, taking advantage of others in order to achieve her or his own selfish desires? Does it potentially impair his or her capacity for mature, measured, rational judgment and decision-making? Under stress or in response to provocation, slight, insult or emotional injury, will the person remain a reasonable and rational adult or will he or she be temporarily taken over or possessed by a narcissistically wounded, frustrated, petulant, irrational little boy or girl, lashing out impulsively against the perceived perpetrator in a fit of primitive, vengeful, raging retribution?

This fundamentally human yet, in NPD, highly exaggerated, talionic response poses perhaps the greatest danger. Narcissistic grandiosity, impulsivity, feelings of entitlement, lack of empathy, inadequate conscience, combined with the susceptibility toward narcissistic rage in reaction to perceived insults or threats and an unrelenting need for revenge or retaliation leading to a paranoid worldview. Here is where pathological narcissism can and does insidiously lead to sociopathy. The psychopathic narcissist creates and maintains his or her own version of reality or Weltanschauung, seen and interpreted through the warped and distorted lens of pathological self-centeredness and self-deception. Certainly we all participate in some degree of self-deception. Reality is made to comport with the narcissist's grandiose and inflated self-image, and those around him or her are pressured to perceive reality in this same way. In some cases, this distortion of reality can become delusional, crossing over the line from neurosis to psychosis.

Crucial to this discussion is the strong correlation between the problems of narcissism, sociopathy, and evil. Perhaps most frightening to face is the fact that evil deeds could potentially be committed by anyone, given the right or wrong set of circumstances. (Recall, for example, the classic psychology experiments by both Milgram and Zimbardo demonstrating this sobering fact, as well as the atrocities ignored and committed by ordinary German citizens during the Holocaust, a phenomenon Hannah Arendt has dubbed the "banality of evil." ) Each of us harbors the innate capacity for evil. Yet we prefer for obvious reasons to deny that disturbing reality, choosing instead to unconsciously project that potentiality for evil behavior, the so-called shadow, onto others--the devil, political opponents or parties, movements, groups, foreign governments, terrorists, immigrants, minorities, religions, women or men--rather than consciously acknowledging it in ourselves. For some, a consciously chosen moral, religious or spiritual persona can serve to mask an unconscious and dangerous dark side, capable of expressing itself destructively in various forms, such as sexual indiscretions or political dirty tricks which must be covered up and denied when discovered. Or much worse.

Another striking similarity between narcissistic and sociopathic individuals is their extraordinary cunning and native intelligence. The ability to deceive and manipulate others toward one's own self-serving ends is one of the hallmarks of sociopathy, and an expression of the profound pathological narcissism underlying it. As convicted killer Joran van der Sloot's now public psychological evaluation from prison suggests, the person suffering from, and cruelly causing others to suffer from what I call psychopathic narcissism, is fundamentally an immature, selfish, self-centered, resentful and raging child inside a powerful adult body. (See my prior post.) They are angry with their parents, angry with authority, angry with God, angry with life. They have been hurt, abused, emotionally wounded, deprived, overindulged, spoiled, abandoned or neglected in various ways--some grossly and some much more subtly--and are still bitterly lashing out against life and others. Against society. Against authority. Like the Joker character played by Heath Ledger in the The Dark Knight (2008), sociopaths sow seeds of chaos and leave destruction in their wake. When you have a pissed-off five or ten-year-old with poor impulse control living in an adult body, with the freedom and power and resources to do just as he or she pleases, you have an extraordinarily dangerous person capable of the most heinous, and, in the case of world leaders, catastrophic evil deeds. Such angry, vindictive, embittered, opportunistic, impulsive and sometimes predatory people see the world as their personal playground, and for some, everyone in it as their next potential victim or conquest. To quote convicted mass murderer Charles Manson, the poster boy for such evil or antisocial tendencies : "I'm still a little five-year-old kid." (See my prior post on the "inner child.")

If violent offenders like Jodi Arias or Joran van der Sloot are the spoiled brats, the self-centered, manipulative, narcissistic individuals many make them out to be, and the bloody killers they both eventually admitted to being, what might have made them so?  In the case of van der Sloot, could his privileged, protected and permissive upbringing have been the primary root of his psychological problems? Extremely negative, traumatic childhood experiences are typically part of the psychopathic narcissist's family history. The severe childhood neglect, abandonment and abuse of Charles Manson is one textbook example. Yet, we must remember, as Sigmund Freud made clear, that during the most crucial phases of personality development in childhood, profound damage or "fixation" can be done not only by getting too little love, attention, gratification of needs, but equally by receiving too much of these necessary positive influences. Children naturally need love, affection, support, attention and recognition. But they also need firm limit-setting, boundaries, appropriate and consistent consequences for bad behavior, discipline, and what developmental psychologists call optimal frustration. Optimal frustration is how children learn to delay gratification, persevere at tasks, develop inner strength and independence, and adapt to what Freud referred to as the "reality principle." When such structure, limit-setting and discipline is lacking, the seeds of psychopathic narcissism find fertile ground in which to grow.

So, to sum up, there can be a very fine, sometimes imperceptible line dividing narcissism and sociopathy, a line which can be crossed over at any time. The sociopath lives on the far side of this line, having bitterly turned against society, repeatedly and often impulsively engaging in illegal activity resulting in multiple arrests, lying, manipulating, conning, deceiving, and aggressive, vindictive behavior aimed at undoing or repaying a hurt and avoiding being "pushed around" by others, particularly by legitimate authority figures. The narcissist, on the other hand, is usually better adapted to the culture, functions at a higher level, is often financially and socially more successful, skirts the law more skillfully, typically avoiding a formal arrest record, chooses to work within the system, outwardly accepting rather than rejecting society, yet still plays by his or her own self-serving and rebellious rules, unceasingly seeks admiration and stimulation, and may be no less vindictive and persistent, albeit sometimes more subtle, in getting even for the smallest of perceived slights. The psychopathic narcissist lies somewhere between these two poles on a spectrum of personality disorder. And, in some ways, psychopathic narcissism may prove to be the most difficult condition to recognize, since it is neither clearly one nor the other, but rather a complex hybrid capable of committing evil subtly and concealing it behind a sophisticated tissue of lies, distractions, denial, prevarication, obfuscation, bullying, intimidation, manipulation, gaslighting, and disinformation. 

How can such exceptional liars be detected? How can these superbly skilled actors be unmasked? Even highly trained and experienced forensic psychologists and psychiatrists are sometimes taken in and conned by these impressive individuals, some of whom can even fool a polygraph examination. In forensic psychology, we have various methods and tests to detect deception or malingering. But clinically, most telling to the seasoned forensic evaluator is discerning the presence of a long-standing pattern (since childhood or adolescence) of deceptiveness, impulsivity, manipulation, irresponsibility, and selfish disregard for (if not outright violation of) others' rights, needs and feelings without remorse, frequently taking the form of unlawful behavior commonly (but not always) leading to arrests. These individuals suffer from psychopathic narcissism. Some manage to consistently outwit the law. And they can be very successful, rising to the pinnacles of power, celebrity and wealth. But in most (though not all) cases, even these clever criminals eventually slip up or get too cocky, resulting in detection, prosecution, and possible incarceration.

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