How and Why to Diagnose Psychopathic Narcissism

When a mental disorder is defined by suffering inflicted upon others.

Posted Jan 08, 2018

There has been much discussion recently, here at PT and elsewhere, regarding whether or not President Donald Trump presumably meets the diagnostic criteria for Narcissistic Personality Disorder, Antisocial Personality Disorder, or, as some suggest, perhaps even some sort of major or minor Neurocognitive Disorder, such as senile dementia, something entirely different. Additionally, we have heated debate both within and without the mental health profession about the very nature and validity of so-called mental disorders in general, as well as whether it is ethical and appropriate to diagnose a still-living public figure from afar, without the benefit of having actually formally evaluated that individual in person, as is customary. (See my prior post.)

By "evaluating," I minimally mean meeting the person face-to-face (including via video conference), directly interacting with him or her for some significant time (my initial consultations/evaluations take 90-120 minutes), identifying the presenting problem or precipitant for the evaluation, taking a detailed psychiatric history, substance abuse history, some family history, as well as a recent history of any subjective symptoms or complaints, and assessing, through the utilization of at least a Mental Status Examination—and sometimes (but not necessarily always) other various standardized psychological or neuropsychological tests (especially when detecting the possible presence of a neurocognitive disorder)—the person's current, here-and-now mental status, including cognitive functioning such as memory and concentration, sleep, appetite, sexual drive, mood, affect, suicidal or homicidal ideation, and the possible presence of psychotic symptoms such as delusions and/or hallucinations.

Conducting such evaluations is what psychiatrists, clinical psychologists, and other licensed mental health professionals are more or less trained to do. Arriving at any formal diagnosis is dependent upon the data gleaned from this evaluation, though it is not uncommon (at least for me) to defer assigning a psychiatric diagnosis to someone even after such a formal evaluation due to insufficient or conflicting information. Diagnosing is a serious, difficult, and potentially consequential process, not to be taken lightly. It is a mixture of science, skill, and art, and is, by definition, to be engaged in only by licensed or supervised clinicians. This is why assigning a diagnosis to contemporary public figures without having examined them (or at least having access to the results of someone else's clinical evaluation) is a highly dubious proposition. I am not saying that a seasoned clinician cannot observe certain tell-tale signs and behaviors of a particular condition and proffer some educated guess as to a diagnosis. Only that this is all it will be: an educated guess, a sophisticated surmise, based on extremely limited and insufficient information.

Having said that, according to a fascinating 2006 psychobiographical study by Duke University Medical Center of 37 former U.S. presidents' lives, a stunning 50 percent of them allegedly suffered from some sort of diagnosable mental illness, including major depression, bipolar disorder, substance abuse, and anxiety disorders—many manifesting symptoms during their presidential tenures. The list includes some of our greatest presidents, like Thomas Jefferson and Abraham Lincoln. So, clearly, merely manifesting a mental disorder or certain symptomatology does not, in and of itself, disqualify someone from serving as president. Or from doing it well. It is, rather, the specific psychopathologies increasingly cited collectively by clearly concerned and largely well-intentioned clinicians—narcissistic personality disorder, antisocial personality disorder, delusional disorder, dementia, etc.—and attributed to President Trump from afar that is at issue here.

Fellow PT blogger Allen Frances, a prominent psychiatrist intimately involved in the creation of official diagnostic criteria for the American Psychiatric Association, has publicly argued that since, by definition, a mental disorder must "cause clinically significant distress or impairment," a diagnosis of Narcissistic Personality Disorder cannot be accurately applied to President Trump, whom Frances sees as not having suffered from his symptoms at all. In fact, quite the contrary. (See his post here.) Be that as it may, this is generally so for most mental disorders. But, in point of fact, the most recent version of APA's diagnostic manual, DSM-5, defines a mental disorder as follows: "A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities" (p. 4).

By this current definition, a mental disorder can be diagnosed based on the objective observation of certain dysfunctional signs or symptoms of "disability" in social or occupational activities, even though there may not be evidence of subjective distress or suffering. Some suggest that the President's behavior is indicative of some degree of disability or dysfunction in his social and current occupational (President of the United States) activities. But, to whatever extent this is true, these symptoms are not, unto themselves, sufficiently severe to warrant an official diagnosis. Not yet, and not without further evaluation. Moreover, as the DSM-5 explicitly points out, "The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. Although a systematic check for the presence of these criteria as they apply to each patient will assure a more reliable assessment, the relative severity and valence of individual criteria and their contribution to a diagnosis require clinical judgment" (p. 3).

While when diagnosing Major Depression or Panic Disorder, for example, we clinicians place emphasis on the person's subjective experience of suffering, this is not necessarily the case in diagnosing certain other mental disorders such as  substance abuse, psychotic or personality disorders. The reason for this is that such individuals frequently tend to deny having a problem or suffering from it. Typically, it is not until the alcoholic "bottoms out," or the schizophrenic must be acutely hospitalized, or the narcissist loses his or her status, or the sociopath is arrested and incarcerated, that their subjective suffering finally surfaces. But we are sometimes called upon to diagnose these conditions prior to that happening. Thus, in such cases, the diagnosis is based not on the person's subjective report of "significant distress," but rather on a more objective assessment of inferred suffering or functional "impairment," negative consequences, and, in the case of narcissistic and antisocial symptoms, on distress or suffering inflicted upon others by the patient's behavior along with negative consequences resulting from these actions. 

Narcissistic Personality Disorder, for instance, like any other mental disorder or specific psychopathology, must, by definition, in order to be properly diagnosed, 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. Indeed, unlike most other mental disorders, 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, bullying, manipulation, deception, and, in more extreme cases, physical violence. (In my own clinical experience as a forensic psychologist, 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 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 serial 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 sociopaths, wreaking havoc and causing suffering to all those within their smaller sphere of influence.

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. As stated in the DSM, 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 clinicians 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 posts and my book Anger, Madness, and the Daimonic), antisocial personality disorder is, at its core, an anger disorder. Sociopathy centers around a deep-seated hostility or resentment 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 person with 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 theater. A carefully constructed and meticulously cultivated and 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 and buried deep beneath the thick, cold ice of the defensive false self. This is why some defendants seen by forensic psychologists or psychiatrists 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 expresses 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, inferiority, rejection, victimization, hurt, terror, abandonment, and betrayal as did the perpetrator during his or her own childhood. The sexual abuser, 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 people's lives and to selfishly exploit others for their own narcissistic ends. (We see this evidenced in the recent rash of testimony about the inappropriate sexual behavior of such sometimes powerful and influential individuals.) 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.

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, more to the point, force others to suffer) from a fundamental lack of empathy? Kindness? Compassion? 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 opportunistic 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 an enraged, frustrated, petulant, irrational little boy or girl, lashing out impulsively against the perceived perpetrator in a fit of primitive, vengeful 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 and compulsive 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, 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. And that delusional belief system may be shared and defended to some degree by those surrounding and supporting the psychopathic narcissist. (See my prior post.)

So, to sum up, there can be a very fine, sometimes imperceptible line dividing narcissism and sociopathy, a line that 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. What I call the "psychopathic narcissist" lies somewhere between these two poles on a spectrum of personality disorder. And, in some ways, my proposed diagnostic term of psychopathic narcissism may prove to be the most difficult condition to recognize and properly diagnose, 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. 

Even highly trained and experienced forensic psychologists and psychiatrists are sometimes taken in and conned by these impressive individuals, some of whom can coolly fool a polygraph examination. Many manage to consistently outwit the law. Deceive their spouses. Con their family and friends. 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. Negative consequences. That is when their subjective suffering really begins to show itself. And it is not until then, often after repeated and increasingly negative consequences, that they finally start to suffer sufficiently to seek help or come to the attention of clinicians and are formally diagnosed. But, tragically, for most—and particularly for those upon whom they have inflicted suffering—that is a little late in the game.