Can Someone Have Two or More Personality Disorders?

One of the unfortunate things about the current state of personality disorder diagnosis is that there are too many different competing systems. Each system is more or less internally consistent, but different systems cannot be combined and used together. This is mainly because they are based on different theories and are designed for different purposes.

In one system, it may be possible to have a valid diagnosis of two or more different personality disorders, and in another system, that would be impossible. This makes it very difficult for the general public to understand which sources to trust and why the experts disagree about questions like:

• Can clients have more than one personality disorder?
• How many different personality disorders are there?
• How should clinicians diagnose personality disorders?

Therefore, anyone discussing personality disorders needs to specify the system they are using and why they chose it.

Different Systems of Diagnosis for Personality Disorders

Let me give you two examples of diagnostic systems currently in use that are at opposite ends of the diagnostic spectrum as to whether someone can have two or more personality disorders at the same time. The first is the DSM-5, and the second, the one I use, is James F. Masterson’s developmental, self, and object relations system.

The DSM-5

The DSM-5 is a diagnostic manual that translates personality disorder diagnoses into numbers that can be used for insurance reimbursement or in hospital or clinic charts. It is designed so that medical professionals who are untrained in diagnosing personality disorders can more easily do so.

To that end, it only uses lists of observable behaviors and symptoms and their frequency. It ignores other potentially more important information, such as the clients’ motives for the behaviors, because these cannot be reduced to something easily observed and counted.

The DSM is updated every few years. A group of mental health experts gets together and argues with each other until they find a compromise about how personality disorders should be defined and what type of organizational system to use with the new edition (APA, 2013).

The Cluster System

The DSM-5 expands the usual number of personality disorders to 10 different diagnoses with some overlapping characteristics and assigns them to three different cluster categories:

Cluster A = Odd or Eccentric Disorders

Cluster B = Dramatic, Emotional, or Erratic Disorders

Cluster C = Anxious or Fearful Disorders

The DSM-5 has been criticized for having too many personality disorders and using the concept of comorbidity to explain the overlap. Its system is not designed to identify the best treatment, only to get a diagnosis for a form.

James F. Masterson’s Developmental, Self, and Object Relations Diagnostic System

The system I use is based on the object relations approach of James F. Masterson. In that system, borderline personality disorder, narcissistic personality disorder, and schizoid personality disorder are totally independent and not overlapping diagnoses. Under each of these three categories are listed each diagnosis's main recognized subtypes (Masterson, 1981).

Example: Narcissistic personality disorder in Masterson’s system has three basic subtypes. Some of Masterson’s subtypes are called by different names by other theorists, adding to the confusion. So, I will list them below with the common names other theorists might use.

Exhibitionist

This is the one narcissistic subtype that most theorists can agree on. The exhibitionist is what most people think of when they hear the word narcissist—an arrogant show-off who exhibits himself or herself for admiration and expects to be treated as special.

Style: Overt—Easy to see the narcissistic traits and behaviors.

Closet Narcissist

People with this subtype are unable to manifest the fake grandiosity and apparent self-confidence of the exhibitionist. They want to avoid the spotlight because they fear being exposed as fake or inadequate. They often get their narcissistic supplies indirectly through their association with people or things that they admire (Masterson, 1993).

Paul Wink (1991) wrote a very influential article in which he called this subtype a “vulnerable narcissist.”

Style: Covert—Harder to recognize as a narcissist because more obviously insecure and tries to hide their desire to be special. More likely to express envy. Some theorists simply call this subtype covert narcissists.

Devaluing Narcissist

This subtype is the most destructive because people with it prefer to get their narcissistic supplies from sadistically destroying other people’s self-esteem and anything that they create or enjoy.

Most theorists refer to this subtype as a “malignant narcissist.” I prefer the term malignant to Masterson’s devaluing because all people with NPD devalue other people.

Style: Overt or Covert

3 Buildings With a Common Basement

Ralph Klein, the former director of training at the Masterson Institute, taught us a simple way to understand the three main personality disorders and the group of lower functioning people with personality disorders who cannot be neatly categorized because they present in a much more confused and unstable manner. He described it this way:

Imagine three tall separate buildings with a common basement connecting them. There is the Borderline building, the Narcissist building, and the Schizoid building. The higher floors are occupied by higher-functioning individuals with these diagnoses.

Klein went on to say that everyone who was able to work out a stable and predictable “deal” with their parents got to live in one of the individual buildings.

The Basic Borderline Deal: I will never become a separate adult and leave you. I will be compliant and stay childlike, and in return, you will love me and not abandon me.

The Basic Narcissist Deal: I will enhance your self-esteem through my achievements. If you want me to, I will be your admiring audience. In return, you will support my self-esteem and not devalue me.

The Basic Schizoid Deal: I will let you use me as a tool. I will accept that I can expect no support or protection from you. In return, you will not expel me from the family.

As you can see, the Schizoid Deal has the fewest benefits.

However, as bad as the above “deals” are, at least the child grows up in a fairly consistent environment and knows what to expect from his or her caregivers.

The Basement People

These are the children who grow up in such chaotic environments that no clear deal is possible. Think of the children of drug addicts or children who grow up in multiple foster homes.

They run back and forth in the common basement under the three buildings and tend to display a changing mix of borderline, narcissistic, or schizoid traits. They present in therapy with a much more confusing diagnostic picture than the people in the three buildings who had been able to make a relatively stable deal with their parents.

You could theoretically describe them as having comorbid personality disorders, but that would make them sound more stable than they actually are.

Summary

Whether someone can qualify for two or more separate personality disorders depends on the system of diagnosis being used. I find James F. Masterson’s system of diagnosis the most useful. The DSM-5 and other systems that allow for multiple diagnoses make it harder for the therapist to choose the right treatment.

If you are looking for a professional diagnosis because you suspect that you or someone you know might have a personality disorder, and want a diagnosis to help choose the right type of therapy, you might want to focus on choosing a therapist whose system of diagnosis makes sense in this context. Not all systems of diagnosis are invented with treatment in mind.