Dear colleagues, my name is Sam Vaknin, and I am the author of Malignant Self-Love: Narcissism Revisited, and other books about personality disorders.
I am also a visiting professor of psychology in Southern Federal University, Rostov-on-Don, Russian Federation, and a professor of finance and psychology in SIAS-CIAPS, the Centre for International Advanced and Professional Studies.
Welcome to the Fourth World Congress on Neuropsychiatry, Sleep Disorders, and Medicine, held in November 2019, Rome, Italy.
This is my video presentation, and it will focus on psychosis, delusions, and personality disorders.
But first, let us try to understand the very concept of psychosis.
Psychosis is a chaotic form of thinking that is a result of a severely impaired reality test. The patient cannot tell inner fantasy from outside reality and internal objects from external objects.
Some psychotic states are short-lived and transient. They're called micro-episodes. These last from a few hours, or three minutes even, to a few days, and sometimes they are reactions to stress. Psychotic micro-episodes are common in certain personality disorders, most notably borderline and schizotypal personality disorders. But even narcissists have psychotic micro-episodes if they are deprived of narcissistic supply, something I will discuss later.
Persistent psychosis are a kind of fixture of the patient's mental life and manifest for months or years.
Psychotics are fully aware of events and people out there. They cannot, however, separate data and experiences originating in the outside world from information generated by internal mental processes.
It's like they have no boundary, like they kind of flow into reality, and reality flows into them. They confuse the external universe with their inner emotions, cognitions, beliefs, preconceptions, fears, expectations, and representations.
Similarly, patients suffering from narcissistic personality disorder, and to a lesser extent antisocial and histrionic personality disorders, these patients fail to grasp others as full-fledged entities. They regard even their nearest and dearest as cardboard cutouts, two-dimensional representations, introjects, or symbols. They treat other people as instruments of gratification, functional automata, or extensions of themselves.
Consequently, both psychotics and the personality disorder have a distorted view of reality. They are not rational. No amount of objective evidence can cause them to doubt or to reject their hypotheses and convictions.
Full-fledged psychosis involves complex and ever more bizarre delusions, and their unwillingness to confront and consider contrary data and information, a kind of confirmation bias gone awry. It's a preoccupation with subjective rather than objective. Thought becomes utterly disorganized and fantastic.
There is a thin line separating the nonpsychotic from the psychotic perception and ideation.
On this spectrum, we also find schizotypal and paranoid personality disorders.
The Diagnostic and Statistical Manual defines psychosis as restricted to delusions or prominent hallucinations, with hallucinations occurring in the absence of insight into their pathological nature.
But what are delusions and hallucinations and how do they differ?
A delusion is a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.
A hallucination is a sensory perception that has the compelling sense of reality over true perception, but that occurs without external stimulation of the relevant sensory organ.
Delusion is therefore a belief. It's an idea or a conviction firmly held despite abundant information to the contrary. The partial or complete loss of reality test is the first indication of a psychotic state or a psychotic episode. Beliefs, ideas or convictions shared by other people, members of the same collective, are not strictly speaking delusions.
Conspiracy theories, for example, are not delusions, although maybe hallmarks of a form of psychosis called shared psychotic disorder in cults, for example.
There are many types of delusions. Start with a paranoid delusion to believe that one is being controlled or persecuted by stealth powers and conspiracies. This is common in the paranoid, antisocial, narcissistic, borderline, avoidant, and dependent personality disorders.
Then there is the grandiose magical kind of delusion. It is a conviction that one is important, omnipotent, possessed of occult powers or a historic figure. Narcissists invariably harbor such delusions.
Another form of delusion is the referential delusion, also known as idea of reference or referential ideation. The belief that external objective events carry hidden or coded messages, or that one is the subject of discussion, derision, or opprobrium, even by total strangers. This is common in avoidant, schizoid, schizotypal, narcissistic, and borderline personality disorders.
Hallucinations are false perceptions based on false sensa, false sensory input, not triggered by any external event or entity. The patient is usually not psychotic. He is aware that what he sees, smells, feels, or hears is not there.
Still, some psychotic states are accompanied by hallucinations. For example, fornication, the feeling that bugs or ants are crawling over or under one's skin.
There are a few classes of hallucinations.
There's auditory hallucinations, the false perception of voices and sounds, such as buzzing, humming, radio transmissions, whispering, motor noises, and so on.
There's gustatory hallucinations, the false perception of taste.
Olfactory hallucinations, the false perception of smell and scent, burning flesh, candles.
Somatic hallucinations, the false perception of processes and events that are happening inside the body or to the body. Example, piercing objects, electricity running through one's extremities, and so on. Usually, somatic hallucinations are supported by an appropriate and relevant delusional content.
Tactile hallucinations is the false sensation of being touched or crawled upon or that events and processes are taking place under one's skin, usually supported by appropriate and relevant delusional content.
Then there's visual hallucinations, the false perception of objects, people, or events in broad daylight or in an illuminated environment with eyes wide open.
There is hypnagogic and hypnopompic hallucinations, images and trains of events experienced while falling asleep or when waking up, not hallucinations in the strict sense of the word.
So hallucinations are common in schizophrenia, affective disorders, and mental health disorders with organic origins. Hallucinations are also common in drug and alcohol withdrawal and among substance abuses.
Pathological narcissism is a defense mechanism intended to isolate the narcissist from his environment and to shield him from pain, hurt, injury, both real and imagined.
Hence, the construct of false self, an all pervasive psychological concept which generally or gradually displaces the narcissist's true self. It is a work of fiction intended to elicit praise and deflect criticism.
The unintended consequence of this fictitious existence is a diminishing ability to grasp reality correctly and to cope with it effectively. Self-efficacy is affected and a sense of agency.
Narcissistic supply replaces genuine, veritable and tested feedback. Analysis, disagreement and uncomfortable facts are screened out. Layers of bias and prejudice distort the narcissist's experience.
Yet deep inside the narcissist is aware that his life is an artifact, a confabulated sham, a vulnerable cocoon. The world is inexorably and repeatedly intrusive, intrudes upon these ramshackle battlements, reminding the narcissist of the fantastic and feeble nature of curiosity. And this is the much dreaded grandiosity gap.
To avoid the agonizing realization of his failed defeat-strone biography, the narcissist resorts to reality substitutes. The dynamics are simple.
As the narcissist grows older, his sources of supply become scarcer and his grandiosity gap yawns wider. Mortified by the prospect of facing this actuality, the narcissist withdraws even deeper into a dreamland of concocted accomplishments, famed omnipotence and omniscience, and a kind of bratish entitlement.
The narcissist's reality substitutes fulfill two functions. They help him to rationally ignore painful realities with impunity, and they prefer an alternative universe, a virtual reality, in which the narcissist reigns supreme and emerges triumphant all the time.
The most common form of denial involves persecutory delusions and a persecutory object. I describe these in several of my videos on my YouTube channel.
The narcissist perceives slights and insults when none were intended. He is hypervigilant. He becomes subject to ideas of reference. People are gossiping about him, mocking him, prying into his affairs, I don't know, cracking his email.
He is convinced that he is the center of malign and malintentioned attention. People are conspiring to humiliate him, to punish him, to obscure with his property, to delude him, to impoverish him, to confine him physically or intellectually, to censor him, to impose on his time, to force him to action or to inaction, to frighten him, coerce him, surround him, beseech him, change his mind, part with his values, murder him, abscond with his property, and so on and so forth.
The narcissist's paranoid narrative serves as an organizing principle. It structures his here and now and gives meaning to his life. It aggrandizes him as worthy of being persecuted.
The mere battle with his demons is an achievement not to be sniggered at. By overcoming his so-called enemies, the narcissist emerges and powerful, a happy ending, a happy grandiose ending.
The narcissist self-inflicted paranoia, objections of threatening internal objects and processes, the persecutory object, legitimizes, justifies, and explains his abrupt, comprehensive, and rude withdrawal from a nominal and unappreciative world.
The narcissist's pronounced misanthropy, fortified by these oppressive thoughts, renders him a schizoid, devoid of all social contact, except the most necessary and the ineluctable.
But even as the narcissist divorces his environment, he remains aggressive or even violent.
The final phase of narcissism involves verbal, psychological, situational, and mercifully more rarely, physical abuse directed at his foes, at his inferiors. It is a combination of a creeping mode of psychosis, the sad and unavoidable outcome of a choice made long ago to forgo the real in favor of the surreal.
One of the most important symptoms of pathological narcissism, narcissistic personality disorder, is grandiosity.
Grandiose fantasies, the megalomaniacal delusions of grandeur, permeate every aspect of the narcissist personality. They are the reason that the narcissist feels entitled to special treatment, which is typically incommensurate with his real life accomplishments.
The grandiosity gap is the abyss between the narcissist's self-image as reified by the false self and reality.
When narcissistic supply is deficient, the narcissist decomposes and he acts out in a variety of ways.
Narcissists often experience psychotic micro episodes during therapy, for example, or when they suffer narcissistic injuries in a life crisis.
But can the narcissist go over the edge? Do narcissists ever become truly and fully psychotic?
Let's start with some terminology.
As we said, the narrow definition of psychosis is restricted to delusions of prominent hallucinations, with the hallucinations appearing the absence of insight into the pathological nature.
And we have defined delusions and hallucinations before.
Granted, the narcissist's hold on reality is tenuous. Narcissists sometimes fail the reality test. They have an impaired reality test.
Admittedly, narcissists often seem to believe in their own confabulations. They are unaware of the pathological nature and origin of their self delusions and are therefore technically delusional, though they rarely suffer from hallucinations, disorganized speech, or disorganized or catatonic behavior.
In the strictest sense of the word, narcissists do appear to be psychotic, though.
But actually, in my view, they are not.
There is a quantitative and qualitative difference between benign, though well entrenched, self-deception, malignant con artistry, and losing it.
Pathological narcissism should not be construed as a form of psychosis only because the narcissist is usually fully aware of the difference between true and false, real and make-believe. They are invented and the extant, right and wrong.
The narcissist consciously chooses to adopt one version of the events, an aggrandizing narrative, fairytale evidence, what-if counterfactual life is emotionally invested in this personal myth.
The narcissist feels better as fiction than as fact, but he never loses sight of the fact that it is all just fiction.
So pathological narcissism should not be construed as a form of psychosis.
And throughout, the narcissist is in full control of his faculties, cognizant of his choices and goal-oriented. His behavior is intentional, directional, is manipulated, and his delusions are in the service of his stratagems, has his chameleon-like ability to change guises, his conductand his convictions on a dime.
Again, not typical of psychotics.
Narcissistic delusions rarely persist in the face of blanket opposition and reams of evidence to the contrary. The narcissist usually tries to convert his social milieu to his point of view. He attempts to condition his nearest and dearest to positively reinforce this delusion of the false self.
But if he fails, he modifies his profile on the fly. He plays it by ear. His false self is extemporaneous, perpetual work of art, permanently reconstructed in a reiterative process designed around intricate and complex feedback loops, again utterly and atypical when we deal with psychotics.
So I would say that narcissism is not psychosis.
Though the narcissistic personality is rigid, its content is always in flux. Narcissists forever reinvent themselves, adopt their consumption of narcissistic supply to the marketplace.
Narcissists are attuned to the needs of their suppliers. Like the performers that they are, they resonate with their audience. They give the audience what it expects and wants. They are efficient instruments for the extraction and consumption of human reactions.
As a result of this interminable process of fine tuning, narcissists have no loyalties, no values, no doctrines, no affiliations, no beliefs, and no convictions. The only constraint is their addiction to human attention, positive or negative.
Psychotics, by comparison, are fixated on a certain view of the world and their place in it. They ignore any and all information that might challenge their delusions.
Gradually, psychotics retreat into the inner resources of their tormented minds and they become dysfunctional.
Narcissists cannot afford to shut out the world because they so heavily depend on the world for the regulation of their labile sense of self-worth.
Owing to this dependence, narcissists are hypersensitive, hypervigilant, alert to every bit of new data. They are continuously busy rearranging their self-delusions to incorporate new information in an egosyntonic manner.
And this is why narcissistic personality disorder is insufficient grounds for claiming diminished capacity in an insanity defense.
Narcissists are never divorced from reality the way psychotics are. They crave reality. They need it. They consume it in order to maintain the precarious balance of their disorganized borderline psychotic personality.
All narcissists, even the freakiest ones, can tell right from wrong, act with intent, and are in full control of their faculties and actions.
Ferenczi and Sandor wrote in Notes and Fragments, International Journal of Psychoanalysis, volume 30, 1949, page 234.
I quote, a surprising fact in the process of self-splitting is the sudden change of the object relation that has become intolerable into narcissism.
The man abandoned by all gods escapes completely from reality and creates for himself another world in which he can achieve everything that he wants, has been unloved, even tormented, and he now splits off from himself, a part of which is the form of a helpful, loving, often motherly minder, commiserates with the tormented remainder of the self, nurses him, decides for him.
And this was the deepest wisdom, the most penetrating intelligence.
He is a guardian angel that sees the suffering or murdered child from the outside. He wanders through the whole universe, seeking help, invents fantasies for the child that cannot be saved in any other way.
But in the moment of a very strong repeated trauma, even this guardian angel must confess his own helplessness and well-meaning deceptive swindles, and then nothing else remains but suicide.
Study of narcissism is a century old, and the two scholarly debates central to its conception are still undecided.
Is this such a thing as healthy adult narcissism, as Kohut says, or are all the manifestations of narcissism in adulthood pathological as Freud and Krenberg promulgate.
Moreover, is pathological narcissism the outcome of verbal, sexual, physical, or psychological abuse, the overwhelming view? Or on the contrary, the sad result of spoiling the child and idolizing it as Millon and the late Freud said.
The second debate is easier to resolve if one agrees to adopt a more comprehensive definition of abuse, overweening, smothering, spoiling, over-valuing, and idolizing the child, putting him on the pedestal. They are all forms of parental abuse, actually.
This is because, as Karen Horney pointed out, the child is dehumanized and instrumentalized when the child is spoiled and put on a pedestal. His parents love the child not for what he really is, but for what they wish and imagine him to be, the fulfillment of their dreams and frustrated wishes.
The child becomes the vessel of his parents' discontented lives, a tool, the magic brush with which they can transform their failures into successes, their humiliation into victory, their frustrations into happiness. The child is taught to ignore reality and to occupy the parental fantastic space.
Such an unfortunate child feels omnipotent and omniscient, perfect and brilliant, worthy of admiration and entitled to special treatment.
True, the faculties that are owned by constantly brushing against bruising reality, empathy, compassion, realistic assessment of one's abilities and limitations, realistic expectations of oneself and of others, personal boundaries, teamwork, social skills, perseverance, and goal orientation, not to mention the ability to postpone gratification and to work hard to achieve it via impulse control, these are all lacking or missing altogether.
The child turned adult sees no reason to invest in his skills and education, convinced that his inherent genius will shine through and should suffice.
The child turned adult feels entitled for merely being rather than for actually doing, rather as the nobility in days gone by felt entitled not by virtue of its merit but as the inevitable foreordained outcome of its birthright.
In other words, the child turned adult is not meritocratic but aristocratic.
A narcissist is born, but such a mental structure evidently is brittle, susceptible to criticism, to disagreement, vulnerable to the incessant encroachment and encounter with a harsh and intolerant world.
Deep inside, narcissists of both kinds, those wrought by classic abuse and those yielded by being idolized, both of them feel inadequate, fawning, fake, inferior, imposter syndrome, and deserving of punishment.
This is Millon's mistake. He makes a distinction between several types of narcissists. He wrongly assumes that the classic narcissist is the outcome of overvaluation, idealization, idolization, and spoiling, and thus he is possessed of supreme unchartered confidence and is devoid of self-doubt.
According to Millon, it is a compensatory narcissist that falls prey to nagging set-outs, feelings of inferiority, and a masochistic desire for self-punching.
Yet this distinction is both wrong and unnecessary. There's only one type of narcissist, though there are two developmental paths to it.
And all narcissists are besieged by deeply ingrained, though at times not conscious, feelings of inadequacy, fears of failure, masochistic desires to be penalized, a fluctuating sense of self-worth, regulated by narcissistic supply, and an overwhelming sensation of fakeness.
The grandiosity gap between a fantastically grandiose and unlimited self-image, and the actual limited accomplishments and achievements of life, the grandiosity gap between the ego ideal and the false self is grating. Its recurrence threatens a precariously balanced house of cards that is a narcissistic personality.
The narcissist finds to his chagrin that people out there are much less admiring, accommodating, and accepting of him than his parents were.
As he grows old, the narcissist often becomes the target of constant derision and mockery, a sorry sight indeed.
His claims for superiority appear less plausible and substantial the more and longer he makes them. Pathological narcissism, originally a defense mechanism intended to shield the narcissist from a luxurious world, becomes a liability, the main source of hurt, the generator of injuries, counterproductive and dangerous.
Overwhelmed by negative or absent narcissistic supply, the narcissist is forced to let go of his grandiosity. The narcissist then resorts to self-delusion.
Unable to completely ignore contrarian opinion, data, and reality, the narcissist transmutes them. Unable to face the dismal failure that it is, the collapsed narcissist partially withdraws from reality.
To soothe and solve the pain of disillusionment, the narcissist administers to his aching soul a mixture of lies, distortions, half-truths, confabulations, and outlandish interpretations of events around him.
These solutions can be classified this way.
The delusional narrative solution, the narcissist constructs a narrative in which he figures as the hero, brilliant, perfect, saintly, irresistibly handsome, destined for great things, entitled, powerful, wealthy, the center of attention, etc.
The bigger the strain of this delusional charade, the greater the gap between fantasy and reality, the more the delusion coalesces and solidifies.
Finally, if it is sufficiently protracted, it replaces reality and the narcissist's reality test deteriorates. He withdraws his bridges, may become schizotypal, catatonic, or schizoid.
The other solution is the antisocial solution. The narcissist renounces reality. To his mind, those who pusillanimously fail to recognize his unbound talents, the made superiority, overarching brilliance, benevolent nature, entitlement, cosmically important mission, perfection, and so on, these people do not deserve consideration.
The narcissist's natural affinity with the criminal, his lack of empathy, his uncompassion, his deficient social skills, his defiance, his disregard for social laws and mores and morals, these criminal affinities now erupt and blossom. He becomes a full-fledged antisocial, sociopath, or psychopath.
He ignores the wishes and needs of others. He breaks the law. He violates all rights. He causes pain. Natural and legal laws and rules, he discards. He holds people in contempt in his name. He derives society in his cause and decries them. He punishes the ignorant ingrates that to his mind drove him to this state by acting criminally and by jeopardizing their safety, lives, emotions, and property.
Another solution would be the paranoid schizoid solution.
When narcissism fails as a defense mechanism, the narcissist develops paranoid narratives, self-directed confabulations, which place the narcissist in the center of others' allegedly maligned intention and attention.
Narcissist becomes his own audience and self-sufficient as his own, sometimes exclusive source of narcissistic supply.
Narcissist develops persecutory delusions. He perceives slights and injuries and insults when none were intended or exist. He becomes subject to ideas of reference mentioned before. He is convinced that he is the center of maligned and malintentioned attention. People are conspiring to humiliate him, punish him, and so on and so forth.
Some narcissists withdraw completely from a world populated with such menacious and ominous subjects. These are really projections of internal objects and processes, of course. These narcissists avoid all social contact except the most necessary. They refrain from making people, from falling in love, from having sex, from talking to others, or even from corresponding with others.
In short, they become schizoids, not out of social shyness, but out of what they feel to be their choice.
This evil, hopeless world does not deserve me, goes the inner refrain, and I shall waste none of my time and resources on it.
The paranoid aggressive or explosive solution is when other narcissists who develop persecutory delusions, when they resort to an aggressive stance, a more violent resolution of their internal conflict, they become verbally, psychologically, situationally, physically abusive. They insult, castigate, chastise, berate, demean and deride, and decry their nearest and dearest, often well-wishers, often loved ones. They explode in unprovoked displays of indignation, righteousness, condemnation, and blame.
Theirs is an exegetic bedlam. They interpret it in even the most innocuous, inadvertent, and innocent comments as designed to provoke and humiliate them.
They sow fear, revulsion, hate, and malignant envy, everyone. They flail against the windmills of reality, apathetic, forlorn sight, but often they cause real and lasting damage. Fortunately, mainly to themselves.
There is a masochistic avoidant solution. The narcissist is angered by the lack of narcissistic supply. He directs some of this fury inwards, punishing himself for his failure, becomes depressed.
This masochistic behavior has the added benefit of forcing the narcissist's closest to assume the roles of dismayed spectators or of persecutors, and thus either way to pay him the attention that he craves.
Self-administered punishment often manifests as self-handicapping masochism, a masochistic copout. By undermining his work, his relationships, and his efforts, the increasingly fragile narcissist avoids additional criticism and censure, negative supply.
Self-inflicted failure is the narcissist doing, and thus proves that he is the master of his own fate.
Masochistic narcissists keep finding themselves in self-defeating circumstances which render success impossible. They maintain a kind of an objective assessment of their performance and make it improbable, as Millan said. They act carelessly. They withdraw in mid-effort. They're constantly fatigued, bored, or disaffected, and thus passive aggressively sabotage their lives. Their suffering is defiant, and by deciding to abort, they reassert their omnipotence.
The narcissist pronounced and public misery and self-pitty are compensatory, and as Millan said, they reinforce his self-esteem against overwhelming convictions of worthlessness. They again make an objective assessment of their performance improbable.
The narcissist's tribulations and anguish render the narcissist in his eyes, unique, simply, virtuous, righteous, resilient, and significant.
These narcissists are, in other words, generators of self-supply. They are, in other words, all these tribulations and anguish, all this pain, all this hurt, all these injuries, they are a form of self-generating narcissistic supply.
Thus, paradoxically, the worse is anguish and unhappiness, the more relieved and elated such a narcissist feels.
I refer you all to Theodore Millon's and Roger Davis' seminal tome, Personality Disorders in Modern Life, second edition, near 2000.
Thank you for listening.