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Bipolar Disorder Misdiagnosed as Narcissistic Personality Disorder (NPD)

Uploaded 8/6/2010, approx. 8 minute read

My name is Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.

The manic phase of bipolar disorder is often confused and misdiagnosed as narcissistic personality disorder.

Bipolar patients in a manic phase exhibit many of the signs and symptoms of pathological narcissism, for instance hyperactivity, self-centredness, lack of empathy, and control freakery.

During this recurring manic chapter of the disease, the patient is euphoric, has grandiose fantasies, spins unrealistic schemes, and has frequent rage attacks even when her wishes and plans are inevitably frustrated.

So in this sense, these are all narcissistic behaviors and narcissistic traits.

But the manic phases of the bipolar disorder are limited in time.

Narcissistic personality disorder is not.

Furthermore, in bipolar disorder, the mania is followed by a usually long protracted depressive episode.

Narcissists also are frequently dysphoric or depressed.

But there's a difference between the narcissist's depression and the bipolar's depression.

Whereas the bipolar sinks into deep self-deprecation, self-evaluation, unbounded optimism, and all pervasive guilt and anhedonia in ability to have pleasure.

The narcissist, even when he's depressed, never experiences any of this. He never forgoes or loses sight of his grandiosity, of his sense of entitlement, of his hotiness, and of his lack of empathy.

The sick, the diseased core of pathological narcissism survives the narcissist's depression.

And the bipolar disorder patient loses his manic attributes when he's depressed.

The bipolar patient, when depressed, is no longer hyperactive, no longer grandiose.

Narcissistic dysphoria, narcissistic depression, are much shorter. And more importantly, they are reactive. They are in response to things that happened in the narcissist's world.

The narcissist is dejected when confronted with the abyss between his inflated self-image and grandiose fantasies and the drab reality of his life.

Narcissist finds it difficult to confront his failures, his lack of accomplishments, the disintegration of his interpersonal relationshipsand his low status.

So the narcissist's depression is in reaction to reality.

Yet one dose of narcissistic supply is enough to elevate the narcissist from the depths of misery to the heights of manic dysphoria.

It's not the same with the bipolar patient.

The source of the bipolar patient's mood swings is brain biochemistry, not the availability or lack of availability of narcissistic supply.

Whereas the narcissist is in full control of his faculties even when maximally agitated, the bipolar often feels that she has lost control of her brain.

This is called flight of ideas. She feels that she's no longer a master of her own speech and attention span. And this is called distractibility. She sometimes loses mastery of her motor functions. This never happens to the narcissist.

The bipolar is prone to reckless behaviors and to substance abuse only during the manic phase.

The narcissist does drugs, drinks, gambles, shops on credit, and indulges in unsafe sex, or in other compulsive behaviors, both when elated and when deflated.

As a rule, the bipolar's manic phase interferes with her social and occupational functioning.

Many narcissists, in contrast, reach the highest rounds of their community, church, firm or voluntary organizations. They are pillars of the community, most of the time. They function flawlessly though the inevitable blow-ups and grating extortion of narcissistic supply usually put an end to the narcissist's career and social liaisons.

But the narcissist is functional. The bipolar patient is dysfunctional.

It's a very important distinction.

The manic phase of bipolar sometimes requires hospitalization and more frequently than admitted, involves psychotic features.

Narcissism never hospitalized as the risk for self-harm, suicide, or mutilation. This risk is minute.

Moreover, psychotic micro-episodes in narcissism are decompensatory in nature.

In other words, they appear only under unendurable stress, for instance, in therapy.

The bipolar's mania provokes discomfort in both strangers and in the patient's nearest and dearest.

Her constant cheer and compulsive insistence on interpersonal, sexual, occupational or professional interactions engenders unease and repulsion in her environment. Her lability of mood, the rapid shifts between uncontrollable rage and unnatural good spirits, is downright eerie and intimidating.

The narcissist, by comparison, is Greg Aris. It's true that he is calculated, called, controlled, and goal-orientated, but he is also usually accepted by society. His cycles of mood and effect are far less pronounced and less rapid and therefore easier to accept.

The bipolar's swollen self-esteem overstated self-confidence, obvious grandiosity and delusional fantasies, are similar to the narcissist. And they are the source, of course, of the diagnostic confusion that I mentioned in the beginning.

Both types of patients purport to give advice, to carry out an assignment, to accomplish a mission, or to embark on an enterprise for which they are uniquely unqualified and lack the talents, the skills, the knowledge, and the experience required.

So they have a very unrealistic assessment of their own abilities and capacities on the one hand and their own limitations on the other hand.

But the bipolar's manic-flower is far more delusional than the narcissist's.

Ideas of reference and magical thinking are common, and in this sense, the bipolar is closer to the schizotypal than to the narcissistic.

There are other differentiating symptoms between bipolar and narcissism.

Sleep disorders, most notably acute insomnia, are common in the manic phase of bipolar and uncommon in narcissism. So is manic speech, because speech, the pressured, uninterruptible, loud, rapid, dramatic, staccato speech or singing or humorous asides that are usually incomprehensible, incoherent, chaotic, and they last for hours.

This is typical of bipolar. The narcissist never engages in such behavior. It reflects her bipolar's inner turmoil and her inability to control her racing and kaleidoscopic thought processes.

The narcissist is far more structured, far more organized.

As opposed to narcissist, the bipolar patient in the manic phase is often distracted by the slightest stimuli. He's unable to focus on relevant data or to maintain the threat of conversation.

Bipolar's are all over the place. They are simultaneously initiating numerous business ventures, joining a myriad organizations, writing umpteenth letters, contacting hundreds of friends, perfect strangers, acting in a domineering, demanding and intrusive manner, totally disregarding the needs and emotions of the unfortunate recipients of their unwanted attentions. They rarely follow up on these projects and schemes dreamt up during the manic phase.

Again, the narcissist has all these features, but in very, very small doses, and this makes the narcissist, A, more realistic in its goal setting and B, more acceptable to society.

The transformation in bipolar patients from the manic to the depressive and back transformation is so marked that the bipolar is often described by her closest as not herself.

Indeed, some bipolars relocate, change name and appearance and lose contact with their former life during the manic phase.

Antisocial or even criminal behavior is not uncommon in bipolar disorder.

An aggression is marked and it is directed at both others in the form of assault and at oneself in the form of suicide.

Some bipolars describe an acuteness of the senses, akin to experiences recounted by drug users. So their sense of smell or factorial sense of sound and signs are accentuated and they attain kind of an earthly quality.

Narcissist has none of these experiences.

As opposed to narcissist, bipolars regret their misdeeds following the manic phase and they try to atone for their actions. They are remorseful. They realize and accept that something is wrong with them. They seek help.

During the depressive phase, they are egodystonic. They don't feel good with themselves and their defenses are autoplastic. They blame themselves for their defeats, failures and mishaps.

Of course, a narcissist is exactly the opposite.

Narcissist is not remorseful and he's alloplastic. He blames the world and others for his misconduct.

Finally, pathological narcissism is already discernible in early adolescence. The full-fledged bipolar disorder, including the manic phase, rarely occurs before the age of 20.

The narcissist is consistent in his pathology, not so the bipolar.

The onset of the manic phase is fast and furious and results in a conspicuous metamorphosis of the patient.

Narcissists are far more stable and to a big extent, logistically, far more predictive.

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