I am often asked the following question.
Some patients are diagnosed both with narcissistic personality disorder and borderline personality disorder.
But the two disorders are utterly incompatible.
For example, the borderline patient experiences emotions very deeply. She is actually overwhelmed by emotions. She drowns in them, whereas the narcissist is incapable of experiencing at least positive emotions.
The borderline patient has a modicum of empathy, affective emotional empathy. The narcissist lacks affective or emotional empathy altogether.
The narcissistic empathy is what I call cold empathy, combination of cognitive and reflexive empathy.
So these two disorders are incompatible. How could anyone have both?
This is the topic of today's video. Stay tuned and become all the wiser.
My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited, and I'm also a professor of psychology.
Before we start, we need to make a distinction between dual diagnosis and comorbidity.
Comorbidity is when you are diagnosed with two mental health issues which belong to the same family. So for example, two personality disorders. If you've been diagnosed with schizoid personality disorder and narcissistic personality disorder, you have a comorbidity, lucky you.
Dual diagnosis is when you are diagnosed with two mental health issues that belong to different families, different classifications. So, for example, if you abuse substances and you are also a psychopath, that would be a dual diagnosis. If you abuse alcohol and at the same time you have bipolar disorder, that would be a dual diagnosis.
But if you have a bipolar disorder and a major depression this would be a comorbidity because both these issues belong to the same family known as mood disorders.
Got it? I sure hope so.
Let us proceed.
When someone has a comorbidity, they are diagnosed with two mental health issues of the same family.
So in the case of narcissistic personality disorder, diagnosed together with borderline personality disorder in the same patient or the same client or the same person, this would be a comorbidity.
But in order to understand how these two can operate together, despite being utterly mutually exclusive, we need to understand that there is a hierarchy in comorbidity.
One of the disorders is primary. The other disorder is secondary. One of the disorders is dominant. The other one is recessive. One of the diagnosis is active. The other one is latent or dormant.
So definitely one of the disorders, the primary disorder, controls the secondary disorder and prevents it from expressing in day-to-day life.
Secondary disorders are traits and behaviors, whereas the primary disorder incorporates numerous psychological and clinical features, psychodynamics, internal processes, cognition, affect, every dimension, personality. The primary disorder is the patient.
One cannot take away narcissistic personality disorder from the narcissist because the narcissist is his disorder.
So the primary disorder characterizes the individual in every dimension of the individual, every nook and cranny, every field and area of functioning, every territory and realm of his life, every behavior, every trait, every reaction, every perception, every cognition, and every affect.
Whereas the secondary disorder is simply a compendium of several traits and several behaviors which usually belong to another personality disorder.
So when you have the primary personality disorder, it characterizes the individual. And on top of that, you have some traits and some behaviors that belong to another second personality disorder.
These traits and behaviors amount to a subclinical disorder.
One could generalize and say that in a comorbidity, we have a clinical primary disorder coupled with a subclinical secondary disorder, or if you wish, even a style.
So in the case of NPD and BPD, we would have as a primary disorder, narcissistic personality disorder. And as a secondary disorder, we would have traits and behaviors that characterize borderline personality disorder, but they are largely subclinical or more typical of a style, a borderline personality organization.
Secondary disorders are triggered, whereas primary disorders are always there, unwavering, omnipresent, always functioning, primary disorder is constantly active, does not need to be activated because it's always on.
The secondary disorder is triggered mainly by environmental stressors.
So environmental stressors trigger the secondary disorder and the secondary disorder takes over for a limited period of time suppressing the primary disorder.
In other words, when the individual is exposed to stress, for example, abandonment, rejection, humiliation, shaming, fear, a sense of threat, etc. These are all stressors. They create stress and anxiety.
When an individual with a comorbidity is exposed to this, the primary disorder subsides, is deactivated, switches off, disappears, and the secondary disorder takes over.
And for a while, a limited period of time, the individual transitions from the primary disorder to the secondary disorder.
Does this remind you of anything?
Yes, a self-state. The secondary disorder is a self-state, as is the primary disorder. The primary disorder is a dominant self-state. The secondary disorder is a recessive or submissive or subordinate self-state and it emerges only in time of need, only in an emergency, only under stress, anxiety, intolerabledecompensation, we'll come to it a bit later.
Okay, next.
One way to look at secondary disorders is as a form of what is called functional overlay.
So secondary disorder may be forms of functional overlay.
What on earth is a functional overlay?
I got you this time, didn't I? Look it up. No, no, I'm kidding. I will explain to you.
A functional overlay is when you have a core problem. It could be a psychological problem, a neurological problem, it could be anything.
When you have a core medical problem, a core psychiatric problem, and yet you display symptoms that belong to another problem, not to the main problem, not to the core problem, but to another problem.
Let me give you an example.
Imagine that you have a neurological problem. There's some problem with your brain or with your connection between your brain and your spine, what is known as the central nervous system.
Imagine that you have a central nervous system issue or disorder. And at the same time, you're very depressed. You're very anxious.
The depression and the anxiety have nothing to do with the neurological problem. They are the functional overlay of the neurological problem.
Sometimes they mask, they disguise the neurological problem and they make proper diagnosis very difficult.
We could think of, we could conceive of secondary mental health disorders, secondary personality disorders, we could conceive of them as functional overlays in this case.
So if you have narcissistic personality disorder and borderline personality disorder, the borderline personality disorder would be a functional overlay over the narcissistic personality disorder.
When a psychiatrist would be confronted with someone, with a patient, with this comorbidity, the borderline personality disorder elements, behaviors, traits, affects, and cognitions would tend to confuse the psychiatrists because they don't belong in narcissistic personality disorder.
And they would even sometimes mask or disguise the narcissistic personality disorder, which is the primary problem.
So this is functional overlay.
Secondary disorders, as I said, are triggered. They are not always on. Most of the time they're dormant. Most of the time they're latent. Most of the time they're off. Like there's an off and on switch and the secondary disorders are off.
But they're triggered. They're triggered by the environment, by circumstances, by other people, by anticipation of events.
This process is known as catastrophizing. All these create triggers. The triggers could be external, triggers could be internal, but the secondary disorder is always lurking, awaiting to be awakened, a little like the sleeping beauty, the kiss of stress or the kiss of anxiety wakes her up.
And so secondary disorders are dormant, they're waiting to be awakened, they're triggered, but they could be also triggered by the primary disorder.
If you have a primary disorder and it's sufficiently all pervasive, sufficiently disabling or dysfunction, sufficiently problematic, it could generate a secondary disorder. And the secondary disorder would be triggered by the primary disorder.
Let me give you an example.
Imagine that you are born with autism spectrum disorder. As a child, you are very awkward, you're weird, you're a freak show. Everyone mocks you, ridicules you. Everyone pushes you away. You have no company. No one wants to be in your company. No one wants to play with you. No one wants to talk to you. You're considered to be an alien.
As a child, you would develop narcissism as a defense against autism.
So in the case of autism, the autism would be the primary disorder and the primary disorder of autism would trigger a secondary disorder of narcissistic personality disorder.
So you have initially autism spectrum disorder and the rejection by the environment, the shunning, the humiliation, the shame would trigger in you narcissism. Narcissism would become a functional overlay, a veneer, it's like paint on the wall. The wall is the core, the wall is the essence and it's painted over.
So autism is the essence and it's painted over. So autism is the wall and it's painted over with narcissism.
Otto Kernberg suggested that a similar process is at work between narcissism and borderline.
He said that narcissistic personality disorder is a defense against borderline dynamics, a defense against emotional dysregulation, against suicidal ideation, against dissociative states, etc.
So the individual, especially in early childhood, defends against borderline personality disorder by developing narcissistic personality disorder.
We can see here a situation where a primary disorder, which according to Kernberg is borderline, engenders, fosters a secondary disorder, which according to Kernberg, is narcissism.
But it seems that the situation in adult comorbid individuals is different.
In adulthood, when there is a narcissism borderline comorbidity, NPD, BPD comorbidity, it is the narcissism that is dominant. NPD is dominant.
The narcissism is a primary disorder, precisely because it is a defense against the borderline.
What is a defense?
What is the defense of narcissism against the borderline?
The suppression of the borderline state.
The individual develops narcissistic defenses and narcissistic cognitive distortions such as grandiosity in order to suppress the dynamics and the energy of the underlying borderline state.
So in adult situations with adults, the narcissism, the pathological narcissism suppresses the borderline traits, behaviors, emotions, and cognitions. The narcissism suppresses the borderline.
Whenever we have a situation where one disorder suppresses the other, one of them is a primary disorder and the suppressed disorder is the secondary one.
So in NPD BPD comorbidity, NPD suppresses BPD so we can safely say that the primary disorder that is always on is NPD, narcissistic personality disorder. And the disorder that is repressed, that is buried, that is disabled, that is deactivated, this disorder, the borderline personality disorder, is the secondary disorder. It's the recessive disorder.
Here's a simple test.
If you want to make up your mind, make up your mind, which is the primary disorder and which is the secondary disorder, there are two tests.
Number one, how often is the individual a narcissist and how often is the individual a borderline? Time, frequency.
Test number two, which of the two disorders is inactive psychodynamically? Which of the two disorders is suppressed, buried, disabled, deactivated? This disorder would be the secondary disorder.
These are two simple tests.
When we look at patients with a comorbidity of narcissistic and borderline personality disorders, they are narcissists most of the time. And the borderline disorder is inactive unless and until it is triggered internally or externally.
Only during decompensation, the secondary disorder of borderline emerges in such individuals.
Let me explain this convoluted sentence. I love big words. Ten dollar words.
Okay, decompensation is when the defense mechanisms, the psychological defense mechanisms, are deactivated. They're shut off.
And then you are defenseless against reality, against other people, against the world. You're forced to confront very unpleasant destabilizing and traumatizing truths.
So, sometimes when you're exposed to a lot of stress, a lot of a shameful, disgraceful situation, exposure, when you're exposed to an abrupt change or transformation or to a disaster, in such conditions, you decompensate. Your defenses shut down. You become defenseless. You regress. You become like an infant, like a baby.
In a state of decompensation, the primary disorder is disabled because the defenses, the defense mechanisms belong to the primary disorder. They collaborate with the primary disorder. Primary disorder uses the defense mechanisms on a regular basis.
When they are shut off, the primary disorder is weakened to the point that it becomes inactive.
At that point in time, with the primary disorder gone, with the defense mechanisms inactivated in a state of decompensation defenselessness, helplessness, shame, terror in these conditions the secondary disorder emerges and takes over.
Let's take the example of a narcissist. A narcissist who is exposed to narcissistic mortification, abrupt, shaming and humiliation, usually in front of a public, publicly.
So in a state of narcissistic mortification, the narcissist experiences decompensation. All the narcissistic defenses shut down. One after the other, they become utterly useless.
And then the primary disorder, which is narcissistic personality disorder, becomes weak, becomes disabled by the decompensation, shuts down.
And the borderline comorbidity, the borderline personality disorder takes over.
Now the narcissist resembles a borderline. The narcissist suffers from affective dysregulation, overwhelmed by emotions, especially negative emotions, such as shame, the narcissists develop suicidal ideation.
So if you observe a narcissist, post-mortification, in the wake, in the aftermath of mortification, you would say, this person is not a narcissist, this person is a borderline.
But of course, the borderline personality disorder is a secondary state, and it was brought to the surface and it took over the individual in a condition of decompensation, condition of utter collapse.
Only then does the secondary disorder emerge and surface and becomes visible.
One last comment about covert states.
We could easily conceive of covert states or reconceive of covert states as comorbidities with a primary disorder and a secondary disorder.
For example, if you have a primary disorder, which is narcissistic personality disorder, and a secondary disorder, which is negativistic personality disorder, also known as passive aggressive personality disorder, if you put these two together, the narcissistic personality disorder is the dominant primary disorder.
The negativistic, passive-aggressive personality disorder is the secondary subsidiary disorder.
If you put the two together, what you get is what is known as covert, fragile narcissist, vulnerable narcissists.
So the diagnosis of covert narcissists, fragile narcissists, vulnerable narcissism, is actually a combination of two personality disorders.
One of them is dominant, visible, easily discernible, observable, and the other is hidden, occult, suppressed in the dark recesses of the mind, awaiting to erupt once the conditions are right and ripe. Stress, anxiety, humiliation.
So we could reconceive of covert diagnosis or diagnosis of covert states as actually comorbidities, combinations of two mental health issues.
Covert narcissists equals NPD plus passive aggressive personality disorder. For example.
Okay, I hope you had great fun because I did and say hello to your secondary disorder on my behalf.