So many women are asking to interview me lately that I'm beginning to seriously consider the possibility that I'm actually a desirable man.
Well, talk about delusional disorder.
My name is Sam Vaknin, I'm the author of Malignant Self-Love, Narcissism Revisited, and I'm a professor of psychology.
And today we are going to discuss a very intricate problem.
For those of you who are my students, this is within the unit on presentation intake interviews, and what was the last part? Presentation intake, and presenting signs and symptoms.
So, here's the question. Even skilled diagnosticians, even diagnosticians, therapists, psychologists with decades of experience in institutional settings find it very difficult to distinguish between psychopathy, autism, schizoid personality, and PTSD or complex PTSD.
Let me repeat, psychopathy, the extreme form of antisocial personality disorder, autism spectrum disorders, schizoid personality and schizoid personality disorder, and complex post-traumatic stress disorder or straight out post-traumatic stress disorder.
These are the people with these problems present so identically that in the intake interview, the first time the therapist or the diagnostician comes across the patient or the client, it's very difficult to tell them apart.
Now, we already know that people with borderline personality disorder, emotional dysregulation disorder, people with this disorder are actually indistinguishable from secondary psychopaths when they are exposed to stress, humiliation, and rejection.
So, there is a confluence, there is a confluence or a convergence between borderline personality disorder and secondary, factor two, psychopathy.
But we are talking about factor one psychopathy, the classic psychopath, the animal, the beast, the monster, in short, me.
Factor one psychopath, someone with autism spectrum disorder, mainly high functioning autism, or formerly known as Asperger, level one autism, Asperger's disorder, schizoid personality and personality disorder, and complex trauma.
How do we tell them apart? All four conditions present the same. In all four conditions, there is extreme reduced affect display, reduced affect display is a fancy name because we psychologists will like fancy names. It gives us the illusion that psychology is a science.
So, reduced affect display simply means not showing emotions, flat affect, not displaying any emotional reaction to past events, to present occurrences, to future catastrophizing or speculations, no emotions, no display of emotion, a flat presentation of emotions and a flat presentation of personal experiences.
These people describe the most harrowing, most traumatizing, most exceptional, most extreme situations. And you don't see a hint of a flicker of anything resembling an emotion of the faces. This is a poker face. And there is reticent self disclosure. It's like pulling teeth, talking to these people. They refuse to kind of come clean. They refuse to share, confess, admit. They refuse to talk. It's very, very difficult to get these kind of people, these kind of patients or clients to actually talk about their lives.
What had happened? How they had failed? What led to these events? And how do they extricate themselves? And how do they feel about these occurrences nowadays? They absent themselves. They shut themselves off. You can see the curtain falling. You can see there's nobody there suddenly.
When you try to talk to them about emotions, about personal experiences, when you try to kind of coerce them or convince them or cajole them into self disclosure, they become reticent, reluctant, and their body language changes. It becomes very defensive or very aggressive for both.
And this is common to all four types, including survivors of trauma and including survivors of complex trauma, complex post-traumatic stress disorder.
So the first thing we see when such a patient or client enters the clinic, the first thing you see is the body language. And the body language is, again, very defensive and very aggressive, a bizarre mixture, kind of passive aggression.
And the second thing you see is that when you try to talk to them, they shut off. They vanish. They absent themselves.
And the third thing you see, they refuse to talk about emotions, personal experiences. They refuse to self disclose, and they refuse to attach emotions to anything they divulge on their personal histories.
All four types of patients also use language in a highly idiosyncratic way, in a special way.
Narcissists abuse language. Narcissists leverage language as a weapon. They use language to be fuddled, to confuse, to gaslight. So they abuse language.
But psychopaths, people with autism spectrum disorder, schizoids, and victims of trauma, use language not in order to obtain any goal or to score points, as the narcissist does. They simply corrupt language. They undermine language. They render, it's like their language festers. It's like it became infested or infected with something.
First of all, they are likely to use very vulgar, a very vulgar type of language, you know, with obscenities and profanities and so on. The language is likely to be portrayed as though it's rotting from the inside.
Whenever they try to communicate something, which is very rare, or if they have to respond to the therapist or the diagnostician or the psychologist, for example, in court-mandated evaluations, they tend to play with language. They tend to become ambiguous and equivocal. If you ask them, did you do this and this? They're going to say, how do you define doing this and this? Or they're going to answer in a way which is essentially hair-splitting and nitpicking, wiggling their way out, finagling their way out of conundrums and predicaments using language. Language is their exit strategy.
They think that if they can redefine and reframe situations, behaviors and traits, they're scot-free, they're home-free. It's like a monopoly game. They're playing a game all the time and you can feel it. Their language is a gambit like in chess. So it's very ambiguous and very equivocal and leaves place for vagueness and kind of finagling and wiggling. The language is non-committal. It's clinical. It's impersonal. They're likely to describe the most terrifying, traumatizing, horrific experiences in very, very impersonal and clinical terms, as though they were talking about the third party at making clinical observation for some medical chart or some paper about to publish in an academic journal.
They corrupt the language and they render it circumspect and cynical and cold and detached.
And so this is the fourth thing you notice, the misuse of language. All four types of patients, the psychopath, the autism, the autist, the schizoid and the traumatized victim, trauma victim, all four types of patients are inaccessible.
You feel that there's a kind of transparent partition that you cannot penetrate.
They look at you, they're watching you and you're watching them through a glass darkly. There's something, something standing between you and them. It's ephemeral. It's ethereal on one hand, but on the other hand, it's very real and it tends to regenerate all the time.
The more intimate the conversation becomes, the more the clinician tries to broach difficult topics, painful topics or threatening topics, the more the partition solidifies, becomes thicker. And so there is this membrane between the patient and the diagnostician or therapist. The patient is inaccessible. The client is sealed off from the world.
When you talk to a psychopath or trauma victim or schizoid or an autistic person, you feel that he is ensconced and cocooned in his own tiny bubble of a universe.
Drifting away from you, nevermind how desperately you're trying to reach out and hold on to them. They're out of grasp. They're like slimy goldfish. You can never get hold of them. You cannot nail them down. You cannot get them to commit even linguistically.
And so they're sealed off and they're emotionally numb. They're incapable of true intimacy, true communication, let alone intimacy. You can never get anywhere with them because you keep getting the feeling that there is somebody there, but out of reach, out of reach. And you feel that you're being reduced by these patients into a caricature, a two-dimensional icon avatar, a symbol.
These four types of patients don't relate to the clinician or the therapist as another human being. They reduce him to a function and then they become very defensive and they try to isolate themselves from the situation and from the other person that's the therapist.
And so you have this eerie feeling that the temperature had dropped and the oxygen had been sucked out of the room and you're in the presence of someone who is suspending their humanity.
These people, all four types, the psychopath, the schizoid, the trauma victim, the borderline, which is a form of psychopath, and the narcissist. Deep inside, we now know from multiple studies, starting in the 90s, we know that deep inside, they harbor, they have, they experience self-loathing, self-hating. And so sometimes they act out, they act out by becoming self-defeating or self-destructive or self-trashing or aggressive or passive aggressive.
And so even the schizoid, who is utterly detached ostensibly from the outside world, happy in his own nest, in his own den, happy, thriving in his solitude. Even the schizoid actually has moments of rage and acting out and reaching out desperately, trying to connect.
Actually, the prevailing theory of schizoid personality is that the schizoid defense is an attempt to maintain object relations, an attempt to maintain relationships with other people by somehow rejecting them, by somehow isolating them.
Because even rejecting someone, even isolating yourself from someone is a form of connection. So it's one step removed from psychosis or schizophrenia. That's why it's called schizoid, almost schizophrenia.
So even the schizoid has these moments of rejecting others, sometimes aggressively rejecting others, especially when he feels uncomfortable or discomfited by the presence of others when he feels overwhelmed.
And so all these four patients are self-destructive and all of them act out one way or another.
The psychopath is defiant and contumacious and reckless and impulsive. Borderline, of course, when she becomes a secondary psychopath.
The trauma victim is dysregulated, heavily dysregulated emotionally. She has typically mood lability. And I'm saying she because majority of victims of complex post-traumatic stress disorder are women. Not all, but the majority.
Now, one thing.
So to summarize this part, as a clinician, as a diagnostician, as a therapist, there's a conundrum.
How to tell these apart? Of course, you wouldn't treat a trauma victim as you would as you would treat a psychopath. You wouldn't administer the same techniques to a borderline as you would to an autistic person and definitely would not try to treat someone with autism spectrum disorder as you would someone with schizoid personality disorder. These are seriously different problems, issues in mental health, and they require totally different approaches.
It's very dangerous to misdiagnose. And misdiagnosis is very common in clinical practice, precisely because all the presenting signs and symptoms on the face of it, and initially, sometimes for five sessions, 10 sessions, they seem to be the same.
Only when you delve deeper, you begin to discover differences. For example, attitude to sex and intimacy.
The psychopath's attitude to sex and to sexuality, psychopath's psychosexuality, is very unique and is not typical of the schizoid, of the trauma victim, the borderline, and definitely not of someone with autistic personality, autistic disorder.
So the psychopath, first of all, makes a distinction between sex and intimacy. There's a Madonna whore complex, which also applies to narcissists.
The psychopath is very likely to regard his sexual partner, even his long-term sexual partners, as intimate. He doesn't do intimacy at all, not with his sexual partners, not with anyone.
So consequently, his sex is devoid of intimacy. Even when it looks outwardly as intimate, it's not.
Psychopaths regard their bodies as dispensable, disposable objects. So they trash themselves. They self-trash sexually.
It's very common for a psychopath to engage in very extreme sexual practices, reckless or not. Sexual practices which objectify his or her body, sexual practices which trash the psychopath, disrespect his boundaries, physical or otherwise. It is only in sex that the psychopath allows himself to be abused in effect by his sexual partners.
So they regard their bodies as a kind of coin or commodity. They leverage their bodies, the psychopaths leverage their bodies and use them to obtain goals. The goals could be instant gratification, satisfaction of an impulse.
Harvey Cleckley said in his famous Mask of Sanity, the masterpiece, Mask of Sanity, Harvey Cleckley said in 1942 that psychopaths, the sexual activities of psychopaths are like scratching your back. He said that psychopaths act on a whim. They rarely have any deep motivation to engage in sex. They engage in sex because they want to scratch their backs. It's just an impulse, an itch. They scratch the itch.
So sex with them is utterly meaningless. Their bodies are utterly meaningless. Actually in the psychopath's life, everything is meaningless. And so it's very shocking, very unsettling. I would even say horrifying and gross to observe the sexual history of a psychopath.
In the sexual history of a psychopath, he or she subjects herself to the most degrading and despoiling treatment by others. She is likely to find herself in situations which no healthy or normal person, not even a mentally ill person would find herself or himself.
Psychopaths are unlikely to have sexual boundaries. They are unlikely to be sexually dysregulated. They're likely to engage in extreme and reckless sex from a very early age. It's very common in the history of psychopaths to engage, for example, in group sex in teenage years or to give a series of 100 low jobs on consecutive days to all the boys in the school. It's utterly normal occurrence in the sexual history of psychopaths.
And the same people, psychopaths, usually develop comorbidities or dual diagnoses like eating disorders and some of them suffer from body dysmorphia, although this is much more common in secondary psychopathy and therefore in borderline personality disorder.
So attitude to body, attitude to sex, attitude to the bodies of other people, the willingness to self trash sexually, the willingness to be objectified, degraded and despoiled, subjecting oneself to these situations, seeking them actually. This is a hallmark, a major hallmark, by the way, according to Cletley and many other authorities. It's a major hallmark of psychopathy.
And it is a differential diagnosis in the sense that it does not exist in trauma victims among people with autism, schizoids and narcissists. It is common among psychopaths all year long. And it's common among borderlines when they switch into a psychopathic state, secondary psychopathic state.
So this is the first differentiating or differential sign.
Now, psychopaths are deceitful. They're deceitful. They're disloyal. They're unfaithful. They're manipulative. They're parasites.
Psychopathic women are usually gold diggers. They're gold-oriented.
This is not, this is another differential diagnosis.
This is not the case with schizoids, with borderlines, with people with autism spectrum disorder and with trauma victims.
Many psychopaths are like this.
So when you see a history of deceitfulness, cheating, for example, in multiple relationships, serial cheating, betrayal, a history of adultery and unfaithfulness, extramarital sex, non-consensual extramarital sex, when you see a history of parasitism, when you see a history of antisocial, even criminal activities, actions, when you see extreme goal orientation, which is without scruples, without boundaries, without rules and without limits, which is reckless and callous and ruthless, when you see these things, this is a psychopath.
Finally, a psychopath is likely to be very devaluing and humiliating of others. Psychopaths hold everyone in disdain and contempt, which is not the case with the narcissists, by the way. The narcissist does have role models. The narcissist tends to adopt public intellectuals, important politicians, footballers, you name it, it tends to adopt public figures and idealize and idolize them.
This is not the case with the psychopath. The psychopath holds everyone, and when I say everyone, I mean everyone, in disdain and contempt.
Psychopaths are compelled, it's almost compulsive, they're compelled to devalue you, to humiliate you, and this is apparent and transparent in the therapy setting, where the psychopath embarks almost immediately on doubting the therapist's credentials, experience, knowledge, intelligence, wisdom, etc.
Devaluation and humiliation, degradation and despoiling of other people are psychopathic acts when they are indiscriminate and when they don't target only specific individuals like intimate partners.
Psychopaths are also very hypervigilant and very paranoid, much more so than trauma victims.
So when we see someone who is viciously, viciously, contemptuous, disdainful, hatefully devaluing, totally hypervigilant and paranoid, that's likely to be a psychopath, not a trauma victim.
The etiologies of this identical presentation, the etiologies couldn't be more different, and this is why it makes it crucial. It's crucial to apply the differential diagnostic signs and symptoms and criteria that I've just described, because if you get it wrong, you can, as a clinician, as a therapist, you can wreak havoc and create enormous damage.
The etiologies of these four groups or classes of disorders is very different.
The psychopath has no empathy. He has no positive emotions. The narcissist has no access to his positive emotions, but he does have positive emotions.
The psychopath does not have positive emotions. There's nothing to access, nothing there. He has no empathy. He has nothing to report. His self-reporting is denuded, minimal or sometimes non-existent, not because he's playing mind games or not because it's a power play, although they're prone to both. It's because he has nothing to report. There's nothing there.
So the psychopath is goal-oriented. He defines himself via his environment. He derives his identity from his actions and from his environment, and this is why his goal orientation is extreme.
Psychopaths are primitive two-state devices, almost animals, almost in an animalistic level. Feel good, feel bad. So they're a two-state device.
They mimic humans because they are great mimics. They have thespian skills, exactly like the narcissist, but it's mimicry. It's not real.
The etiology of the psychopath is severe damage, probably cerebral, probably brain damage, to the ability to experience empathy or positive emotions. That's the root of psychopathy in effect.
The autistic person is oblivious to social and sexual cues. He cannot read other people. He cannot read their body language. His thinking is concrete.
So he is incapable of understanding and applying metaphors, similes, similes, jokes. He has a problem with humor. So his language is very concrete and very simplified. It's a dictionary language. It's like it's a walking, talking lexicon or dictionary.
So he doesn't understand other people. He doesn't get them. He is no clue. He's clueless.
And this renders his reactions weird, even antisocial sometimes, unintentionally.
The autistic person is reluctant or unable to verbalize his internal world, his inner world.
And that is partly because this inner world overwhelms him and partly because he had been rejected all his life, owing to anticipated rejection. He doesn't want to expose himself. He doesn't want to be mocked, shunned, ostracized, ignored, punished.
The schizoid just wants to be left alone. That's all he wants. He is incapable of strong emotions. He is incapable of intense experiences.
The schizoid flatlines, flatlines into solitude. The schizoid's solitary confinement is his comfort zone.
It defies belief because we are all social creatures, even narcissists, even psychopaths, but not the schizoid.
He thrives when he's alone.
And the survivor of trauma, she represses, she numbs her emotions because she finds her emotions and the memories that are attached to these emotions threatening. She feels that she will be overwhelmed if she allows herself to directly touch upon and interact with what had happened to her, with her trauma.
So she's reluctant to revisit her harrowing experiences and she's triggered by any attempt to be intimate with her in any way.
Though all four present identically in clinical settings, you need to dig deeper. You need to delve deeper. You need to ask yourself, how do they regard their bodies? How do they regard sex and intimacy? Are they deceitful, unfaithful, goal-oriented, parasitic to the extreme? Are they immediately vicious in devaluing and humiliating other people? Are they hypervigilant to the point of paranoid ideation?
And if the answer to all this is yes, that's a psychopath. And you did your job.