NPD and BPD - Part III : Bibliography

Hi, everyone,

This is part three of the trilogy about the co-relation of NPD and BPD. It
is a non-representative SAMPLE of a sea of literature connecting the
"Cluster B" (to use DSM III-R terminology) PDs (BPD, NPD, HPD and AsPD).

Please write to me: vaknin@terminal.cz to get additional references.

The most famous and substantial work on this purported connection is by
Otto Kernberg. It is entitled:
"Borderline Conditions and Pathological Narcissism" (Jason Aronson, 1975).
It is one of a series of monumental works on pathological narcissism. He
claims that both BPD and NPD are the result of a pathological development
of early narcissism. Admittedly, Kernberg was one of the main proponents of
the Objects-Relations school of psychodynamics (now largely out of favour).

Cohen Y: GRANDIOSITY IN CHILDREN WITH NARCISSISTIC AND BORDERLINE
DISORDERS. A COMPARATIVE ANALYSIS. Psychoanalytic Study of the Child 1991;
46:307-24. The author draws a distinction between two clinical pictures in
children, borderline and narcissistic disorders. Both belong to the realm
of personality disorders - or, perhaps, disorders in the development of the
personality - but only the former has been widely reviewed and thoroughly
investigated in the professional literature. He raises the question how
and when these disorders emerge, stressing that both derive from the early,
preoedipal period, and precede completion of the separation-individuation
processes. Both disorders reveal manifestations of grandiosity which the
author views as a defense against the two underlying emotional experiences
of the disorders: the experience of feeling alone in the borderline case,
and the experience of "worthlessness" in the narcissistic personality.

Battegay R: DEFENSE AND COPING IN THE ANTINOMY BETWEEN SELF-MAINTENANCE AND
ADAPTATION. Journal of the American Academy of Psychoanalysis 1991;
19(3):471-83. The author's own Abstract: After definitions of the terms
defense and coping, the disturbances of both linked to narcissistic
personality disorders, borderline personality disorders, and major
depressions are described. All three are characterized by deficient
narcissism. In narcissistic personality disorders, defense and coping are
hindered mainly because of a lack of narcissistic investment of the ego, in
borderline personality disorders preponderantly because of a
fragmentation-prone ego with its rigid defenses, and in major depressions
primarily because narcissistic emptiness or depletion breaks down interest
of the ego to get along with the environment or leads to an extreme
overinvestment of the remaining narcissism in the objects. Finally, the
three levels of object relations--the narcissistic--fusionary one, the
level of active ego
performances, and the level of free decisions--and their functioning with
respect to coping in the three disorders mentioned are discussed.

It is so difficult to distinguish these PDs one from the other that special
statistical tools have to be developed:

Livesley WJ, Schroeder ML: DIMENSIONS OF PERSONALITY DISORDER. THE
DSM-III-R CLUSTER B DIAGNOSES. Journal of Nervous & Mental Disease 1991;
179(6):317-28. Summary: This study describes a psychometric approach to
refining descriptions of antisocial, borderline, histrionic, and
narcissistic personality disorders in an attempt to achieve greater
distinctiveness. The authors developed descriptions of each diagnosis from
content analysis of the literature. Psychiatrists' ratings were used to
organize the features of each diagnosis into a set of carefully defined
behavioral
dimensions. Self-report scales were developed to assess each dimension.
Scales were administered to a general population sample (N = 274) and a
sample of patients with a primary diagnosis of personality disorder (N
=133). Scales demonstrated satisfactory levels of internal consistency.
Some dimensions showed a low correlation with other dimensions defining the
same diagnosis. These dimensions could be eliminated without affecting
reliability. The structure underlying the dimensions delineating each
diagnosis was evaluated using factor analysis. For each diagnosis, the
structure was highly similar in the two samples. Based on these results,
specific proposals are made for redefining diagnoses.

The correlation between Cluster B disorders is VERY HIGH:

Dowson JH: DSM-III-R NARCISSISTIC PERSONALITY DISORDER EVALUATED BY
PATIENTS' AND INFORMANTS' SELF-REPORT QUESTIONNAIRES: RELATIONSHIPS WITH
OTHER PERSONALITY DISORDERS AND A SENSE OF ENTITLEMENT AS AN INDICATOR OF
NARCISSISM. Comprehensive Psychiatry 1992; 33(6):397-406. Summary: Modified
versions of the revised Personality Diagnostic Questionnaire (PDQ-R) for
DSM-III-R personality disorders (PDs) were completed by 60 patients and
their informants. Patients' ratings gave a mean number of 4.5 PDs per
subject and narcissistic (NAR) PD in 42%. Informants' ratings gave NAR PD
in 38%. For patients and informants, NAR PD scores (i.e., the number of
positive NAR PD criteria for each subject) were significantly correlated
with histrionic (HIS) and borderline (BOR) PD scores and with scores of
some PDs outside DSM-III-R's "cluster B." Also, there were significant
correlations between patients' and informants' NAR PD scores and between
NAR PD scores and total number of positive criteria (i.e., for all 13 PDs)
for patients and informants. For patients' ratings, there were significant
associations between NAR PD and HIS, BOR, and passive-aggressive (PAG) PDs
and, for informants' ratings, between NAR and HIS PDs. There was no
significant association between patients' and informants' diagnoses of NAR
PD. Grandiosity, the most characteristic feature of narcissism, is related
to NAR PD criteria 3 through 6. The patients' evaluation of criterion 6
(i.e., "Has a sense of entitlement ...") shows satisfactory item-total
correlation and endorsement frequency, together with "fair to good"
reliability when patients' and informants' ratings are compared (kappa =
0.62). The identification of a sense of entitlement by the patient may be a
relatively reliable and valid indicator of narcissism.

As opposed to common opinion, the reaction to sexual abuse could be NPD -
rather than BPD

Gabbard GO, Twemlow SW: THE ROLE OF MOTHER-SON INCEST IN THE PATHOGENESIS
OF NARCISSISTIC PERSONALITY DISORDER. Journal of the American
Psychoanalytic Association 1994; 42(1):171-89. Summary: Psychoanalytic case
material is presented to illustrate how mother-son incest may be involved
in the pathogenesis of a particular subtype of narcissistic personality
disorder. Male patients with this disorder have a grandiose view of
themselves as entitled to occupy a special position with others, combined
with a paranoid tendency to anticipate imminent betrayal. The enormous
guilt related to perceived oedipal transgressions leads these patients to
fear retaliation from an enraged, vindictive, and castrating father at any
moment. In addition, these men often feel that their special role vis-a-vis
mother is a precarious one contingent on doing her bidding. Hence, they
also live in dread of an impending disaster involving either abandonment or
humiliation by their mothers.

Sexual Narcissism - typical of ALL cluster B PDs (BPD as well as NPD)

Hurlbert DF, Apt C, Gasar S, Wilson NE, Murphy Y: SEXUAL NARCISSISM: A
VALIDATION STUDY. Journal of Sex & Marital Therapy 1994; 20(1):24-34.
Summary: Sexual narcissism, an egocentric pattern of sexual behavior, has
recently been described in the literature and has been discovered to be
associated with cluster B type personality disorders. Although the research
seems to have validated sexual narcissism as a characteristic of borderline
and histrionic personality disorders, it is yet to be tested with
narcissistic personalities. In an effort to further explore this
relationship as well as the validity of sexual narcissism, this study
systematically compared a sample (ages 24-33 years) of males with
narcissistic personality disorder with an adequately matched sample of
males without personality disorders. As compared to the control group,
narcissistic men were found to have significantly lower self-esteem, more
negative attitudes toward sex, greater egocentric patterns of sexual
behavior, more conservative or traditional gender-role orientation, and
greater sexual preoccupation. Despite these findings, there were no
significant differences between the groups on sexual depression and the
narcissistic men evidenced significantly higher sexual esteem. Implications
for these findings are discussed.

Even in Harvard they teach that BPD and NPD are related... :o)))

Psychoanalytic Approaches
.... "A more lasting contribution is the idea of narcissism, originally
associated by psychoanalysts with a very
early stage of life at which an infant directs all its libido toward the
immediate satisfaction of physical needs and makes no distinction between
the self and the external world. Psychodynamic theory suggests that after
undergoing various transformations, this narcissistic libido can take
pathological forms, producing narcissistic, borderline, and other
personality disorders. (See Mental Health Letter, September 1986.) ....
.... Many (psychologists), however, believe that the more severe forms of
personality disorder, especially borderline personality, have their
beginnings very early in life, while the milder forms are derived from
later disturbances in development....

The Harvard Medical School Mental Health Letter, September (Part I),
October 1987 (Part II)

Dr. Hannig relaing to this issue

Q. I have known all my life that there was something "wrong" with me. I am
an intelligent 24 year old and about 9 months ago it was suggested to me
that I may have BPD. I looked up everything I could on BPD and I strongly
fit the description.
I recently withdrew from school (I was supposed to graduate this December)
because I was "falling apart". I am tired of sabotaging everything in my
life (including my relationships) and living my life as a mirror of what is
around me at the time.
I have just started to see a psychiatrist and when I told him I suspected
BPD he told me he didn't think that was right, he told me he thought it was
more narcissistic personality disorder. So I went back to doing my research
and this is my question: Is it possible to have characteristics of BPD,
narcissistic personality disorder as well as Histrionic
personalitydisorder?
I still believe that I have a stronger leaning towards BPD but I share many
of the traits of the other two...what does that mean?
By the way your web site is amazing...it has helped my parents understand
that, no matter what I am afflicted with, I am not a bad, manipulative,
drama queen on purpose. Thank you!

A. You bring up many important concepts.
First of all, one study showed that 82% of borderlines had at least one
more personality disorder diagnosis.
Of the three, so far only the borderline personality disorder is medically
treatable.
The Narcissistic PD (NPD) and Histrionic PD's (HPD) have many theories. No
one knows for sure that I've encountered, and so far there isn't much
success in treatment. I have found that treating all treatable causes of
biological unhappiness (particularly the BPD), can markedly reduce the
other symptoms. The approach I use for treating the BPD - particularly
listening to Zig Ziglar and mastering his teaching - works for the NPD and
HPD as well.
To me, the NPD is a maladaptive defense system where the individual divides
the world into inferior and superior people - where the NPD individual
believes he/she is superior and judges others by whether they recognize
that concept or not. They rarely seek or follow through on help because
it's everyone else who has the problem. They usually dislike hearing they
could have anything wrong with them. Recovery depends on how much the
individual wants a happy, fulfilling and successful life.
To me, the HPD is a desperate maladaptive defense system where the
individual tries to remain the center of attention as a way of coping with
pain/stress. They often seem to be acting like a toddler in many respects.
It's commonly associated with the BPD and anxiety disorders, and is usually
worse under stress - the "drama queen" that you described. I've had many
patients with the HPD who did much better when the other problems were
treated, and they worked to be better. They have considerable learning to
do regarding social skills.
Every problem has the same process: 1) make all the diagnoses, 2) treat all
the medical problems, 3) retrain the brain.

There is a lot more. But I think I illustrated the point. The strong
correlation between BPD and NPD is part of the mainstream of psychology.

Dr. Sam Vaknin
Capital Markets Institute Ltd.
E-mail : vaknin@terminal.cz
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