Can bipolar disorder be misdiagnosed as narcissism?

Answer 1

The manic phase of Bipolar I Disorder is often misdiagnosed as Narcissistic Personality Disorder (NPD).

Bipolar patients in the manic phase exhibit many of the signs and symptoms of pathological Narcissism - hyperactivity, self-centeredness, lack of empathy, and control freakery. During this recurring chapter of the disease, the patient is euphoric, has grandiose fantasies, spins unrealistic schemes, and has frequent rage attacks (is irritable) if her or his wishes and plans are (inevitably) frustrated.

The manic phases of the Bipolar disorder, however, are limited in time - NPD is not. Furthermore, the mania is followed by - usually protracted - depressive episodes. The narcissist is also frequently dysphoric. But whereas the bipolar sinks into deep self-deprecation, self-devaluation, unbounded pessimism, all-pervasive guilt and anhedonia - the narcissist, even when depressed, never forgoes his narcissism: his grandiosity, sense of entitlement, haughtiness, and lack of empathy.

Narcissistic dysphorias are much shorter and reactive - they constitute a response to the Grandiosity Gap. In plain words, the narcissist is dejected when confronted with the abyss between his inflated self-image and grandiose fantasies - and the drab reality of his life: his failures, lack of accomplishments, disintegrating interpersonal relationships, and low status. Yet, one dose of Narcissistic Supply is enough to elevate the narcissists from the depth of misery to the heights of manic euphoria.

Not so with the bipolar. The source of her or his mood swings is assumed to be brain biochemistry - not the availability of Narcissistic Supply. Whereas the narcissist is in full control of his faculties, even when maximally agitated, the bipolar often feels that s/he has lost control of his/her brain ("flight of ideas"), his/her speech, his/her attention span (distractibility), and his/her motor functions.

The bipolar is prone to reckless behaviors and substance abuse only during the manic phase. The narcissist does drugs, drinks, gambles, shops on credit, 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 his/her social and occupational functioning. Many narcissists, in contrast, reach the highest rungs of their community, church, firm, or voluntary organization. Most of the time, they function flawlessly - though the inevitable blowups and the grating extortion of Narcissistic Supply usually put an end to the narcissist's career and social liaisons.

The manic phase of bipolar sometimes requires hospitalization and - more frequently than admitted - involves psychotic features. Narcissists are never hospitalized as the risk for self-harm is minute. Moreover, psychotic microepisodes in narcissism are decompensatory in nature and appear only under unendurable stress (e.g., in intensive therapy).

The bipolar's mania provokes discomfort in both strangers and in the patient's nearest and dearest. His/her constant cheer and compulsive insistence on interpersonal, sexual, and occupational, or professional interactions engenders unease and repulsion. Her/his lability of mood - rapid shifts between uncontrollable rage and unnatural good spirits - is downright intimidating. The narcissist's gregariousness, by comparison, is calculated, "cold", controlled, and goal-orientated (the extraction of Narcissistic Supply). His cycles of mood and affect are far less pronounced and less rapid.

The bipolar's swollen self-esteem, overstated self-confidence, obvious grandiosity, and delusional fantasies are akin to the narcissist's and are the source of the diagnostic confusion. Both types of patients purport to give advice, carry out an assignment, accomplish a mission, or embark on an enterprise for which they are uniquely unqualified and lack the talents, skills, knowledge, or experience required.

But the bipolar's bombast 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:

Sleep disorders - notably acute insomnia - are common in the manic phase of bipolar and uncommon in narcissism. So is "manic speech" - pressured, uninterruptible, loud, rapid, dramatic (includes singing and humorous asides), sometimes incomprehensible, incoherent, chaotic, and lasts for hours. It reflects the bipolar's inner turmoil and his/her inability to control his/her racing and kaleidoscopic thoughts.

As opposed to narcissists, bipolar in the manic phase are often distracted by the slightest stimuli, are unable to focus on relevant data, or to maintain the thread of conversation. They are "all over the place" - simultaneously initiating numerous business ventures, joining a myriad organization, writing umpteen letters, contacting hundreds of friends and 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 their projects.

The transformation is so marked that the bipolar is often described by his/her closest as "not himself/herself". Indeed, some bipolars relocate, change name and appearance, and lose contact with their "former life". Antisocial or even criminal behavior is not uncommon and aggression is marked, directed at both others (assault) and oneself (suicide). Some biploars describe an acuteness of the senses, akin to experiences recounted by drug users: smells, sounds, and sights are accentuated and attain an unearthly quality.

As opposed to narcissists, bipolars regret their misdeeds following the manic phase and try to atone for their actions. They realize and accept that "something is wrong with them" and seek help. During the depressive phase they are ego-dystonic and their defenses are autoplastic (they blame themselves for their defeats, failures, and mishaps).

Finally, pathological narcissism is already discernible in early adolescence. The full-fledged bipolar disorder - including a 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 episode is fast and furious and results in a conspicuous metamorphosis of the patient.

More about this topic here:

Stormberg, D., Roningstam, E., Gunderson, J., & Tohen, M. (1998) Pathological Narcissism in Bipolar Disorder Patients. Journal of Personality Disorders, 12, 179-185

Roningstam, E. (1996), Pathological Narcissism and Narcissistic Personality Disorder in Axis I Disorders. Harvard Review of Psychiatry, 3, 326-340

Vaknin, Sam - Malignant Self Love - Narcissism Revisited, 8th revised impression - Skopje and Prague, Narcissus Publications, 2007

Asperger's Disorder is often misdiagnosed as Narcissistic Personality Disorder (NPD), though evident as early as age 3 (while pathological narcissism cannot be safely diagnosed prior to early adolescence).

In both cases, the patient is self-centered and engrossed in a narrow range of interests and activities. Social and occupational interactions are severely hampered and conversational skills (the give and take of verbal intercourse) are primitive. The Asperger's patient body language - eye to eye gaze, body posture, facial expressions - is constricted and artificial, akin to the narcissist's. Nonverbal cues are virtually absent and their interpretation in others lacking.

Yet, the gulf between Asperger's and pathological narcissism is vast.

The narcissist switches between social agility and social impairment voluntarily. His social dysfunctioning is the outcome of conscious haughtiness and the reluctance to invest scarce mental energy in cultivating relationships with inferior and unworthy others. When confronted with potential Sources of Narcissistic Supply, however, the narcissist easily regains his social skills, his charm, and his gregariousness.

Many narcissists reach the highest rungs of their community, church, firm, or voluntary organization. Most of the time, they function flawlessly - though the inevitable blowups and the grating extortion of Narcissistic Supply usually put an end to the narcissist's career and social liaisons.

The Asperger's patient often wants to be accepted socially, to have friends, to marry, to be sexually active, and to sire offspring. He just doesn't have a clue how to go about it. His affect is limited. His initiative - for instance, to share his experiences with nearest and dearest or to engage in foreplay - is thwarted. His ability to divulge his emotions stilted. He is incapable or reciprocating and is largely unaware of the wishes, needs, and feelings of his interlocutors or counterparties.

Inevitably, Asperger's patients are perceived by others to be cold, eccentric, insensitive, indifferent, repulsive, exploitative or emotionally-absent. To avoid the pain of rejection, they confine themselves to solitary activities - but, unlike the schizoid, not by choice. They limit their world to a single topic, hobby, or person and dive in with the greatest, all-consuming intensity, excluding all other matters and everyone else. It is a form of hurt-control and pain regulation.

Thus, while the narcissist avoids pain by excluding, devaluing, and discarding others - the Asperger's patient achieves the same result by withdrawing and by passionately incorporating in his universe only one or two people and one or two subjects of interest. Both narcissists and Asperger's patients are prone to react with depression to perceived slights and injuries - but Asperger's patients are far more at risk of self-harm and suicide.

The use of language is another differentiating factor.

The narcissist is a skilled communicator. He uses language as an instrument to obtain Narcissistic Supply or as a weapon to obliterate his "enemies" and discarded sources with. Cerebral narcissists derive Narcissistic Supply from the consummate use they make of their innate verbosity.

Not so the Asperger's patient. He is equally verbose at times (and taciturn on other occasions) but his topics are few and, thus, tediously repetitive. He is unlikely to obey conversational rules and etiquette (for instance, to let others speak in turn). Nor is the Asperger's patient able to decipher nonverbal cues and gestures or to monitor his own misbehavior on such occasions. Narcissists are similarly inconsiderate - but only towards those who cannot possibly serve as Sources of Narcissistic Supply.

More about Autism Spectrum Disorders here:

McDowell, Maxson J. (2002) The Image of the Mother's Eye: Autism and Early Narcissistic Injury , Behavioral and Brain Sciences (Submitted)

Benis, Anthony - "Toward Self & Sanity: On the Genetic Origins of the Human Character" - Narcissistic-Perfectionist Personality Type (NP) with special reference to infantile autism

Stringer, Kathi (2003) An Object Relations Approach to Understanding Unusual Behaviors and Disturbances

James Robert Brasic, MD, MPH (2003) Pervasive Developmental Disorder: Asperger Syndrome

Vaknin, Sam - Malignant Self Love - Narcissism Revisited, 8th revised impression - Skopje and Prague, Narcissus Publications, 2007

Based on my book "Malignant Self Love - Narcissism Revisited"

(c) 2007 Lidija Rangelovska Narcissus Publications

AnswerIt would seem to me that Bipolar and some forms of Autism are equally likely to be misdiagnosed as NPD.

Psychiatry is, in many ways, an inexact science, and diagnosis can often be prettyy subjective, relating as much to the specialisation and intellectual preferences if the practitioner as to the nature of the patient.

For instance a neurochemical specialist is unlikely to diagnose any personality disorder as the very concept argues with his core philosophy...likewise a behaviourist is extremelly unlikely to be comfortable diagnosing autism or neurochemical bipolar.

This is why it is SO important not to generalise too much about any mental disorder, because there will always be a varied spectrum of individuals presenting with entirely different symptoms hung with the same label ... some of whom would never have been hung with that label AT ALL by many other practitioners.

The DSM is an imperfect "color chart" for the spectrum of human nature.

There are no absolutes.

AnswerFabulous article!

I am medicated for a bipolar condition (together with anxiety/compulsive disorders) and diagnosed with Autism. I get extremely manic and euphoric but know crashing nutso lows too in which I am certainly far far from narcissistic... in fact I doubt I have ever been worth the air I breathe when I'm in that state... but mania is certainly a state in which I have had immense idiotic ideas about changing huge world events (as us nutters do) and whilst that's narcissistic, mine are always really generous, like I think I could bring about world peace and solve all religious differences and bonkers like that... and my father had this and sometimes thought he could cure cancer or was Jesus or Elvis but he was not actually a narcissist. There isn't anyone I know who has had mania who hasn't driven someone nuts with 'me me me' stuff. that doesn't make them narcissists though and some of the loveliest, most giving people I know have bipolar.

I know that my father didn't have NPD because he loved people in their own right, not just for what they could give/do for him. I also had the contrast around me of a relative who was extremely solitary and very much saw pretty much all human beings as inferior and looked for their 'use'/reflection upon them and for that person it was not a happy space for them or anyone like me who loved people or life or the world like some mad optimist. I'd like to say this was the last one like this, but it wasn't. So I can recognise both bipolar relatives without narcissism and narcissistic ones without clear bipolar.

As for Autism and narcissism,I have met some Auties who would qualify as having both as Autism is not a personality state so an autie can have any personality trait as well as Autism. There is also a new work coming out called Spoiled Child Syndrome which has been confused with Autism.

I doubt very much whether anyone who JUST had narcissistic personality disorder could be diagnosed with Autism as that's pretty full on and the language disorder aspect wouldn't be accounted for by NPD if the person had clearly dysfunctional language or regression at age two but its possible that some with late speech may have felt others were 'unworthy' of their communication, but that would be soooooooo easy to confuse with others who couldn't dare to speak out of excessive shyness or anxiety such as those with Sensitive-Avoidant Personality or those who simply couldn't handle intimacy like Solitary-Schizoid folks or those who couldn't handle entanglement and struggled to trust like Vigilant-Paranoid folks or or or so it is way too hard to simply associate non-speech with NPD as even if its got ANYTHING to do with personality it could be a range of other personaity issues, not to mention depression.

And when it comes to personality if someone were Solitary and Vigilant and had no interest in intimacy or entanglement they could easily be mislabelled as NPD unless they also had traits that opened them up to giving to others like the Self Sacrificer trait or the generosity of the Artistic type. So It'd be sad if folks who were simply very Solitary and Vigilant were considered 'selfish' as this is always such a sad social judgment placed on these people just because they prefer to remain relatively uninvolved. Anyway, that's my view....

Answer

As a mother of a child who is 14 and has struggled all throughout his school years with several diagnosis all clinical (meaning diagnosed by a survey on behaviors) I have fought schools, gone through therapy, read books, changed everything about my life and home to meet the diagnosis of ADHD. This child we have now discovered is possible autistic in he is intellegent, and is able to learn, but has a problem socially. Now after discovery he was in a court ordered probation due to me calling to protect all children involved in my own home the system penalized him instead of helping him. When the discovery came about that the school failed to access in all areas of disability back when the child was in 4th grade we bring this to the attention of the new school and the placement to have them kick him out for things that were not suppose to get you kicked out and then to have to fight to make the wrong for everyone who did not do there job right. I would say after medicating my child, letting them add more labels blaming his poor academics on his "Bad Behavior" as the school puts it. If a child has Aspergers they have a hard time relating to their peers, expressing themselves verbally, the list goes on. When this placement kicked him out they made this minor signed a paper that he was narcissitic and egocentric. Which is an excuse not to properly identify in all areas of disabilities and an excuse to not have to admit to but blame the child for Failure to Adjust.

Neurological Disorders need to be diagnosed by Nuerologist and NueroPsychs not just Psychiatrist or Psychologist. The psychotropic meds are harming our childrens growing brains. To many slip through the cracks and our juvenile penal system believes in rehabilitation but yet they are not helping by keeping children doped up on psychotropic meds instead of making sure the diagnosis was correct to began with. It would save our budget and our future.

AnswerMy father seems to me to clearly have NPD. However my eldest sister recently took him to a professional to ask if he may have Aspergers. She thought this likely as he is wierd in a high functioning autistic way and she believes that he is brilliant. She would not have mentioned that he sexually abused others of us (he has seven children) as he has strongly denied this and she believes him, and I presume she did not ask for a diagnoses of anything other than Aspergers. One of the tests was to judge emotions by looking at photoes of peoples eyes, which he failed spectacularly. I have heard of this second hand as I do not have anything to do with my Dad and do not talk about this to my eldest sister. While I can see that he has many traits of someone with Aspergers, his abuse of us, and clear pursuit of narcissistic supply, and particularly the fact that the way to stop him pushing himself into my life was simply to be clear and strong about what he did to me seems that NPD is still a good diagnosis. Autism/Aspergers may be misdiagnosed as NPD, but might it be possible that someone has both, or that the misdiagnosis could be the other way. diagnosesNo matter what the disorder or condition. You should allways see a medical physician to rule out any and all physical problems. Children in particular. Hearing and eyesight problems are notorious for "creating" disorders. and don't trust the school system to give you an accurate diagnoses. Also Allergies to food cause "hyperactivity".

In adults things like Thyroid imbalance, cancer, or brain tumors cause personality problems and depression etc., or can excacerbate an already pre-exisiting condition.

and last of all Narcisssists are physically human so likey to suffer other disorders like the rest of us. If anything it makes them suffer more because it reminds them they too are not imortal.

answerI would think that because NPD is difficult to track down and diagnose.. that it would be far more common to have a narcissist be wrongly "diagnosed" as Bipolar or Autistic as oposed to the other way around. I had a roomate long ago who was originally diagnosed treated for Bulimia. After another year of psychiatric treatment and evaluations she was diagnosed as having Narcissistic Pesonality Disorder. The bulimia was just a symptom. Ironically I was just recovering from my first run in with an N when i was hooked up with her. (not my idea) She did things to stab me in the back then came back to me as a friend and i rejected her. She was very upset and went on a bulemic binge again. Once you get burned by an N you tend to be on guard for other postential N's diagnosed or not. Let's just say you should be on guard for anyone with Narcisssitic traits.

answer

I do not believe they are the same. I've worked with both. The lies, manipulation, and bizarre attention seeking behavior does not seem essential to autism. There may be a relation of empathy, vigilant behavior, some obsessions, and other behaviors that may be appear with both. That said, I wouldn't be surprised if many are misdiagnosed. I also can relate to the previous answer. Someone with NPD can wear you down quickly and put you on defense for similar behaviors.

To Spoil or Not To Spoil

Mr. Vankin - Your narcissism shines through in every post I read. You are a very smart individual and in a way your efforts are helpful but I believe it would serve you better to tone it down a bit and offer more encouragement. Even the placebo effect of offering hope can help some people and isn't that really what its all about.

The deep depression that sometimes accompanies the severe narcissistic injury does sometimes require hospitalization. As usual, you speak from your own experiences like they are everyone else's. The realization that a person actually despises one's own mother, and the attending search for the reason's why, can often send someone spiraling into the abyss. This I'm sure you are aware of.

The labels are just that, multisyllabic words used by 'professionals' to guard the gate. All the diagnosis point to one thing, abandonment. Adults with MPD, NPD, OCD, ADD, etc. were children at one time who weren't seen by their caregivers as separate human entities, but sex toys, punching bags or annoyances to be quieted at all costs. The parents didn't have the emotional fortitude due to their own similar experiences.

To all of you listening to Mr. Vankin, please take his explanations with a grain of salt, he is a highly functioning 'narcissist' who profits from his education (absolutely nothing wrong with that). I too have this issue, as we all do to some degree. Until Mr. Freud, it was called 'spoiled'. With the advent of TV as a babysitter and our society's removal of the father from the family structure, we are simply reaping what we have sown (some of you will reach for the mouse at that biblical reference so let's say get what you give.)

It's like this. Everyone sits on sliding scale from complete selfishness to complete altruism. Think Hitler to Gandhi. All of us get most of our position on this scale from our parents or the other adults in our environment. That means if your child has a sense of entitlement he most assuredly got it from his parents. As they say, the truth hearts but all this looking to the 'mental health industry' is simply people attempting to absolve themselves of the responsibility for their own actions. If you overindulged your child to keep them quiet as a flowering 2 year old, guess what? He or she will be a selfish 5, 10, 20, and 40 year old that thinks the world revolves around them. The harsh reality often shows itself as deep depression and all the other 'disorders'.

Here's a prime example. While sitting in my therapist's lobby a couple days ago, I noticed a mother and her 10yr old son sitting close. Mom was all over the kid, doing his homework for him, using language fit for a 3 year-old, and holding him like a baby. Guess who really needed the therapy? This poor boy will be lost like a tiger in Tupelo in 10 years if she doesn't get a quick handle on her behavior. But guess what? The therapist will direct his efforts towards the child not to upset the payer of the bill out of fear she will go somewhere else to find her answers. And this will do more damage to the child.

Folks, the answers are within. Only when a person realizes this basic fact of life does real change happen. We are tilting at windmills looking for someone else to take away the pain. Perspective is critical. Next time you think you have it so bad, poor some hot tea, Google 'holocaust photos' and get a good dose of the perspective heaven in which you currently reside.

Make it a great day!

Answer 2

It is possible, though highly improbable, that a hypomanic state may lead to a diagnosis of Narcissistic Personality Disorder.

What mitigates against this is that Bipolar patients nearly invariably first seek treatment for the depressive features of the condition, resulting in many Bipolar patients being misdiagnosed as depressives. When manic symptoms first require intervention, they are invariably the result of full blown manias, often with psychotic features.

Such manias are clinically unmistakable due to the energy levels involved (the patient, under observation, may not sleep for days on end), and the frankly delusional nature of the the self regard.

Answer 3

I certainly hope it hasn't been because that's not an easy mistake to make.