Differential Diagnosis

 
 

Axis I Disorders

 
 
 

Depressive isorders

 

Although persons with Narcissistic Personality Disorder (NPD) will report feelings of “emptiness,” their experience of this hollowness does not include a need for the companionship of others.  In contrast to the person with depression, the person with NPD will describe feelings of boredom and a restlessness associated with that boredom).  “Narcissistic patients often do not have available the sense of longing for or of awareness of the possibility of a significant relation with others and of missing such a relation.”¹
 
 

Manic or Hypomanic Episodes

 

Although grandiosity may be seen in Manic or Hypomanic Episodes, the association with mood change or functional impairment helps distinguish these episodes from Narcissistic Personality Disorder.

“Patients in Hypomanic and acute manic phase can appear quite similar to narcissistic patients and actually expose most of the core characteristics for NPD . . . .  However, the active search for admiring attention and profound envy of others in narcissistic patients are not found in manics.”²
 
 

Chronic Substance Use

 

It is important to distinguish the symptoms of NPD from those that may develop in association with chronic substance use.
 
 

Brief Psychotic Episodes

 

There may be a predisposition in persons diagnosed with NPD.³
 
 
 

Axis II Disorders

 

The DSM-IV-R⁴ observes that other personality disorders share features associated with Narcissistic Personality Disorder (NPD) and that, therefore, diagnosis can be difficult.  For this reason careful attention must be paid to distinguishing among these disorders according to the differences in their characteristic features.

NOTE:  If someone presents with features meeting the criteria for one or more additional personality disorder as well as for Narcissistic Personality Disorder, then all disorders can be diagnosed.

Grandiosity is the most useful feature for distinguishing Narcissistic Personality Disorder from the other Cluster B Personality Disorders (Histrionic, Antisocial, and Borderline), “whose interactive styles are respectively coquettish, callous, and needy.”⁵   Moreover, while persons with Borderline (BPD), Histrionic (HPD), and Narcissistic personality disorders may require much attention, in contrast to BPD and HPD, for those with Narcissistic Personality Disorder this attention must be admiring.

Additional distinctions can be drawn between Narcissistic Personality Disorder and other Personality Disorders:
 

Features Distinguishing NPD   from Borderline Personality Disorder

 

NPD’s relative stability of self-image, lack of self-destructiveness, impulsivity, and abandonment concerns.

O. Kernberg differentiates between the person with NPD and those with borderline personality disorder (BPD) on the basis of, “their relatively good social functioning, their better impulse control, and what may be described as a ‘pseudosublimatory’ potential, namely, the capacity for active, consistent work in some areas which permits them partially to fulfill their ambitions of greatness and of obtaining admiration from others.  Highly intelligent patients with this personality structure may appear as quite creative in their fields:  narcissistic personalities can often be found as leaders in industrial organizations or academic institutions; they may also be outstanding performers in some artistic domain.  Careful observation, however, of their productivity over a long period of time will give evidence of superficiality and flightiness in their work, of a lack of depth which eventually reveals the emptiness behind the glitter.  Quite frequently these are the ‘promising’ geniuses who then surprise other people by the banality of their development.  They also are able to exert self-control in anxiety-producing situations, which may at first appear as good anxiety tolerance; however, analytic exploration shows that their anxiety tolerance is obtained at the cost of increasing their narcissistic fantasies and of withdrawing into ‘splendid isolation.’ This tolerance of anxiety does not reflect an authentic capacity for coming to terms with a disturbing reality.

“In short, the surface functioning of the narcissistic personality is much better than that of the average borderline patient:  therefore, their capacity for regression—even to the level of psychotic functioning when undergoing psychoanalysis—may come as a real surprise to the analyst.”⁶

Except for instances of severe forms of NPD, these individuals are more capable of high, sustained achievement and will have a more successful work history than the person with Borderline Personality Disorder.

Both persons with NPDs and BPDs place great importance on attention; however, unlike borderlines, who “seek nurturing attention because they need it, narcissists feel they deserve admiring attention because of their superiority.”⁷

Persons with either Narcissistic Personality Disorder or Borderline Personality Disorder have weak interpersonal relationships, are unable to love others, have difficulty empathizing, are egocentric in their perceptions of reality, and have a great need for attention.  Unlike the borderline personality, however, because the personality of someone with NPD is more well-integrated, people with NPD are less likely to have episodes of psychotic states, especially when under stress.

A key distinguishing feature of BPD is neediness; in contrast, for NPD an important discriminator is grandiosity.  Likewise, persons with NPD are less self-destructive, have better impulse control, a higher tolerance for anxiety, and are less preoccupied with dependency and abandonment issues than are BPDs.⁸

Finally, the self-mutilation and persistent overt rage that are often characteristic of the borderline personality are absent in NPD.
 
 

Features Distinguishing NPD from    Histrionic Personality Disorder

 

While the characteristic distinguishing feature of Histrionic Personality Disorder (HPD) is coquettishness, that of NPD is grandiosity.

Both personality types tend towards the demonstrative, exhibitionistic, dramatic and seductive in their behavior.  What distinguishes these qualities in the person with NPD are the person's haughty, cold, and exploitative attitudes.  In contrast, the person with HPD is warm and playful and can be dependent on others; moreover, these individuals are capable of love, empathy and concern whereas those with NPD are not.  Finally, the behavior of the person with NPD has the qualities of being controlled, calculated and relentless in its objectives, while that of the person with HPD is more spontaneous and without ulterior motives.⁹

The person with NPD has not developed “the seductive strategies of the histrionic person to solicit rewards and protections.”¹⁰
 
 

Features Distinguishing NPD from  Antisocial Personality Disorder

 

The narcissist's key characteristic is grandiosity, whereas that of the antisocial is callousness.

While persons with Narcissistic Personality Disorder and Antisocial Personality Disorder (ASPD) share tendencies to be tough-minded, glib, superficial, exploitative, and unempathic, NPD does not necessarily include characteristics of impulsivity, aggression, and deceit.  In contrast to the person with NPD, the person with ASPD may not have as great a need for the admiration and envy of others.  And, unlike the person with ASPD, someone with Narcissistic Personality Disorder usually does not have a history of childhood Conduct Disorder nor of criminal behavior as adults.

“All antisocials are assumed to have a narcissistic personality structure, but not all narcissists are antisocial.  The most important differential features are the more severe superego pathology [in the ASPD]—that is, lack of concern and understanding of moral functions, and the impaired capacity to be involved in mutual, nonexploitive relationships found in ASPD.  Interpersonal and affective manifestations (anxiety and depression) are more pronounced in NPD, while [ASPDs] show more acting out, particularly with drug and alcohol abuse.  Narcissists are usually more grandiose, while ASPD patients are exploitive, have a superficial value system, and are involved in recurrent antisocial activities . . . .  Exploitiveness in antisocial patients is probably more likely to be consciously and actively related to materialistic or sexual gain, while exploitive behavior in narcissistic patients is more passive, serving to enhance self-image by attaining praise or power.¹¹

Unlike a person with ASPD, the person with NPD has “not learned to be ruthless or competitively assertive and aggressive when frustrated.”¹²

A critical distinguishing feature is that in Antisocial Personality Disorder, there are no feelings of guilt or remorse:  “. . . even after being confronted with the consequences of their antisocial behavior and in spite of their profuse protestations of regret, persons with antisocial personality disorder have no change in behavior toward those they have attacked or exploited or any spontaneous concern over this failure to change their behavior.”¹³
 
 

Features Distinguishing NPD from  Obsessive-Compulsive Personality Disorder

 

Individuals with both NPD and OCPD may be perfectionists, believe that others cannot do things as well as they can, have a strong need to control and be emotionally cold.  Rather than being self-critical like the person with Obsessive-Compulsive Personality Disorder, however, someone with Narcissistic Personality Disorder is more likely to believe that he or she has actually achieved perfection.  Moreover, the perfection of persons with OCPD does not take the form of devaluing or being contemptuous of others, demanding admiration, or behaving in a haughty manner.¹⁴   As Akhtar and Thomson observed, “The obsessional seeks perfection; the narcissist claims it.”¹⁵

The value systems of these two personality types differ as well:  the person with OCPD has deeply held, rigid but genuine moral and sociopolitical beliefs.  In contrast, the person with NPD might espouse such deeply held values but actually lacks any true commitment to them.¹⁶
 
 

Features Distinguishing NPD from  Paranoid or Schizotypal Personality Disorder

 

Persons with Narcissistic, Paranoid, or Schizotypal personality disorders can exhibit social withdrawal and suspiciousness.  However, if these features present in those with Narcissistic Personality Disorder, the behaviors result from the person’s fear of having his or her imperfections or failures found out by others.

Although people with these disorders all display grandiosity, “. . . the paranoid person’s grandiosity is usually connected to self-righteousness and self-justifying argumentation, and his or her anger is unrelated to exploitiveness or envy . . . .  Narcissistic and paranoid individuals can also share devaluation, sensitivity to criticism, and lack of empathy . . . .  However, narcissists are more exploitive, envious, attention seeking, arrogant, and not pervasively mistrustful or in search of hidden motives.  NPD patients sometimes show brief paranoid ideations, usually related to the belief that other people envy them and want to hurt them, or spoil their achievements . . . .  People functioning on a lower level with malignant narcissism [NPD] or borderline features can nevertheless manifest sustained paranoid features.”¹⁷
 
 

Features Distinguishing NPD from  Schizoid  Personality Disorder

 

“Emotional aloofness and lack of mutual interpersonal relations or genuine deep interest in other people are common characteristics in both schizoid and narcissistic personality disorders.  While narcissists are ambitious and high achieving, more actively in pursuit of advantageous or admiring relations, and more exploitive, the schizoid individual is passive, withdrawn, and resigned . . . .  However, contrary to narcissists, schizoid individuals actually show a capacity to empathize with other people and to observe, describe, and evaluate others with depth and differentiation . . . .  In addition, a sense of superiority . . . , inclinations toward a cognitive, intellectual style (as contrary to an emotional, bodily anchored style); and the presence of compensatory internal life and grandiose fantasies can be found in both personality disorders.  While narcissists can appear flamboyant and charming, schizoid persons are indifferent, and colorless.”¹⁸
 
 

Features Distinguishing NPD from  Paranoid Psychosis or Schizophrenia   with Grandiose Delusions

 

“Although grandiosity occurs in both NPD and psychotic disorders, the presence of psychotic illness and loss of reality testing contraindicate a diagnosis of NPD . . . .”¹⁹   Unlike persons with NPD, these individuals retain a capacity to feel empathy for others and to feel lonely, that is miss the companionship of others.  Loneliness, for the person with NPD, is an emptiness “characterized by the addition of strong feelings of boredom and restlessness.  They do not have available certain aspects of the capacity for human relationships which are preserved—in their own way—by schizoid, and (even more so) by depressive patients.  Patients with depressive personality, and even schizoid patients, are able to empathize deeply with human feelings and experiences involving other people, and may feel painfully excluded from and yet able to empathize with love and emotion involving others.”²⁰
 

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Click on the note number to return to where you were above; click on the author's name to go to the bibliographic entry.

¹O. Kernberg, 1984, p. 219
²Ronningstam, 1999, p. 682
³APA, 1987, p. 330
⁴APA, 2000, p. 716
⁵APA, 2000
⁶O. Kernberg, 1984, pp. 229-230
⁷Ronningstam, 1999, p. 681
⁸Ronningstam, 1999; Akhtar and Thomson, 1982
⁹Ronningstam, 1999
¹⁰Millon, 1998, p. 87
¹¹Ronningstam, 1999, p.81
¹²Millon, 1998, p. 86
¹³O. Kernberg, 1998, p. 43
¹⁴Ronningstam, 1991
¹⁵Akhtar & Thomson, 1982, p. 18
¹⁶Akhtar & Thomson, 1982
¹⁷Ronningstam, 1999, p. 682
¹⁸Ronningstam, 1999, p. 682
¹⁹Ronningstam, 1999, p. 682
²⁰O. Kernberg, 1984, pp. 217-218