Differential Diagnosis (2024)

Differential Diagnosis

Axis I Disorders

Depressive isorders

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

Manic or HypomanicEpisodes

Although grandiosity may beseen in Manic or Hypomanic Episodes, the association with mood change orfunctional impairment helps distinguish these episodes from NarcissisticPersonality Disorder.

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

Chronic SubstanceUse

It is important to distinguishthe symptoms of NPD from those that may develop in association with chronicsubstance use.

Brief Psychotic Episodes

There may be a predispositionin persons diagnosed with NPD.³

Axis II Disorders

See Also

Cluster C Personality Disorders: Living with Fear and AnxietyPersonality Disorders – Fundamentals of Psychological DisordersThe Ten Personality Disorders: Cluster A Personality DisordersParanoid Personality Disorder (PPD): Symptoms & Treatment

The DSM-IV-R⁴observes that other personality disorders share features associated withNarcissistic Personality Disorder (NPD) and that, therefore, diagnosiscan be difficult. For this reason careful attention must be paidto distinguishing among these disorders according to the differences intheir characteristic features.

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

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

Additional distinctions canbe drawn between Narcissistic Personality Disorder and other PersonalityDisorders:

Features DistinguishingNPD
from Borderline PersonalityDisorder

NPD’s relative stability ofself-image, lack of self-destructiveness, impulsivity, and abandonmentconcerns.

O. Kernberg differentiatesbetween the person with NPD and those with borderline personality disorder(BPD) on the basis of, “their relatively good social functioning, theirbetter impulse control, and what may be described as a ‘pseudosublimatory’potential, namely, the capacity for active, consistent work in some areaswhich permits them partially to fulfill their ambitions of greatness andof obtaining admiration from others. Highly intelligent patientswith this personality structure may appear as quite creative in their fields:narcissistic personalities can often be found as leaders in industrialorganizations or academic institutions; they may also be outstanding performersin some artistic domain. Careful observation, however, of their productivityover a long period of time will give evidence of superficiality and flightinessin their work, of a lack of depth which eventually reveals the emptinessbehind the glitter. Quite frequently these are the ‘promising’ geniuseswho 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, analyticexploration shows that their anxiety tolerance is obtained at the costof increasing their narcissistic fantasies and of withdrawing into ‘splendidisolation.’ This tolerance of anxiety does not reflect an authentic capacityfor coming to terms with a disturbing reality.

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

Except for instances of severeforms of NPD, these individuals are more capable of high, sustained achievementand will have a more successful work history than the person with BorderlinePersonality Disorder.

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

Persons with either NarcissisticPersonality Disorder or Borderline Personality Disorder have weak interpersonalrelationships, are unable to love others, have difficulty empathizing,are egocentric in their perceptions of reality, and have a great need forattention. Unlike the borderline personality, however, because thepersonality of someone with NPD is more well-integrated, people with NPDare less likely to have episodes of psychotic states, especially when understress.

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

See Also

What Is the Hardest Mental Illness to Live With? - Illinois Recovery Center

Finally, the self-mutilationand persistent overt rage that are often characteristic of the borderlinepersonality are absent in NPD.

Features DistinguishingNPD from
Histrionic PersonalityDisorder

While the characteristic distinguishingfeature of Histrionic Personality Disorder (HPD) is coquettishness, thatof NPD is grandiosity.

Both personality types tendtowards the demonstrative, exhibitionistic, dramatic and seductive in theirbehavior. What distinguishes these qualities in the person with NPDare 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 whereasthose with NPD are not. Finally, the behavior of the person withNPD has the qualities of being controlled, calculated and relentless inits objectives, while that of the person with HPD is more spontaneous andwithout ulterior motives.⁹

The person with NPD has notdeveloped “the seductive strategies of the histrionic person to solicitrewards and protections.”¹⁰

Features DistinguishingNPD from
Antisocial PersonalityDisorder

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

While persons with NarcissisticPersonality Disorder and Antisocial Personality Disorder (ASPD) share tendenciesto be tough-minded, glib, superficial, exploitative, and unempathic, NPDdoes not necessarily include characteristics of impulsivity, aggression,and deceit. In contrast to the person with NPD, the person with ASPDmay not have as great a need for the admiration and envy of others.And, unlike the person with ASPD, someone with Narcissistic PersonalityDisorder usually does not have a history of childhood Conduct Disordernor of criminal behavior as adults.

“All antisocials are assumedto have a narcissistic personality structure, but not all narcissists areantisocial. The most important differential features are the moresevere superego pathology [in the ASPD]—that is, lack of concern and understandingof moral functions, and the impaired capacity to be involved in mutual,nonexploitive relationships found in ASPD. Interpersonal and affectivemanifestations (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 antisocialactivities . . . . Exploitiveness in antisocial patients is probablymore likely to be consciously and actively related to materialistic orsexual gain, while exploitive behavior in narcissistic patients is morepassive, 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 assertiveand aggressive when frustrated.”¹²

A critical distinguishing featureis that in Antisocial Personality Disorder, there are no feelings of guiltor remorse: “. . . even after being confronted with the consequencesof their antisocial behavior and in spite of their profuse protestationsof regret, persons with antisocial personality disorder have no changein behavior toward those they have attacked or exploited or any spontaneousconcern over this failure to change their behavior.”¹³

Features DistinguishingNPD from
Obsessive-CompulsivePersonality Disorder

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

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

Features DistinguishingNPD from
Paranoid or SchizotypalPersonality Disorder

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

Although people with thesedisorders all display grandiosity, “. . . the paranoid person’s grandiosityis 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, sensitivityto criticism, and lack of empathy . . . . However, narcissists aremore exploitive, envious, attention seeking, arrogant, and not pervasivelymistrustful or in search of hidden motives. NPD patients sometimesshow brief paranoid ideations, usually related to the belief that otherpeople 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 paranoidfeatures.”¹⁷

Features DistinguishingNPD from Schizoid
Personality Disorder

“Emotional aloofness and lackof mutual interpersonal relations or genuine deep interest in other peopleare common characteristics in both schizoid and narcissistic personalitydisorders. While narcissists are ambitious and high achieving, moreactively 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 acapacity to empathize with other people and to observe, describe, and evaluateothers with depth and differentiation . . . . In addition, a senseof superiority . . . , inclinations toward a cognitive, intellectual style(as contrary to an emotional, bodily anchored style); and the presenceof compensatory internal life and grandiose fantasies can be found in bothpersonality disorders. While narcissists can appear flamboyant andcharming, schizoid persons are indifferent, and colorless.”¹⁸

Features DistinguishingNPD from
Paranoid Psychosisor Schizophrenia
with Grandiose Delusions

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

Click on the note number to return to whereyou 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
¹⁵, p. 18
^16
17Ronningstam,1999, p. 682
¹⁸Ronningstam,1999, p. 682
¹⁹Ronningstam,1999, p. 682
²⁰O.Kernberg, 1984, pp. 217-218