10. The Personality Disordered

They are mortified by the increasing probability of abandonment following their behavior.

Each PD has its own "story", a "narrative". The way to healing is replete with the residues of these narratives. To heal, a PD MUST break through his or her narrative and OUT into the world while assuming personal responsibility.

All PDs engage in scapegoating and bag-punching. To the personality disordered, their parents, abusers, the world, God, or history are responsible for what they are and for what they do DECADES after the original abuse. Research shows that the brain is more plastic than many thought. I can CHOOSE to heal. If I don't - it is because I gain from my infirmity. The same is true for BPDs, AsPDs and every other PD.

11. Robert Hare

Robert Hare is considered to be a heretic in DSM IV terms. His PCL-R was severely criticized by the compilers of DSM IV (especially after he insisted that they muddled up the definition of AsPD ...)

In this case, I think the DSM may be right. The overlap between AsPD and psychopath is too great to justify a separate clinical category. In any case, Hare is absolutely NOT the orthodoxy. The DSM is clear: AsPD in, psychopaths out.

A distinction exists between NPDs and AsPDs.

The differences between PDs and neuroses have been more sharply defined. In a nutshell, PDs have ALLOPLASTIC defenses (react to stress by attempting to change the external environment or by shifting blame to it) while neurotics have AUTOPLASTIC defenses (react to stress by attempting to change their internal processes). The second important difference is that PDs TEND to be ego-syntonic (perceived by the patient to be acceptable, unobjectionable and part of the self) while neurotics tend to be ego-dystonic (the opposite).

This is exactly why "PD Clusters" were invented in 1987. I believe that there is a continuum BPD-HPD-NPD-AsPD.

Grandiosity in its typical narcissistic form is UNIQUE to narcissists. It cannot be found in ANY OTHER PD. A sense of entitlement is common to ALL Cluster B disorders, though. Narcissists almost never act on their suicidal ideation - BPDs do so incessantly (cutting - Self Injury - or mutilation).

And so it goes. The differential diagnosis is nowhere near where it should be ideally but is sufficient and developing by the day. At this stage, as long as they don't have DSM-V (actually DSM IV-TR was published), diagnosticians are in the habit of diagnosing multiple PDs. It is extremely rare to diagnose a single pure PD. This is called, as you know, "co-morbidity". I have textbooks at home which URGE diagnosticians NEVER to render a single diagnosis.

NPDs can suffer from brief reactive psychoses exactly as BPDs suffer from psychotic microepisodes. Actually, there is a whole sub-field in psychodynamic theories of narcissism which tries to explain the dynamics of reactive psychoses in pathological narcissism.

NPDs are different from BPDs in these areas:

1. Less impulsive behaviors (FAR less)
2. Less self-destructiveness, almost no self-mutilation, practically no suicide attempts
3. Less instability (emotional lability, in interpersonal relationships, and so on)

Psychopaths, or Sociopaths, are the old names for the antisocial PD. They are no longer in use, generally. But, the line between NPD and AsPD is very thin. I, personally, believe that AsPD is simply an exaggerated form of NPD and that having two diagnoses in such cases is superfluous.

12. Accusing the Victims

I would never DREAM to accuse the victim!

I just meant to distinguish between those victims who don't know better and get burnt - and those who KNOWINGLY, WILLINGLY, sometimes for the fun of it (risk/adventure), sometimes due to vanity (I will be the one to break him or to save him) - go near narcissists.

The first class of victims are real victims. But I refuse to accept victimology. I think it is degrading and scientifically wrong to assume - as a working hypothesis - that victims WANT to be victimized.

13. Multiple Diagnoses and NPD

NPD rarely appears in isolation. It is not in vain that BPD, NPD, HPD and AsPD constitute members of a Cluster (B) of disorders in the DSM.