Question:

Does narcissism often occur with other mental health disorders (co-morbidity) or with substance abuse (dual diagnosis)?

Answer:

NPD (Narcissistic Personality Disorder) is often diagnosed with other mental health disorders (such as the Borderline, Histrionic, or Antisocial personality disorders). This is called "co-morbidity". It is also often accompanied by substance abuse and other reckless and impulsive behaviors and this is called "dual diagnosis".

The Schizoid and Paranoid Personality Disorders

The basic dynamic of this particular brand of co-morbidity goes like this:

1. The narcissist feels superior, unique, entitled and better than his fellow men. He thus tends to despise them, to hold them in contempt and to regard them as lowly and subservient beings.
2. The narcissist feels that his time is invaluable, his mission of cosmic importance, his contributions to humanity priceless. He, therefore, demands total obedience and catering to his ever-changing needs. Any demands on his time and resources is deemed to be both humiliating and wasteful.
3. But the narcissist is dependent on input from other people for the performance of certain ego functions (such as the regulation of his sense of self worth). Without Narcissistic Supply (adulation, adoration, attention), the narcissist shrivels and withers and is dysphoric (=depressed).
4. The narcissist resents this dependence. He is furious at himself for his neediness and - in a typical narcissistic maneuver (called "alloplastic defence") - he blames others for his anger. He displaces his rage and its roots.
5. Many narcissists are paranoids. This means that they are afraid of people and of what people might do to them. Wouldn't you be scared and paranoid if your very life depended continually on the goodwill of others? The narcissist's very life depends on others providing him with Narcissistic Supply. He becomes suicidal if they stop doing so.
6. To counter this overwhelming feeling of helplessness (=dependence on Narcissistic Supply), the narcissist becomes a control freak. He sadistically manipulates others to satisfy his needs. He derives pleasure from the utter subjugation of his human environment.
7. Finally, the narcissist is a latent masochist. He seeks punishment, castigation and ex-communication. This self-destruction is the only way to validate powerful voices he had internalized as a child ("you are a bad, rotten, hopeless child").

The narcissistic landscape is fraught with contradictions. The narcissist depends on people - but hates and despises them. He wants to control them unconditionally - but is also looking to punish himself savagely. He is terrified of persecution ("persecutory delusions") - but seeks the company of his own "persecutors" compulsively.

The narcissist is the victim of incompatible inner dynamics, ruled by numerous vicious circles, pushed and pulled simultaneously by irresistible forces. A minority of narcissists choose the schizoid solution. They choose, in effect, to disengage, both emotionally and socially. See more on Narcissists and Schizoids in FAQ 67.

Read more about the narcissist's reactions to deficient Narcissistic Supply:

The Delusional Way Out

The Roots of Paranoia

HPD (Histrionic Personality Disorder) and Somatic NPD

"Somatic narcissists" acquire their Narcissistic Supply by making use of their bodies, of sex, of physical of physiological achievements, traits, health, exercise, or relationships. They possess many Histrionic features.

Click here to read the DSM-IV-TR (2000) definition of the Histrionic Personality Disorder.

Narcissists and Depression

Many scholars consider pathological narcissism to be a form of depressive illness. This is the position of the authoritative magazine "Psychology Today". The life of the typical narcissist is, indeed, punctuated with recurrent bouts of dysphoria (ubiquitous sadness and hopelessness), anhedonia (loss of the ability to feel pleasure), and clinical forms of depression (cyclothymic, dysthymic, or other). This picture is further obfuscated by the frequent presence of mood disorders, such as Bipolar I (co-morbidity).