Narcissistic Personality Disorder and Borderline Personality

Examining the Co-Occurrence of Narcissistic Personality and BPD

By Kristalyn Salters-Pedneault, PhD | Reviewed by Steven Gans, MD

Updated April 20, 2017

Narcissistic personality disorder (or NPD) is a personality disorder that frequently co-occurs with borderline personality disorder (BPD). The addition of NPD into the diagnostic picture may complicate the treatment and course of BPD.

What Is Narcissistic Personality Disorder?

NPD is one of 11 personality disorders recognized in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.

NPD is one of the "Cluster B", or dramatic/erratic, personality disorders.

Narcissistic personality disorder is characterized by the presence of five (or more) of the following symptoms:

• Has an inflated sense of self-importance
• Is preoccupied with fantasies of success, power, brilliance, beauty or ideal love
• Believes that he or she is “special” and can only be understood by other special or high-status people
• Requires excessive admiration
• Possesses a sense of entitlement
• Takes advantage of others
• Lacks empathy
• Is often envious of others or believes others are envious of him or her
• Behaves in an arrogant, egotistical or haughty way

In short, people with NPD might be described as being very self-absorbed or egotistical. This self-absorption rises to the level of a clinical disorder because it significantly interferes with relationships, occupation or other important domains in life. Many experts believe that this egotistical style is actually the NPD individual's attempt to deal with an underlying poor sense of self-worth.

How Often Do NPD and BPD Co-Occur?

While the overlap between NPD and BPD are discussed quite often in the popular psychology literature and online, very few careful studies of the co-occurrence of NPD and BPD have been conducted. One such study found that only about 16 percent of patients with BPD also meet the diagnostic criteria for NPD.

However, another study that drew from a community (rather than a treatment-seeking) sample found that almost 39% of people with BPD also have NPD.

How Does Narcissistic Personality Disorder Affect BPD?

There are a number of theoretical reasons to believe that someone with both NPD and BPD would be less likely to get better over time. People with NPD have been described as very resistant to treatment; people with NPD often have poor insight about the ways that their behaviors are detrimental to themselves or others. Also, people with NPD may in fact cause more emotional pain to others than they cause themselves. So, their motivation to change their behavior may be very low.

Research does suggest that people with both NPD and BPD are less likely to have their BPD symptoms get better over time. One study that followed BPD patients over six years found that rates of co-occurring NPD were fairly low (about 6 percent) in patients whose BPD eventually went away (remitted). However, rates of co-occurring NPD were higher (around 19 percent) in patients whose BPD did not remit after six years. So, there is a subset of individuals with non-remitting BPD and higher rates of NPD.

Relationships and People with NPD and BPD

The relationships of individuals with BPD are often quite dysfunctional.

However, adding NPD into the mix can create even more disordered conditions. In addition to the chaotic emotional life and fears of abandonment associated with BPD, a person with co-occurring NPD may also take advantage of or manipulate others while having little empathy for others' concerns. This combination can be incredibly destructive in relationships.

Treatment for Narcissistic Personality Disorder and BPD

There are currently no empirically supported treatments for NPD and no published clinical trials of treatments for NPD alone or co-occurring with BPD.

Published research on the treatment of NPD is limited to some case studies or anecdotal accounts, but these types of studies tend to be unreliable and subject to bias.

The case study literature on the treatment of NPD has primarily centered around the use of modified psychoanalytic techniques and has recognized the challenges of successfully treating this disorder.

The clinical literature, in general, tends to regard NPD as a largely untreatable condition, particularly in its most severe forms. Some people believe that because there is some overlap between NPD and BPD symptoms (such as impulsivity and destructive behaviors) treatments designed for BPD like Dialectical Behavior Therapy may also work with NPD. However, this remains to be seen; more research on the topic is sorely needed.

Histrionic Personality Disorder and BPD

Understanding HPD and its relationship to BPD

By Kristalyn Salters-Pedneault, PhD | Reviewed by Steven Gans, MD

Updated December 17, 2017

Histrionic personality disorder (HPD) is a personality disorder that tends to co-occur with other personality disorders, particularly borderline personality disorder (BPD), narcissistic, and dependent personality disorders. There is a great deal of overlap between BPD and HPD features, so much so that some experts believe that HPD may not actually be distinguishable from BPD.

Understanding Histrionic Personality Disorder

HPD is one of 10 personality disorders recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

HPD is one of the Cluster B disorders, which are characterized as dramatic, overly emotional, and/or erratic.

The DSM-5 defines histrionic personality disorder as a pattern of extreme emotionality and attention seeking behavior that begins by early adulthood and is obvious in different situations. In addition, you must have five or more of the following signs or symptoms to be diagnosed with HPD:

• Discomfort in situations in which you're not the center of attention
• Interaction with others that's often characterized by inappropriate sexually seductive or provocative behavior
• Rapidly shifting and shallow expression of emotion
• Consistently uses physical appearance to draw attention to self
• Style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is easily influenced by others or by circumstances
• Considers relationships to be more intimate than they actually are

People with HPD might be described as being overly dramatic, emotional, or attention-seeking. This pattern of behavior rises to the level of a clinical disorder when it significantly interferes with relationships, work, or other important domains in life.

Co-Occurrence of HPD and BPD

There are only a few studies that have examined the co-occurrence of HPD and BPD.

One particularly rigorous study found that about 15 percent of patients with BPD also meet the diagnostic criteria for HPD. In another study that used a community sample, about 10 percent of people with BPD also met criteria for HPD.

HPD Versus BPD

There is marked overlap between the symptoms of HPD and BPD. For example, both share the features of rapidly shifting and reactive emotions, both are associated with impulsive behavior, and both are characterized by very strong expression of emotion.

While some clinicians argue that the qualities of these symptoms are different in HPD versus BPD, for example, that the rapidly shifting emotions in HPD are not experienced with the same depth and intensity as those in BPD, other experts have argued that HPD and BPD are not necessarily distinct disorders. However, despite predictions that the HPD diagnosis would be dropped in DSM-5, it was not, and so it remains its own specific and unique diagnosis.

Treatment for Histrionic Personality Disorder

While there is some advice for clinicians treating HPD, it's generally based on expert opinion or experiences rather than on research data. Much more research is needed on this topic, but in general, psychotherapy is often used and may be helpful.

If you have symptoms of other issues such as depression or anxiety, medication may help to alleviate those symptoms as well.

Borderline Personality Disorder Treatment

Psychotherapy, Medications, Hospitalization, and Self-Help for BPD

By Kristalyn Salters-Pedneault, PhD

Updated July 18, 2017

There are a variety of effective treatments for borderline personality disorder (BPD). What treatments seem to work best, and what should I know about the options available?

Overview

Usually, BPD is treated with a combination of medication and psychotherapy, although during times of crisis, individuals with BPD may require brief periods of hospitalization to remain safe. More recently, self-help tools have been developed to supplement traditional treatments for BPD.

Psychotherapy

Long-term outpatient psychotherapy, or "talk therapy," is an important part of any treatment for BPD. Research has shown that several types of psychotherapy are effective in reducing the symptoms of BPD, including:

• Dialectical Behavior Therapy (DBT)
  Dialectical behavior therapy (DBT) was the first form of psychotherapy found to be effective for people with borderline personality disorder (BPD.) DBT is a form of cognitive behavior therapy which focuses on how thoughts and beliefs can lead to actions and behaviors. In this therapy, people learn how to manage conflict, and learn skills to help them cope with strong emotions. Mindfulness meditation is also often included.
   
• Schema Focused Therapy
  Schema focused therapy is also a form of cognitive behavior therapy for BPD. Schema focused therapy operates with the thought that unmet needs from childhood can lead to unhealthy ways of thinking about the world. This therapy focuses on confronting these maladaptive beliefs and behaviors and instead focus on healthy ways of thinking and coping.
   

• Mentalization Based Therapy
  Mentalization based therapy has been studied to some degree for BPD and may help with anxiety and depression as well as social functioning. This therapy focuses on helping the client to recognize mental states—her own thoughts and feelings, as well as the thoughts and feelings of others she communicates with. Through recognition she is then able to see how these thoughts contribute to her behavior or the behavior of others.

• Transference Focused Psychotherapy
  Transference focused psychotherapy has been studied for BPD and may be as good or better than dialectical behavior therapy according to these studies. This therapy uses the concept of transference—transferring emotions from one person to another, which is a key concept in psychodyamic therapies. Transference focused psychotherapy utilizes the relationship between the client and the therapist so that the therapist can see how a client relates to others. The therapist can then use this awareness to help a person respond more effectively in their other relationships.

Medications

Although there are currently no medications for borderline personality disorderapproved by the FDA, research has shown that some medications do reduce certain symptoms of the disorder. Medication may be particularly effective for BPD when it is used in conjunction with psychotherapy. In addition to helping with BPD symptoms, medications may help with co-existing mental health conditions such as anxiety or depression.

Some of the most commonly prescribed medications for BPD include:

• Antidepressants - Antidepressants may help with feelings such as sadness, but do not appear to be helpful for symptoms such as anger.

• Antipsychotics - Antipsychotics were some of the first medications used to treat BPD and may be particularly helpful for some of the more problematic symptoms of BPD such as anger, impulsivity, and paranoid thinking.
• Anxiolytics (anti-anxiety medicaitons) - Anxiety can go hand in hand with BPD making some of these medications helpful, yet some of these are a double edged sword due to their addictive potential.
• Mood stablizers/anticonvulsants - Mood stabilizers may help with the impulsive thinking common with BPD.

Other potential treatments, such as omega-3-fatty acids, are also being explored. In fact, studies to date have not found significant benefit from most medications for BPD with the exception of atypical antipsychotics (second generations antipsychotics), mood stabilzers, and omega-3-fatty acids.

Hospitalization

Borderline personality disorder is associated with very intense emotional experiences. As a result, people with BPD may need intensive BPD treatment.Sometimes people with BPD are admitted to a psychiatric hospital for intensive inpatient treatment. Inpatient treatment requires you to stay overnight in the hospital.

Another treatment option is partial hospitalization or day treatment. These are programs that are more intensive than traditional outpatient psychotherapy, but do not require you to stay overnight. You may be enrolled in a partial hospital or day program if you may be headed toward a crisis, or if you have just been discharged from inpatient hospitalization and need a period of more intensive treatment to make sure the crisis does not reemerge.

Self Help

Self-help strategies for BPD are an essential part of any treatment program. Of course, these should be used to supplement care from a qualified therapist and not alone. An ideal plan includes learning as much as you can about your disorder through self-help education, learning healthy coping skills for BPD, and finding ways to help you express and manage your emotions.

There are valuable self-help resources available for BPD that can be used in conjunction with more traditional forms of treatment. Books and online resources offer information about BPD and suggest ways to cope with the symptoms.

What to Do in an Emergengcy

If you or someone you love is experiencing a mental health emergency, it is critical that you get help immediately. Call 911 or go to your nearest emergency room. If there is evidence that you (or your loved one) are a danger to yourself or others, you may be admitted for a brief hospital stay on an inpatient psychiatric unit until the crisis has passed. It's recommended that anyone living with BPD put together a safety plan for BPD. In this plan you can anticipate a crisis and make a plan about exactly how you will address your feelings before they become an emergency.

What is Borderline Personality Disorder (BPD)?

An Introduction To Borderline Personality Disorder (BPD)

By Kristalyn Salters-Pedneault, PhD

Updated July 28, 2017

Borderline personality disorder is a serious psychological condition. What are the symptoms? How is it treated? Below, find an overview of some of the basics of BPD.

Overview

BPD is one of several personality disorders recognized by the American Psychiatric Association. Personality disorders are psychological conditions that begin in adolescence or early adulthood, continue over many years, and cause a great deal of distress.

Personality disorders can also often interfere with a person's ability to enjoy life or achieve fulfillment in relationships, work, or school.

Symptoms

BPD is associated with specific problems in interpersonal relationships, self-image, emotions, behaviors, and thinking.

• Relationships: People with BPD tend to have intense relationships characterized by a lot of conflicts, arguments, and break-ups. BPD is also associated with strong sensitivity to abandonment, which includes an intense fear of being abandoned by loved ones and attempts to avoid real or imagined abandonment.
• Self-image: Individuals with BPD have difficulties related to the stability of their sense of self. They report many "ups and downs" in how they feel about themselves. One moment they may feel good about themselves, but the next they may feel they are bad or even evil.
• Emotions: Emotional instability is a key feature of BPD. Individuals with BPD may say that they feel as if they are on an emotional roller coaster, with very quick shifts in mood (for example, going from feeling okay to feeling extremely down or blue within a few minutes). BPD is also associated with feelings of intense anger and emptiness.

• Behaviors: BPD is associated with a tendency to engage in risky and impulsive behaviors, such as going on shopping sprees, drinking excessive amounts of alcohol or abusing drugs, engaging in promiscuous sex, or binge eating. Also, people with BPD are more prone to engage in self-harming behaviors, such as cutting or to attempt suicide.

• Stress-Related Changes in Thinking: Under conditions of stress, people with BPD may experience changes in thinking, including paranoid thoughts (for example, thoughts that others may be trying to cause them harm), or dissociation (feeling spaced out or numb).

Causes

Like most psychological disorders, the exact cause of BPD is not known. However, there is research to suggest that some combination of nature (biology or genetics) and nurture (environment) is at play.

Research has shown that many people diagnosed with BPD have experienced childhood abuse or neglect or were separated from their caregivers at an early age. However, not all people with BPD had one of these childhood experiences (and, many people who have had these experiences do not have BPD).

There is also evidence of genetic contributions and differences in brain structure and function in individuals with BPD.

Treatments

Although at one time experts believed that BPD was unlikely to respond to treatment, research has now shown that BPD is very treatable. A variety of treatments are available for BPD, and these treatments can be delivered in outpatient or inpatient (hospital) settings. BPD is usually treated with a combination of psychotherapy and medication.

Hospitalization or more intensive treatments may be necessary in times of crisis.

Coping

It can be very difficult to live with the symptoms of BPD. Intense emotional pain and feelings of emptiness, desperation, anger, hopelessness, and loneliness are very common. As a result of these experiences, many people with BPD report that they think about suicide, or have made suicide attempts or gestures. Some individuals with BPD engage in self-harming behaviors such as cutting or burning themselves in an attempt to reduce their emotional pain (or, in the case of chronic emptiness, to "feel something.")

The symptoms of BPD can affect a variety of areas, including work, school, relationships, legal status, and physical health. However, despite the suffering that BPD can cause, many people with BPD lead normal, fulfilling lives. There are many success stories!

A Word From Verywell

If you think that you or a loved one may suffer from BPD, it is very important to seek the help of a licensed mental health professional, such as a mental health counselor, social worker, psychologist, or psychiatrist. It is important to remember that many of the symptoms of BPD are symptoms that everyone experiences from time to time. Also, some of the symptoms of BPD overlap with other mental and physical conditions. Only a licensed professional can diagnose BPD.

The good news is that once a diagnosis is made, there is hope. Your therapist or doctor can help to determine a plan of action, which may include psychotherapy, medications, or other treatments. Research has shown that with good treatment, BPD symptoms can be reduced significantly. Many people who were once diagnosed with BPD no longer meet criteria for the disorder with treatment and time.

Introduction to the DSM Personality Disorders

Not many changes in DSM-5

By Kristalyn Salters-Pedneault, PhD | Reviewed by Steven Gans, MD

Updated July 27, 2017

Personality disorders are psychiatric conditions that begin in adolescence or early adulthood, continue over many years, and cause a great deal of distress. Personality disorders also often interfere with your ability to enjoy life or achieve fulfillment in relationships, work or school.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists ten personality disorders, including borderline personality disorder (BPD).

Diagnosis

The DSM-IV-TR used a "multi-axial" diagnostic system. This means that when a diagnosis was made using DSM-IV, attention was paid to five different areas, or axes, that may have affected the individual being diagnosed.

Personality disorders were diagnosed on Axis II of the multi-axial system. This axis is reserved for very long-standing conditions of clinical significance. Mental retardation is the only other condition that was diagnosed on Axis II.

In DSM-5. the most recent version, there are no axes.

Clusters

Personality disorders are organized into three "clusters" in both the DSM-IV-TR and DSM-5. The disorders in each cluster share key features or have overlap in terms of the characteristics of individuals who are diagnosed within that cluster.

'Cluster A' 

The "Cluster A" personality disorders are characterized by odd or eccentric behavior. Individuals with the personality disorders in this cluster tend to experience major disruptions in relationships because their behavior may be perceived as peculiar, suspicious or detached.

The "Cluster A" personality disorders include:

• Schizotypal Personality Disorder
• Paranoid Personality Disorder
• Schizoid Personality Disorder

'Cluster B' 

The "Cluster B" personality disorders are characterized by dramatic or erratic behavior. Individuals with the personality disorders in this cluster tend to either experience very intense emotions or engage in extremely impulsive, theatrical, promiscuous or law-breaking behaviors.

The "Cluster B" personality disorders include:

• Borderline Personality Disorder
• Histrionic Personality Disorder
• Antisocial Personality Disorder
• Narcissistic Personality Disorder

'Cluster C' 

The "Cluster C" personality disorders are characterized by anxiety. Individuals with the personality disorders in this cluster tend to experience pervasive anxiety and/or fearfulness.

The "Cluster C" personality disorders include:

• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder
• Avoidant Personality Disorder

Treatment 

Compared to mood disorders, there is remarkably little research on the treatment of personality disorders. Most of the research that exists focuses on the treatment of BPD. For BPD, there are a number of treatments that are considered effective in reducing symptoms, including psychotherapy and medication options.

In general, many experts believe that personality disorders are difficult to treat because they are, by definition, long-standing patterns of personality. That said, this is a question that has not been subjected to a great deal of careful research. More research is needed to examine the effectiveness of treatments for the personality disorders.

However, recent research has shown that borderline personality disorder is easier to treat than previously thought and that many people improve with continued treatment.

Comorbidity

There is a great deal of comorbidity between the personality disorders, meaning that a person who meets diagnostic criteria for one personality disorder will often also meet criteria for one or more additional personality disorders. One recent study funded by the National Institute of Mental Health found that about 85% of people with BPD also meet diagnostic criteria for at least one other personality or mood disorder.