“Comorbidity is of interest from the viewpoint of a diathesis- personality-stress model that suggests a continuum between normal personality traits, personality disorders, and clinical disorders. According to this view one should find some preexisting personality disturbance in most clinical disorders, although the manifestations may not always be strong enough to meet the diagnostic criteria for personality disorders. It follows that the pattern of association between particular clinical and personality disorders is not a random one, and clinical disorders would be associated with particular personality disorders or classes of disorders.”1
About 35% of those diagnosed with an Anxiety Disorder were also diagnosed with at least one personality disorder; of that number 3% were diagnosed with Narcissistic Personality Disorder (NPD). Moreover, the Cluster B Personality Disorders (dramatic), of which Narcissistic Personality Disorder is a part, had the strongest association with Anxiety Disorders.2
About 53% of those diagnosed with a Depressive Disorders were also diagnosed with at least one personality disorder; of that number, 4% were diagnosed with Narcissistic Personality Disorder.3
According to Ronningstam, although persons with Narcissistic Personality Disorder do not manifest many psychiatric symptoms, they will present for treatment suffering acute depression resulting from “failure, losses, or other severe narcissistic injuries” or with dysthymia displaying symptoms of, “a chronic state of boredom, emptiness, aloneness, stimulus hunger, dissatisfaction, and meaninglessness . . . [in] reaction to a [sic] repeated failures and gradual disillusionment”4 and is commonly seen in middle age when the person with NPD gains an “awareness of limitations or lost opportunities.”5
In a depressed state, the person with NPD may be reacting to feelings of shame or humiliation associated with having "failed" or been "criticized" by others. The depression may also be associated with self-criticism for these perceived failings. As a result, the person may have withdrawn socially.
Co-occurrence rates for Major Depressive Disorder or Dysthymia and NPD are 42-50%.6
Ronningstam points out that while “no evidence implicates a significant relationship between NPD and bipolar disorder, a complex comorbid interaction can sometimes be found in patients with the two disorders. As the self-regulatory functions are impaired, depression and mania can for these patients reflect a narcissistic balance directing feelings of rage and shame.”7
Hypomania may be seen during periods of grandiosity.
“Patients in hypomanic or acute manic phase can show affective, experiential, and behavioral similarities with, and actually meet several of the discriminating characteristics for, NPD. These patients often highly value their manic phase as a means to overcome inferiority, limitations, an attitude that can highly decrease motivation for treatment.”8
Co-occurrence rates for Bipolar Disorders and NPD are 5-12%.9
The DSM-IV-R10 lists NPD as being comorbid with this disorder.
Because persons with NPD already distort reality, as seen in their characteristic grandiosity, they may also develop delusions in response to extreme stressors relating to threats to their self-image. They may come to believe that those who attempt to "thwart" them are at the opposite extreme from themselves, that is, as grossly malevolent and intent on their destruction. Millon and Davis see this persecutory thinking as, "the last-ditch effort to protect the grandiose self from total collapse and establish continuity between pathological narcissism and paranoid and delusional disorders. . . . paranoid symptoms represent a defensive adaptation to a hostile environment that threatens the narcissist at a fundamental level. The paranoid quality may be expressed through a belief that others are conspiring to deprive these individuals of their sense of specialness or somehow cheat them out of a momentous accomplishment, a testament to their brilliance . . . . The difference between believing that others are envious of you and believing that others are actively trying to undo you sometimes becomes rather thin as stressors mount."11
Substance Abuse and Dependency
(especially related to cocaine)
Narcissistic patterns have been identified as “a precondition for addictive behavior . . . and with regard to NPD and “. . . the self-medicating effect of drugs, such a cocaine, . . . [it is believed that, in NPD, drugs] can diminish the disorganizing influence of rage and overwhelming feelings of depression, and contribute to a sense of mastery, control and grandeur, and [increase] the sense of self-sufficiency.”12
Co-occurence rates for substance abuse and NPD are 24-50%.13
Persons with NPD are particularly prone to suicidal ideation and attempts in response to perceived failure, criticism, or humiliation.14 Kohut and O. Kernberg, “related suicide in narcissistic patients to specific types of self-directed aggression—egosyntonic sadism in malignant narcissism and narcissistic rage in response to narcissistic injuries. They also agreed that suicidal behavior in narcissistic patients is not necessarily related to depressed states with accompanying guilt, but contrary, can increase the narcissist’s self-esteem and induce a sense of power, freedom from fear, control over life, and triumph over death."15 Kohut believed that suicide attempts in NPD can be understood as a way to “eliminate the self in order to erase a reality that is filled with disappointments and failures; Ronningstam finds that narcissists are particularly at risk for suicide in, “late middle age . . . when hopelessness, empty depression, and the realization that life events are irreversible [which can lead to a] 'strong wish [on the part of the person with NPD] to end unbearable feelings of mortification and shame due to failure'16 . . . . [Finally,] a specific type of sudden deadly suicidal behavior in response to interpersonal stress or threats can be found in nondepressed narcissists who are grandiose, vulnerable, and impulsive. Such individuals have impaired capacity to identify, experience, and contain feelings."17
NPD and Other Personality Disorders
It is rare that someone diagnosed with NPD will not also be diagnosed with another Axis II disorder; in fact, Ronningstam points out that, among the Axis II Cluster B (dramatic) disorders, “Narcissistic Personality Disorder has one of the highest rates of diagnostic overlap.”18 It has also been suggested that NPD is over-diagnosed, that the constellation of symptoms clinicians identify as constituting NPD do not conform to the DSM requirements, and that clinicians frequently do not identify NPD in patients whose primary clinical diagnosis is Narcissistic Personality Disorder.19
The following chart illustrates the co-occurrence of NPD with other Axis II disorders according to the criteria sets in the DSM-III and DSM-III-R.
Comorbidity of Narcissistic Personality Disorder With Other Axis II Disorders20
Axis II Disorder Percentage of Co-Occurrence Histrionic Personality Disorder 53% Borderline Personality Disorder 47% Paranoid Personality Disorder 36% Avoidant Personality Disorder 36% Passive-Aggressive Personality
28% Antisocial Personality Disorder 16%
The following chart illustrates the comorbidity of NPD with Anxiety and Depressive disorders:
Comorbidity of Narcissistic Personality Disorder With Depressive and Anxiety Disorders21
Comorbid With Comorbidity Rate Depressive Disorders 4% Anxiety Disorders 3%
Moreover, Zukermann observes that when comorbid with NPD, the symptoms of anxiety and depressive disorders are more severe.22
The DSM-IV-R23 also notes the comorbidity between Narcissistic Personality Disorder and Histrionic, Borderline, Antisocial, and Paranoid Personality Disorders.
Ronningstam points out that BPD patients with comorbid NPD have higher suicide rates than those whose BPD is not comorbid with NPD.24
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1Zuckermann, 1991, pp. 62-63
4Ronningstam, 1999, p. 678
5Ronningstam, 1999, p. 676.
7Ronningstam, 1999, p. 678, citing Aleksandrowicz, 1980, and Morrison, 1989
8Ronningstam, 1999, citing Ronningstam, 1996, and Stromberg, Ronningstam, Gunderson, & Tohen, 1998
11Millon & Davis, 2000, p. 303
12Ronningstam, 1999, p. 678, citing Vaillant, 1988; Wurmser, 1974; & Khantzian, 1979, 1982; Millon & Davis, 2000
15Rossingstam, 1999, p. 678, citing Kohut, 1971, & O. Kernberg, 1984
16Ronningstam, 1999, p. 678, citing Kohut, 1977
17Ronningstam 1999, p. 678, citing Ronningstam & Maltsberger, 1998
18Ronningstam,1999, p. 680; Gunderson, Ronningstam, & Smith, 1995
19Gunderson, Ronningstam, & Smith, 1995
21Zuckermann, 1999, p. 158
22Zuckermann, 1999, p. 89