By Alexander Kriss, PhD

Image credit: Chenspec

Matthew, a twenty-year-old man I’d worked with in individual psychotherapy for a few months, began a session saying he was in crisis. “I think I’m a narcissist,” he told me. “I’m terrified of it.”

I asked Matthew why he thought this. He said the night before he had, after much agonizing, confronted his boyfriend, Patrick, about his controlling behavior: Patrick decided when they socialized and with whom; he required advance approval of any expenses related to the apartment they shared; he discouraged Matthew from engaging in any interests that did not help to “build the relationship,” especially Matthew’s longtime passion for oil painting.

“Then Patrick told me that, by bringing this up, I was trying to control him,” Matthew said. “He said I was using guilt to get what I wanted, which he said was worse than anything he had done because all of his rules were completely rational.” Matthew put his head in his hands. “And I couldn’t . . . I see how he flipped the conversation around on me, but I couldn’t really deny that what he was saying was true . . .” He looked up at me with desperate, searching eyes. “Is it true? Am I a narcissist?”

Despite a pantheon of personality disorders listed in psychiatric diagnostic manuals, only two are commonly used by mental health professionals today: borderline personality disorder (BPD) and narcissistic personality disorder (NPD). The “borderline” and “narcissistic” stereotypes are also well-known in public imagination: the former calls to mind a wild woman who manipulates others through seduction and threats of suicide, the latter a grandiose man who will happily step on another person’s neck in order to get what he wants. This gendered split is not a distortion of the aforementioned diagnostic manuals, but a reflection of how doctors use them. One longstanding datum in the Diagnostic and Statistical Manual for Mental Disorders (DSM)—the premiere such manual in the United States—shows that 75% of all people labeled as “borderline” are women, while 75% of all people labeled as “narcissists” are men. It was fitting, then, that Matthew—whom I had diagnosed with BPD—had come to session worried that NPD was the more accurate label.

What the DSM does not attempt to show is why this uncanny divide exists. Like other modern manuals of mental disorder, the DSM defines diagnosis by clusters of symptoms, without any theoretical discussion of what causes them or why. This can lead to the erroneous assumption that the information it presents—such as discrepancies in rates of diagnosis between men and women—is biological fact, rather than something influenced by culture or the diagnostic manuals themselves.

The truth is, what we call BPD and NPD are two ways a person might deal with the same core issue of being forced to grow up in a confusing, chaotic, or invalidating environment. Borderline and narcissistic adults come from similarly troubled origins but, starting in childhood, are treated differently. The one who grew up to adopt a borderline organization was called worthless; she was hit for being disobedient, perhaps, or praised for being beautiful enough to one day ensnare a rich husband—that is, as an object for someone else to possess. The future narcissist was perhaps called a prodigy and forced into public, competitive spaces despite expressing no inherent interest in them; he was praised as strong for his cold-heartedness, berated as weak when he cried.

Psychologists, particularly those of us trained in a psychoanalytic tradition, have long understood that individuals with BPD and NPD feature certain commonalities: both struggle with managing powerful, negative emotions; both rely on splitting the world into good and bad. But where the borderline often casts herself as bad to preserve the goodness of others—on whom she relies for validation that she is real and alive—the narcissist organizes his internal world so that he is always good, the outside world always inadequate and unappreciative. The narcissist can appear better adapted to the world than the borderline, as he possesses a self-idealization that could be misconstrued as confidence. But beneath the brittle surface lies a tumult that, when put under pressure, can compel him into strange and harmful behavior.

People organized around narcissistic defenses are afraid more than anything of vulnerability, of being seen as weak, which makes the therapy situation inherently unappealing to them. They are driven to point out ways they are smarter than the therapist or already knew what the therapist is going to say. Borderline patients like Matthew, on the other hand, could be described as pathologically vulnerable, porous to the point of diffusion, and their reliance on others for cohesion means that they are excellent candidates for a relationship-based treatment like psychotherapy—but also that they can be easily confused or manipulated. I treat NPD in my practice, though most often I encounter it as with Matthew: listening to a patient with BPD talk about a narcissistic partner, parent, or sibling. The two personality organizations tend to gravitate toward each other, a toxic magnetism. One person seeks definition, the other seeks to define; the borderline wants to love even if it hurts, the narcissist wants to wield power even over someone he loves.

Matthew and I discussed this dynamic. That night, he had a long conversation with Patrick, which he relayed to me at our next session.

“I described the way we feed into each other. I ask Patrick to tell me what to do, he happily tells me, then I confuse his orders for my own thoughts. I told him that I was borderline for the first time. I’m still confused about what happened next. Something changed in him, like I’d made him angry. I explained a bit about the diagnosis. I said I was susceptible to him telling me what I am, like that I’m controlling or narcissistic, and also that it was related to stuff from early childhood. And he flew into a rage, shouting, ‘What even happened to you that’s so bad?! I could tell you things that would make your heart turn to ice.’”

Matthew hadn’t known what to do. He didn’t want to invalidate Patrick or turn the conversation back to himself—fuel for Patrick’s charge that Matthew was the true narcissist. I suggested that Patrick may have felt threatened by Matthew’s BPD diagnosis: it made Matthew special in a way that Patrick could not bear. Moments like this show how narcissism is not a pleasant way of living, filled with self-love and confidence—it is a frantic struggle to always be on top, even if that means waging a contest for who is the most ill.

I’ve treated borderline men and narcissistic women—individual circumstances can always overwhelm larger cultural forces. But there is a gendered split to these pathways, the same split found across so many aspects of life. Unfortunately, no edition of the DSM has dared broach the idea that these conditions represented two ways a person might resolve the same core problems according to the strictures of a sexist society. Suffering is not only something we inherit; it is actively shaped by the world around us—our family dynamics, our expectations of what men or women are supposed to be like. Healing, if it is to be effective, must also adapt to evolving understandings of identity development and mental health. This includes a willingness to shed gendered clichés and consider what is truly going on underneath a given diagnostic label, and how that person—and that label—came to be that way.

About the Author 

Alexander Kriss, PhD, is an assistant clinical professor of psychology at Fordham University, director of the Fordham Community Mental Health Clinic, and author of The Gaming Mind and Borderline: The Biography of a Personality Disorder. His private psychotherapy practice is based in Sleepy Hollow, NY.