From: MHM Journal - Volume 6, Issue1

ARE THEY CAUSED BY A MANIC STATE?

A heightened sense of one’s achievements and abilities, lack of empathy, driven and goal directed behaviour are features common to both Narcissistic Personality Disorder and Bipolar Mood Disorder.

Clinically both conditions may look similar, even to the trained observer. Narcissism is not a symptom of bipolar, and neither are all bipolar patients narcissistic but narcissistic tendencies can manifest during a manic or hypomanic episode of a Bipolar Mood Disorder.

A narcissistic PD and the manic/hypomanic bipolar might both display grandiose self perceptions, a pre-occupation with themselves and their own interests, impulsiveness, mood disturbances, and an increase in goal directed behaviour.

Disregard for the differences in these conditions can lead to misdiagnosis and improper management that can be harmful, particularly in the case of the bipolar patient.

Bipolar Mood Disorder is identified primarily by severe shifts in mood.

A bipolar patient will cycle between feelings of elation and euphoria, known as mania, and depressive symptoms.

These interfere with a person’s relationships and ability to carry out day to day functions.

Although the condition may be life-long, the symptoms are episodic.

Bipolar I disorder is differentiated from Bipolar II disorder by manic episode in the former and less severe hypomanic episodes in the latter.

Adults with Cyclothymic Disorder will experience many episodes of hypomania and depressive symptoms over a two year period.

Symptoms of a manic period include:

• An expansive mood and feelings of euphoria that is out of character
• Feeling jumpy or wired
• Extreme irritability
• Period of feeling increased energy
• Racing thoughts
• Talking very fast; pressured speech
• Sometimes uninhibited behaviour, such as striking up a conversation with a stranger in a supermarket.
• Reduced need for sleep
• Excessive/irrational confi dence in one’s own abilities
• Increase in goal directed activity
• General impulsiveness evidence by spending sprees, engaging in risky behaviour or getting involved in poorly thought out business ventures
• Symptoms of a depressive period include:
• Loss of interest in activities that were once enjoyed
• Long periods of worry, sadness, or emptiness
• Tiredness or fatigue
• Difficulty concentrating or focusing
• Changes in appetite or sleep
• Restlessness
• Irritability
• Suicidal thoughts, plans, or attempts

Personality refers to what makes us who we are.

An amalgamation of coping skills, ways of interacting, strengths and weaknesses, psychological defences and genetic characteristics.

Essentially the skills and tools we meet the world with.

A personality disorder results when one’s way of interacting with the world is markedly different from cultural norms or expectations.

Certain aspects of personality may result in continuous interpersonal problems or functionally impairs social and occupational functioning.

A personality disorder isn’t a sudden onset but rather an enduring pattern of behaviours and inner experiences emerging in adolescence or early adulthood.

Narcissistic Personality Disorder is one of ten personality disorders identified in the DSM V.

A person with this disorder will display a high sense of their own self-importance, have an excessive need for admiration and praise and shows a marked lack of empathy towards others. They’re boastful of their achievements, often to the extent of an over evaluation of normal accomplishments.

A narcissist might come across as overly confident, and perhaps even arrogant. However, this over-confident external self is a remarkable early developmental adaptation to protect a very fragile self-esteem that easily damaged under even the slightest criticism.

Symptoms include:

• Love of self/great self-interest
• Feelings of grandiosity
• Often sees himself being the ideal in beauty, intelligence, ambition and talents
• Preoccupation with success and power
• Attention seeking
• Boasting or bragging about one’s own achievements often
• Exaggeration of abilities and achievements
• Having unrealistic goals
• Fantasies of success beyond what is likely or possible
• Hypersensitivity to possible slights and insults from others (coupled with what could be an aggressive or angry response)
• Generally showing arrogant or haughty behaviour
• Belief in one’s own uniqueness/entitlement to special treatment
• Lack of empathy
• Manipulative or exploitative behaviour

Perhaps one of the most marked areas of overlap between BMD and NPD are the heightened self-perceptions observed in both. However similar they look, the clinician should look for subtle differences.

The bipolar individual will have more transient moments of grandiosity. It’s mood-phase specific and fuelled by elated and euphoric feelings accompanying the mania. It doesn’t last and isn’t present during a depressive episode. In extreme cases bipolar grandiosity takes on a delusional quality, such as belief in prophetic or supernatural abilities.

Narcissistic grandiosity is more enduring. Overinflated self-appraisals occur and one might not know the narcissist without the accompanying overinflated self perceptions. Narcissistic grandiosity is also unlikely to take on a bizarre or delusional quality. Bipolar patients and Narcissistic PD’s have a tendency towards impulsivity and increased goal directed behaviour.

Clinically it can be diffi cult to differentiate between a narcissist and a manic bipolar. Both the external and internal experience might look and feel the same, but underlying these experiences are different forces.

The narcissist is driven by a need to constantly be “better than”, and the manic bipolar is essentially driven by a chemical imbalance. Also, the narcissist may have the drive and ambition associated with goal directed behaviour, but lacks the increased energy evident during mania.

Depression or depressive features are common to both. Bipolar is often accompanied by at least one Major Depressive Episode. A narcissistic individual may also be at risk for developing Depression, particularly at around middle age.

Feelings of shame and embarrassment could result from their objective, measurable achievements not matching up to their idealised self leading to depression or dysthymia.

If depression is present, the bipolar individual will have transient depressive symptoms or a depressive episode. An individual with Narcissistic Personality Disorder will more likely develop a Major Depressive Disorder or more enduring depressive features.

The timing of symptoms is key to distinguishing the two conditions. Narcissism associated with Bipolar will manifest during a manic phase and may not be present when the individual is not symptomatic or controlled on medication. Bipolar symptoms are episodic and are labile.

A Narcissistic PD is less likely to have fluctuating moods associated with BMD and will have a more pervasive presentation of symptoms, manifesting in adolescence or early adulthood. Narcissistic symptoms don’t go into remission; they’re enduring and without extensive therapy they are lifelong.

Treatment of the two conditions is different. Treatment of BMD is primarily medication. Therapy aims to help the bipolar individual gain insight into their condition, psycho-educate and assist in recognising the start of a manic episode. Treatment of NPD is primarily long term therapy.

Medication is needed in the treatment of NPD to the extent there is a co-morbid condition requiring medication, such as Major Depressive Disorder.

The Narcissists behaviour is deeply embedded in their psychological defence making therapy difficult and lengthy.

Essentially, treatment and therapy should aim to alleviate symptoms, help people with to understand the causes of their emotions; and with time and commitment lead to improved relationships and overall improved wellbeing.

Mathew is a very driven and ambitious individual and was among the top achievers in one of the best universities. He’s highly qualified but currently unemployed. He recently resigned from his first job saying the job wasn’t worth his abilities. He’d rather wait until a more suitable job comes along rather than waste his talents in the wrong environment. Whilst working he didn’t get along with his supervisor and colleagues, some of whom referred to him as “arrogant, egotistical and manipulative.” “It’s really hard working with people who are not as capable as I am. I never got the recognition I deserved, even when I pointed out my achievements to others. My work was superior to the others and I think my supervisor was just too threatened by me to say so. I’m far too talented to waste my time in just any company”

Sally is an administrator at a law firm and studying towards her LLB. She was brought to the clinical psychologist by her concerned boyfriend who complained she hadn’t slept for days; she stays up all night working and seems not to get tired during the day. Her boyfriend also reported recent uncharacteristically reckless behaviour, such as her sudden resignation from her job. Sally complied with her boyfriend’s request to see a psychologist but admitted that she saw no reason why. She said she felt fantastic and didn’t understand her boyfriend’s concern. “I was depressed before, but without medication I just got out of it. I work all night because there’ s important work to be done. I spend my nights writing to leaders of corporations and countries about how we can solve global problems. I know I have a special gift and it’s up to me to make a difference. I was wasting valuable time in my job”

Mathew was diagnosed with Narcissistic Personality Disorder and Sally was diagnosed with Bipolar Mood Disorder.