Lies, Damn Lies and Delusion

Lie – to speak falsely or utter untruth knowingly, as with intent to deceive

Pathological Lying – long history (maybe lifelong history) of frequent and repeated lying for which no apparent psychological motive or external benefit can be discerned

Confabulation – to fabricate imaginary experiences as compensation for loss of memory

Delusion – a belief or impression maintained despite being contradicted by reality or rational argument, typically as a symptom of mental disorder

I posed myself a question in response to my MILs flat out denial that she had ignored our request to limit herself to one Christmas gift for each child (see post “So you survived Christmas…”), even though we had the evidence physically in front of us. She insisted that she had:

a) NOT sent any extra toys to us at Christmas (see post “So you survived Christmas…”)

b) had sent an extra gift and intended it to be a malicious dig at us – and –

c) sent it to our youngest child but had to put all of our names on the parcel because we had made it so difficult for her to send the children more than one gift despite having sent that child more than one gift already.

You’ll notice how these answers contradict each other.

The question I asked myself was “does MIL know she is lying”?

YES! you all shout, but the really scary answer is probably no, she doesn’t.

It creeps me out to write about this because it genuinely is very scary for me to have someone in my social or familial circle who is so out of touch with most people’s version of reality. I am strongly empathic and can in most circumstances easily put myself in another person’s shoes, feel their feelings and see their perspective. Even if I disagree strongly with their views on something I can still see how their life experiences have led them to hold the position they have. Sometimes it is a bit trickier, some people are harder to figure out as they are very reserved and reveal little of their deeper feelings. And then occasionally you meet someone who is a mindfucker.

My definition of a mindfucker, excuse my French, is a person so incomprehensible that trying to put yourself in their shoes actually causes you psychological harm. The MIL is one of them.

My therapist describes it more politely as “off the Bell Curve”. Here is a Bell Curve.

I love the whole Bell Curve thing, I first learnt about it doing my A Level maths course aged 17. Almost all measurable characteristics in nature produce this graph; the length of blades of grass in your lawn, the heights of 4 year old kids, the weights of new born puppies, the number of cakes you have eaten this year and so on. Most people/things cluster symmetrically around an average or mean value in the middle and the numbers of people/things who have significantly more or less of the measured characteristic fall away from this peak values either side. IQ is the classic example of a characteristic which produces a bell shaped curve when measured in people.

If you look at the picture you notice the areas right out at the edges labelled with the purple arrows? Those are the places where the extremes are found, I am actually at the far right of the bell curve for female height as I am 5 foot 10 inches which is taller than the average height for a man in the UK. But that doesn’t make me abnormal, I’m within the “normal” range (i.e. on the bell curve) just not in the “average” range, in the top 2% range instead.

My MILs behavioural responses are off the bell curve, so unusual that they are not found in almost everyone else in the population, beyond the 2%. That is pretty much the definition of a personality disorder.

Lying

So how does that link in with her lying? Let’s review some indisputable facts:

My MIL sent a parcel wrapped in Christmas paper to us at Christmas with a label on it “to husband, FCW, child 1, child 2” inside was play money, plastic coins and fake notes.

She sent each child a gift, and some books each and a joint present labelled as such.

We had requested that all family members send each child one gift as otherwise they are deluged in presents, in fact we were running out of space to store the toys both sides of the family were sending. MIL had swamped us in toys, mostly found in second hand shops, items that were absurdly inappropriate like a gardening set for a 3 month old.

My husband asked her about the play money gift as she has recently tried to give us real money but with some unpleasant strings attached and been cross when it was refused. This gift of play money seemed to say “fuck you, I’ll send money this way then, ha ha”. He had a nasty feeling she was playing games.

This is how she replied, all of this happened in the course of one conversation:

1. “I didn’t do that”
2. “I don’t remember sending any such thing to you”
3. “Well I meant it to be for child 2”
4. “You made it so difficult for me to send more than one gift to each child”
5. “I had no choice but to put everyone’s names on it”

I see someone making shit up as she goes along, reaching some vaguely plausible story by the end of the conversation which absolves herself of any wrong doing and (bonus points) manages to make herself a victim of someone else’s unreasonable demands.

She knows at statement 1 that she is being called out for something. She probably hasn’t listened much to the accusation but the tone of voice and content of the questions leads her to go on the defensive and she instinctively denies everything. This is a lie reflex similar to that which small children have who are scared of a punitive parent “I didn’t do it, it wasn’t me”.

Then she has had enough time to start being a bit cleverer and tries to deflect criticism by hedging her bets a bit ” I don’t recall doing it” this is deliberate, she knows this is a lie. How come? Because of what she says next “it was for child 2” not “oh yes, goodness me I forgot, that was for child 2”.

Notice also how she doesn’t apologise at all for going against our request for one gift per child. She is on a roll now and has had enough time to conjure up a scenario where she can come out smelling of roses (in her mind). She was the helpless victim of our wicked rule.

Then here’s the scary part, she erases the entire first part of the conversation from her mind and believes the story she has come up with, actually believes it to be the truth. If questioned today on this subject she would repeat the finalised version of this story, that it was for child 2 and we made it so difficult for her to be that generous with our unreasonable demand she felt unable to openly label the gift as such so in desperation put all our names on it. She would deny any recollection of the first part of the conversation or say she was confused and flustered because of the aggressive tone she was questioned with.

She is a liar, there is no doubt in my mind that she knowingly says things she knows are false in order to get herself out of sticky situations. But then something else happens, a layer of bizarre gets iced onto the cake of lie and she can concoct a story where she is the blameless one, clever one, heroic one and she believes it. She reaches the point of believing her own lies.

I thought this was called pathological lying but it’s not. Pathological lying is when you spend your entire life making up random shit about everything for no personal gain, you just can’t separate made up from real. Confabulation is a form of making things up found in people with memory loss who instinctively try to fill in the gap with a story, their brain is trying to help account for an absence. It is a symptom of brain trauma and some neurological conditions. She isn’t doing that either.

No she is lying and then becomes delusional, she believes her lies. The lies can be concretely shown to be lies, real evidence exists to counter them, the first part of the conversation above is an example. How can she say “I didn’t do that” and then say “you gave me no choice but to do that” one of those two statements is a lie at the very least. But still she believes her version and interprets any disagreement as wilful attacks upon her good character.

Lying is normal, we all do it. Social white lies such as “can we have biscuits when we get home?” “no we ran out” when actually the answer is “no I’m worried about all the crap you eat but can’t be arsed to have a fight about this in the school playground” are normal. The number of times a person lies everyday fits a bell curve, some do few, some do lots, most fit in the middle. How many of your lies you believe to be true when pressed also fits a bell curve, with some people easily admitting they are lies, most people grudgingly admitting most lies, some people really resisting admitting their lies and then some tiny percentage of people who say they never lie and always believe them to be true. These people are way off the bell curve. Hello MIL.

This is why I find it a mindfuck, in order for me to follow that train of thought from conscious lie to delusion I have to amputate some really crucial parts of my own mind: the parts where I see other people as just as sharp and astute as I am, the parts where I see the effects of my actions on others, the parts where I have any moral accountability, the parts where I accept I am flawed and can do the wrong thing, the part where I recognise the difference between what is in my head and what is real. Going there is scary for me and the realisation of what my MIL must be capable of if she can do this is horrifying. Worse, what if she isn’t capable of doing anything else, what if this is how she thinks, ALL THE GOD DAMN TIME!

Delusion

This is far from being the only example of my MILs delusional thinking. She invented a story first reported to her divorce lawyer and documented in detail as a result, where her ex-husband grabbed her bum cheek in the queue for service at a restaurant. This was in order to portray him as a really bad person. Next this story was related to me about the second time I meet her and it was an anatomically graphic account of how while sat at a table in the restaurant her shoved his hand forcibly into her lap and indecently assaulted her. That is what was described it to me over afternoon tea, in her garden the second time we met. You see how that conversation isn’t even normal!

Next time she tells the tale her two children were sat opposite her at the table so that is why she was unable to cry out or do anything. Now my husband remembers the trip to the restaurant but has no memory of anything untoward happening. He and his sister were in their mid-late teens at the time so their recollection is pretty good. Notice how the story changed and became more elaborate.

She has delusions about other things as well, she believes she discovered some remarkable chemical law which would have revolutionised the subject. She thinks that the radiation from her mobile phone if left on wakes her 30-40 times a night. She found a painting in a second hand shop and believes it is one of her ancestors and is wearing a necklace she has inherited despite the necklace not matching the picture and her having no evidence that the painting is really her ancestor at all. She believes she has psychic powers and knows the location of a girl abducted in a notorious kidnap case. She believes young waiters in restaurants flirt with her because she is so attractive. She believes she is stronger and more physically capable than she is and has injured herself several times as a result.

Narcissism is so horrible when acted out on other people due to the lack of morals, awareness of others feelings, the lies, the manipulations. But under it all is someone so profoundly disturbed that they are unable to ever accept that they do wrong, their brain cannot compute it. Every single action is designed to protect their desperately fragile self worth and delusion is better than a lie. Delusion says “I am not that person, I didn’t do that wrong thing”, lying says “I know I am but I can make capital out of saying I’m not”.

She really has to believe that she isn’t that person, the whole structure of her personality is set up so as to avoid ever having to consider that possibility even to the extent of denying reality. That is a truly sad and scary place to be. For the first time ever I feel sorry for my MIL.

From blog to book

I am following the advice of a friend who has just written her first book and collating all these blog posts and a few more topics together into a short book which I hope to put on Amazon as an e-book.

I wondered if you, my readers, had any other topics you would like to see addressed which I can add into the book and hopefully eventually put on here as a post.

I have written some material on specific narcissistic traits with examples from my dear MIL’s interactions with us, something about infantilisation of our spouses, something about denial. What else? I look forward to reading your suggestions, thanks for all your comments so far.

What do the diagnostic criteria actually mean?

What do all the dry academic words that attempt to pin down the defining features of NPD actually mean in real life? Here I’m going to attempt to illustrate each one with some examples from life with NPD MIL.

A. An enduring pattern of inner experience and behavior the deviates  markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people and events)

This one is a corker, I mean what is disordered cognition exactly? Thinking you are God or that fairies live in your garden is not what this criteria is referring to. The criterion refers to ways of perceiving and interpreting. So what a disordered person sees in a given situation is very different from what you or I would see and what they then conclude about that event also markedly deviates from what we would conclude.

So how does that work out in a real situation? PD person is sitting outside a cafe and see someone they know walk by, no eye contact is made and they make no attempt to call out to them. The PD person perceives a deliberate snub. MIL actually did this to me but under much more extreme circumstances than this. I was pushing my then very ill child through a hospital corridor to a meeting with the consultant when I walked past MIL sat in the hospital coffee shop. She made no attempt to attract my attention, I had no expectation she would even be in the hospital at that time and I didn’t see  her, I obviously had other things on my mind, like would my child need a vital organ removed or would the doctors be able to save it. MIL brought this up as an example of my treating her rudely.

PD person is told someone can’t make it to their planned event so they cancel the whole thing. This is all or nothing thinking, they didn’t consider going ahead anyway or moving the event to another day. There is no middle ground and no flexibility in their approach.

Bizarre attributions of magical, unusual and unlikely properties to ordinary objects is also a type of cognitive distortion. MIL thinks her mobile phone if left on overnight will wake her “30 or more” times. She doesn’t just switch off her mobile, she unplugs the landline too.

Suspicious or determinedly negative assumptions about people are another example. MIL won’t use Skype to communicate as she thinks unnamed people will be able to hack into her computer through it and spy on her.

The resource “Personality Disorders” at the South West Alabama Behavioural Health care Systems is very helpful on understanding the diagnosis criteria for a personality disorder, it gives lots of examples of disordered thinking patterns.

2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)

This is a frequently misunderstood criteria. Many people who write about personality disorders are talking about Borderline Personality Disorder which is characterised by extreme swings of emotion and volatility. But the criteria for diagnosing a personality disorder do not specify extreme ranges of emotion with, high intensity or great lability. The opposite is also true. A very limited range of displayed or felt emotions, those emotions having little intensity and  rarely leading to crying or laughter would also be characteristic of a personality disorder because they are behaviours that markedly deviate from the norm for our culture. The emotions in this case are too limited.

MIL has a very limited range of emotions, I have only ever seen neutral, panic, smug, envy and angry. I have never seen joy, happiness, fear, curiosity, anxiety, frustration, pride, sorrow, compassion, friendliness, I could go on but you get the idea.  Even when she gets exactly what she wants she isn’t actually happy, she is placated until the next demand surfaces.

Occasions when she has completely failed to show an appropriate emotional response have included my husband and my wedding (total absence of any reaction before, during or after the wedding), on the announcement of my pregnancies (expressed an unwillingness to be pleased incase something went wrong with the pregnancy and as a result she ended up disappointed), the birth of our children (refused to hold our first child and didn’t smile in either of the photos we have of her holding her newborn grandchildren), dealing with her mother’s dementia and death (no matter what happened she only ever expressed slight frustration with her mother and demonstrated little or no grief at her death or funeral).

Even during the course of a normal conversation her facial expressions and tone of voice hardly varies. She can be bloody-mindedly argumentative with you while a smile plays across her face and she speaks with a slight haughty laugh to her voice. In fact appearing unruffled or even slightly amused by everything is all you usually see.

3. Interpersonal functioning

MIL is narcissistic so she has a strong need for control and power in her relationships. She also is very self absorbed. The opinions of others only matters to her with respect to herself, she has to have the good opinion of others even on really insignificant little things. She has little empathy for others’ feelings, why would she? Life is all about her and her feelings which she struggles to regulate, just like a small child.

So when she interacts with other people she does things which try to control them. She went to the supermarket to buy a greetings card marking the arrival of our second child and bought two. One was from her and she expected my mother to take the other card that she had chosen and send that to my and husband and me. My mother politely declined, saying she  would rather choose her own card to mark her grandchild’s birth.  MIL tries to control people ALL the time.

MIL exhibits conversational narcissism in the extreme. Every comment you make is brought round to her somehow, this makes conversation very one sided and alienates people. It is why she has no friends. For example I made our youngest child a dress, my husband drew attention to this as the baby was wearing it and MIL looked, said nothing at all about the dress then remarked “I have stopped making clothes as the patterns cost too much”.

Interactions are more than just conversationally one sided, she only gets in touch when she wants something. Her phone calls or emails are topped or tailed with perfunctory phrases like “hope you and the children are well” or some other sweetener then she gets down to it “I am having a problem with the car…”, she never rings up or gets in touch just to chat. This is what makes her relationships so exploitive, you are only in her thoughts if she can get something out of you.

In order to get you to do what she needs she will manipulate and persist. She will keep pushing and pushing, changing her arguments as to why you should do what she wants, lying and distorting facts, using tiny details and points of logic to unpick your counter arguments, then she tries emotionally to manipulate with sulking, oh poor me victim-martyr behaviour, aggressive silent treatment, outright rage, bad mouthing you to others and then waits until it dies down a bit and tries again. She persisted for more than six months to get us to accept that she would buy a basic provision for our children. We said no as she was using a power play to encroach on our parental responsibilities (we can provide necessities for our kids, this was all about putting my husband in a dependent role and her in the parental role) she is still going on about it. Gifts are never just gifts when a personality disorder is involved, they enmesh you in a web of dependence, indebtedness and obligation.

This inability to accept “No” as an answer is a hall mark of all manipulative behaviour. In Gavin de Becker’s book “The Gift of Fear” he talks about the pre-incident indicators, warning signs that someone is manipulating you into a potentially dangerous situation, and not taking no for an answer is one of them. Persistence in the face of clear a rebuffle is a characteristic of stalking.

4. Impulse control

As with criteria 2 above, impulse control in this context refers to both extremes; little impulse control (as with anti-social personality disorder) and also excessive control (as with avoidant or obsessive-compulsive personality disorder). Rigid and persistent over-control of impulses can show itself as emotional inhibition, a reluctance to do anything that involves any type of uncertainty or risk, a reluctance to start new things or try new activities, and over-conscientiousness or scrupulousness.

This is hard to fathom with respect to my MIL. She seems to flip between the two. Most of the time I would say she is massively over controlled. She is extremely emotionally inhibited seeing obvious display of emotion as a despised weakness even in other people. She never ever wants to be seen to make a mistake or do something incorrectly as that would undermine her belief that she is better than others and expose her to criticism. So she plans things minutely. She also gives up or doesn’t try things for fear of not being able to do it well. Everything in her life is controlled and contained even her diet. We are only ever served one or two dishes in her house (chicken or stew with a bought cake or home made fruit crumble). She won’t try new foods. But when MIL is stressed and panicking (because she fears she may be shown as inferior in some way) or raging (because her own way has been thwarted) she can be stupidly impulsive.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

This is straight forward, MIL’s behaviour is like this all the time, in her house, our house, out for the day, on happy occasions, sad occasions, you name it she will be difficult.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Well it led to the breakdown of her marriage, the alienation of her siblings, the damage to her relationship with her son, her daughter moving abroad to get away from her, she has no friends at all and no social activities.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

Oh yes, MIL’s teenage antics included getting a car and driving it all over her school playing field to churn up the grass just for a laugh, vandalising hospital equipment while awaiting an operation, taking chemicals from the school labs to make stink bombs etc. She was a right pain in the arse by her own account. She boasts about these activities, there is nothing she likes more than being seen to get one over on anyone in authority, who she inevitably regards as inferior to herself.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

No depression or other signs of mental illness, on the contrary she despises mental illness in others seeing it as a character flaw and considers herself to be unusually self aware and psychologically strong.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma)

Her behaviour is not due to alcohol or drugs (which could decrease impulse control and increase emotional expression).

After that long analysis I hope you can see how some of these criteria actually play out in day to day life. Everyone of us at sometime acts in these ways. What makes a personality disorder is the inability of the person to act any other way and the extent of the behaviour. Personality disorders are behaviours taken to an extreme and behaviour that are stuck and inflexible.

In further posts I am going to go through each of the criteria specific to narcissistic personality disorder.

Diagnosing NPD – what the manuals say

How does someone get a diagnosis of narcissistic personality disorder? Well there are two main sources of diagnostic criteria for mental health conditions. One is the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association, the other is the ICD-10 Classification of Mental and Behavioural Disorders published by the World Health Authority. If the person meets the criteria for diagnosis as listed in these academic publications then their clinician (a GP, psychiatrist or psychoanalyst) would be able to diagnose narcissistic personality disorder. Only its not as simple as that.

First off the DSM has changed the criteria for diagnosing personality disorders. The previous edition DSM IV had one version and the present version DSM V has a rather different version. The ICD-10 doesn’t list Narcissistic Personality Disorder at all in the main body of the classification, it could be diagnosed as an other personality disorder not fitting the listed disorders. They include a comment on NPD in the appendix where the DSM IV criteria and listed and it is suggested this is a topic for further discussion and research.

So why all the contradiction and disagreement? The DSM IV criteria have been criticised from within the psychiatric medical community on several points.

Firstly the emphasis in the diagnostic criteria in DSM IV is placed on  the way NPD appears to outside observers in the actions and behaviours of the PD person. Not a lot of emphasis is put on the internal state of mind and thought processes occurring in the PD person which then lead to the behaviours. The result of this is twofold. The clinician has little to go on when trying identify NPD in a therapeutic situation. Imagine a person has all sorts of problems with their relationships and gets depressed, sees a doctor and starts talking about their feelings and thoughts. The DMS IV describes behaviours in a social-interpersonal setting which the clinician never sees. The clinician needs more information about the internal landscape of someone with NPD to identify it in a person in therapy.

The other problem is that the behaviours of someone with NPD overlap with behaviours shown by other personality disorders. This blurring of the boundaries of personality disorders is unhelpful if you believe (as I think many psychiatrists do) that each disorder is caused by a particular and specific developmental disruption in the person’s early life. The nature of the damage done and the age it occurred at will uniquely determine the manifestation of the disorder. Well I’m not sure I would be confident in supporting that discrete definition in its entirity but that seems to be the underlying assumption in wanting less overlap between the disorders.

If the definition of the disorder is heavily behaviourally based there will always be a tendency for cross-diagnosis between disorders as two people can behave in a similar way for entirely different reasons. Ideally one needs to identify the key features of the disorder as they appear externally to others and internally as the person experiences it themselves. The marked thing about NPD is that the external presentation of behaviours almost completely contradicts the internal experience of the sufferer. They act extremely self assured and superior, they feel utterly ashamed and inferior. The external behaviour is enacted as a way of suppressing the internal feelings which the NPD sufferer has, in the main, stuffed into their subconscious.

This criticism of the DSM IV criteria and general debate on the subject in the clinical literature means there has been no agreement between DSM and ICD-10. There is no argument that such a set of behaviours for the surmised reasons exists. NPD is seen in many clinical settings. ICD-10 wants a clear set of symptoms before it will include NPD as a specific named personality disorder, DSM updates itself periodically to try and keep abreast of developments. The WHO manual is more conservative, the American manual is criticised for medicalising all manner of behaviours and being in hock to large pharmaceutical companies (who for a price will sell you a drug to treat the disorders in the DSM).

Below is a straight copy and paste from the relevant tomes.

DSM IV Criteria for diagnosing a personality disorder

A. An enduring pattern of inner experience and behavior the deviates  markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people and events)
2. Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response)
3. Interpersonal functioning
4. Impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).

DSM IV criteria for NPD

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or highstatus people (or institutions).

4. Requires excessive admiration.

5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.

6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.

7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

8. Is often envious of others or believes that others are envious of him or her.

9. Shows arrogant, haughty behaviors or attitudes.

DSM V criteria for diagnosing a personality disorder

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.

B. One or more pathological personality trait domains or trait facets.

C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or sociocultural environment.

E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

DSM V criteria for NPD

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:

A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):

a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.

b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.

b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance
of a need for personal gain.

B. Pathological personality traits in the following domain:
1. Antagonism, characterized by:
a. Grandiosity: Feelings of entitlement, either overt or covert;self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.

b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

ICD-10 Criteria for diagnosing a personality disorder

Conditions not directly attributable to gross brain damage or disease, or to
another psychiatric disorder, meeting the following criteria:
(a)markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
(b)the abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
(c)the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
(d)the above manifestations always appear during childhood or adolescence and continue into adulthood;
(e)the disorder leads to considerable personal distress but this may only become apparent late in its course;
(f)the disorder is usually, but not invariably, associated with significant problems in occupational and social performance.