Bipolar II vs. malignant narcissism

[Salpingo]

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There's a lot in the literature about bipolar/borderline PD diagnostic issues (some arguing that they're on the same spectrum), but I find just as many patients who straddle the line between narcissistic PD and bipolar, type II.

The typical case is the relatively successful executive who suffers from bouts of "depression," often with irritability and lability, some alcohol use thats minimized, that often coincides with problems in their business or relationships. During this period, mistakes are made, with the patient screaming at his family or employees, which is then marked up to "impulsivity," raising the question of a "mixed episode." Of course, when things are going well and the patient is being validated for their brilliance and success, there's grandiosity and elevated self-esteem, even a little euphoria and increased goal-directed activity with diminished sleep requirement. For the sake of argument, a totally random example would be sending out messages on social media at 4am. Nothing crazy enough to really qualify as impairment, but enough to raise an eyebrow.

Medication doesn't seem to work, although there's some marginal benefit from mood stabilizers (which the patient seems to have mixed adherence to). Per the patient, benzodiazepines helps with their mania, and stimulants get them through their depression (interestingly, there isn't any adherence issues here).

I'm curious to get other peoples experiences with these cases, since I could be getting a little cynical with some of these cases. Is it essential to challenge the diagnosis? Do you feel that there is a "true" bipolar II or are we medicalizing bad behavior? Or is it the best way of getting patients to engage in help until they're ready to address interpersonal issues?

 

[thoffen]

I'm not sure if you posed a question, but my reading of your case generated more or less a "yup" internally. I am curious, though, why is this "malignant" narcissism?

 

[HarryMTieboutMD]

bipolar II was only "created" for DSM IV because there people noticed cases where there were definite EPISODES of major depression and manic looking periods that were not so severe that they required hospitalization. The point is that for a BPAD illness to be diagnosed, constellation of symptoms must occur in episodes and represent a distinct change from baseline. Most cases of people diagnosed as BPAD 2 I have seen are either misdiagnosed personality disorders or MDD with emotional dysregulation during affective decompensation. The few I have been comfortable calling BPAD 2 really have hypomanic periods that really border on manic (like they are markedly DIFFERENT) but don't get psychotic/hospitalized/impaired in functioning or they last maybe 5 days instead of a week.

Kraepelin described different "temperaments" (hypomanic, cyclothymic, irritable) that today we might conceptualize as personality disorders that he thought represented the same morbid process, and he wasn't totally incorrect- we do know that certain personality structures are associated and "drive" affective illness.

The term "malignant narcissism" is one of Kernberg's musings that is mostly relegated to irrelevant analytic circles and is now only known because these same, irrelevant analysts (who are probably all sex offenders) who don't contribute anything academically yet are tenured at their respective elite departments decided to break the Goldwater rule and label the current president as such

 

[Salpingo]

I'm not sure if you posed a question, but my reading of your case generated more or less a "yup" internally. I am curious, though, why is this "malignant" narcissism?

Thanks, I edited my original post. I was curious how other people formulate and treat these patients, but I was demonstrating some of my own narcissism when I wrote that .

Malignant narcissism describes the stereotypical narcissist: aggressive, at times sociopathic and mildly paranoid. You feel good when you're on their good side, like the sidekick to the world's greatest superhero, but terribly devalued when you're on their bad. Trump's twitter feed provides some good examples (is it breaking Goldwater to describe a twitter feed?)

It's a useful distinction since many narcissists lack the impairment/distress to qualify for NPD (Allen Frances has been writing that Trump cannot be diagnosed with NPD for that reason alone). Narcissism itself can be normative and even healthy. There are "fragile narcissists" who are more passive but still highly responsive to narcissistic injury; its the idea of the "fake nice guy" who takes pride in being the sensitive type but then becomes despondent when rejected. In the last case, I don't see those patients as overlapping with bipolar as much as pervasive depressive disorder and dependent personality.

Or as best portrayed in XKCD:

 

[slappy]

Or as best portrayed in XKCD:

I'd somehow missed that one. Hilarious and true.