The Narcissistic Personality Disorder and the Differential Diagnosis of Antisocial Behavior
Otto Kernberg, an influential and well-known American psychoanalyst, has contributed much to a developmental object relations understanding of antisocial personality, his preferred term. This paper, which first appeared in Psychiatric Clinics of North America in 1989, draws heavily on the object relations theory of Edith Jacobson to formulate a diagnostic understanding of various antisocial psychologies. Kernberg underscores the centrality of pathological narcissism, superego deficits, and sadism in psychopathy. He also mentions some important treatment and transference guidelines that should be helpful to most clinicians.
The purpose of this article is to focus on the intimate relationship between the narcissistic personality disorder and the antisocial personality disorder. In essence, I propose that practically all patients with an antisocial personality disorder present typical features of the narcissistic personality disorder plus a specific pathology of their internalized systems of morality (their “superego functions”) and a particular deterioration of their world of internalized object relations. The only significant exception to the rule that antisocial personality disorders present narcissistic personality disorders plus severe superego pathology is the relatively infrequent and prognostically grave clinical syndrome of “pseudo-psychopathic schizophrenia,” typically, chronic schizophrenic patients with periodic improvement (with or without treatment) and severe, chronic antisocial behavior during such periods of “improvement” that disappears only when the patient again becomes psychotic. I also describe an intermediary group of patients between the narcissistic personality disorder and the antisocial personality disorder characterized by what I have called the syndrome of “malignant narcissism” (Kernberg, 1984). This syndrome is characterized by the combination of (1) a narcissistic personality disorder, (2) antisocial behavior, (3) ego-syntonic aggression or sadism directed against others or even expressed in a particular type of triumphant kind of self-mutilation or suicidal attempts, and (4) a strong paranoid orientation.
By implication, I am describing a dimension of antisocial behavior that links the narcissistic personality disorder with the antisocial personality disorder, and the syndrome of malignant narcissism as an intermediary personality constellation. This dimensional characteristic linking these three disorders may also be found in other dimensional links connecting other personality disorders among each other, such as, for example, the schizoid personality disorders’ relationship with the schizotypal personality disorder, and the hysterical personality disorders’ relationship with the histrionic, hysteroid, infantile and borderline personality disorders (Kernberg, 1984).
One important complication of this discussion derives from the shortcoming of the description of the antisocial personality disorder in DSM-III-R, where the use of excessively concrete, behavioral criteria instead of personality traits—psychological, intrapsychic criteria—and the heavy emphasis on criminal behavior all risk coming to an improper diagnosis.* The DSM-III-R (American Psychiatric Association, 1987) criteria for the antisocial personality disorder are certainly broad enough to include practically all patients with antisocial personality disorders who present predominantly aggressive interactional patterns and criminal behavior. In this area, sensitivity is high although specificity is probably low.** By stressing the severity of the criminal behavior, these criteria override the philosophical problem of what is antisocial from the viewpoint of particular value systems, and in their stress on childhood antecedents they appropriately direct the clinician to the childhood origins of this character pathology. Unfortunately, however, in this very stress on the criminal aspect of antisocial behavior they include delinquents with very different personality makeup, and blur the distinction between sociocultural and economic determinants of delinquency on the one hand and psychopathology of the personality on the other. Thus, these criteria contribute to causing what Rutter and Giller (1983) have described as the indiscriminate lumping together of delinquent behavior, which, in their view, interferes with discovering predisposing factors for those with a specific personality disorder. These criteria also lead to the critical questions raised by Stone (1984). Another problem with the DSM-III-R (American Psychiatric Association, 1987) criteria is that they neglect the nonaggressive variety or the predominantly inadequate or passive type of antisocial personality disorder, in which chronically parasitic and / or exploitive behaviors predominate rather than directly aggressive ones.
What I find most striking about the description of the antisocial personality disorder in DSM-III-R is the remarkable absence of the focus on pathological personality traits as opposed to direct antisocial behaviors, a criticism that Millon (1981) so cogently formulated.
The problem of the diagnosis of the antisocial personality disorder is complicated by the vicissitudes of the terminology that has confused this field. Unresolved conceptual problems emerge in the context of a historical analysis of the clinical descriptions and terminology.
DSM-I (American Psychiatric Association, 1952) shifted from the traditional term “sociopathic personality,” that stressed the socially maladaptive aspects of these patients and the interplay between personality and social determinants, to the term “sociopathic personality disturbance” for this field. DSM-I differentiated the “antisocial reaction” from the “dissocial reaction,” the first referring to the psychopath in a strict sense, and the second to patients who disregard social codes and develop within an abnormal social environment, but are still able to display strong personal loyalties. Throughout all these years, Cleckley’s (1941) The Mask of Sanity, the fourth edition of which was published in 1964, remains, in my view, the basic text describing what we now call the antisocial personality disorder. DSM-II (American Psychiatric Association, 1968), in an effort to circumscribe the diagnosis of psychopathy to the antisocial personality in a restricted sense, shifted the terminology to “antisocial personality,” and proposed a capsule definition that, in essence, derived from Henderson’s (1939) and Cleckley’s (1941) work:
This term is reserved for individuals who are basically unsocialized and whose behavior pattern brings them repeatedly into conflict with society. They are incapable of significant loyalty to individuals, groups or social values. They are grossly selfish, callous, irresponsible, impulsive and unable to feel guilt or to learn from experience and punishment. Frustration tolerance is low. They tend to blame others or offer plausible rationalizations for their behavior. A mere history of repeated legal or social offenses is not sufficient to justify this diagnosis.
From a clinical viewpoint, this is a brief but remarkably relevant and meaningful definition. It also contains references to the narcissistic personality features of these patients. DSM-III (American Psychiatric Association, 1980) maintained the same term—antisocial personality—adding the characteristic label “disorder” at the end, but shifted its approach to the broader, criminal-behavior-oriented focus. The epidemiological research carried out by O’Neal et al. (1962), Guze (1964a, b), and particularly Robins (1966) was the crucial determinant of this approach.
In my view, psychoanalysis has contributed to both confusing the diagnostic issues and to clarifying the structural characteristics of the antisocial personality. Alexander and Healy (1943), in this country, developed the concept of the “neurotic character” to refer to severe character pathology, including here character pathology with antisocial features, thereby implicitly blurring the distinction between the antisocial personality disorder proper and the other personality disorders. Eissler (1950), in applying the term “alloplastic defenses” in contrast to “autoplastic defenses,” also contributed to a homogenized approach to character pathology that blurred the differential diagnosis of the antisocial personality. The overemphasis in the psychoanalytic literature of the 1940s and 1950s on Freud’s (1916) description of “criminals from (an unconscious) sense of guilt” interpreted antisocial behavior (naively, I think, from the viewpoint of contemporary psychoanalytic thinking) as a reaction formation against unconscious guilt rather than an expression of severe deficits in the development of the normal superego.
It was only with Johnson (1949) and Johnson and Szurek’s (1952) description of “superego lacunae” that psychoanalytic thinking began to focus on the structural—rather than the dynamic—aspects of antisocial personalities. Their relatively simple formulation was rapidly overtaken by the more sophisticated description of severe superego pathology linked to the narcissistic personality by Rosenfeld (1964) and Jacobson (1964, 1971), whose work has influenced my own views on the origins and nature of superego pathology in narcissistic personalities, and the relation of this pathology to the antisocial personality proper (Kernberg, 1984, 1986).
Rutter and Giller’s (1983) book Juvenile Delinquency: Trends and Perspectives reviews comprehensively the epidemiological studies dealing with the relationship between juvenile delinquent behavior and abnormal personality functioning, reevaluating in the process our present knowledge regarding the etiology of these conditions. From the viewpoint of the ongoing debate regarding biological, psychological, and sociological factors influencing the development of antisocial behavior, they point to the evidence of a clear relation between specific constellations of early childhood development in the family and the individual’s later degree of social compliance, but state that the mechanisms by which the familiar factors are associated with delinquency are still unclear. They also point to a relation between social change and increase in delinquency, again stressing our current lack of available knowledge regarding the corresponding mechanisms. They conclude that multiple causes appear to be active in codetermining juvenile delinquency, including peer group influence, social control and social learning, biological factors influencing extreme types of antisocial behavior, and situational factors. They propose that it is absurd to look for a single explanation for juvenile delinquency and emphasize that no clear strategy of prevention is yet available.
Lewis et al.’s (1985) study of childhood antecedents of children who later commit murder pointed to the prevalence, in these cases, of psychotic symptoms, major neurological impairment, psychotic first degree relatives, violent acts witnessed during childhood, and severe physical abuse, thus strongly highlighting biological and psychosocial antecedents to antisocial behavior.
Dicks’s (1972) book Licensed Mass Murder reports the investigation of the background and personality development of a series of SS mass murderers before and after their concentration camp functions. It provides dramatic evidence that these criminals, while suffering from severe personality disorders with a predominance of narcissistic, paranoid, and antisocial features from early childhood on, only engaged in the most repugnant criminal behavior in the context of the social facilitation of the SS training and death camps, reverting to their previous, nondelinquent personality functioning during and after their prison terms, thus illustrating what amounts to an almost empirical study of social facilitators of severe and chronic criminality (obviously, the “burn-out” tendencies of middle aged delinquents also need to be taken into consideration here).
A PROPOSED DIAGNOSTIC FRAME
Antisocial behavior should ideally be defined in terms of its psychological meanings rather than in behavioral and / or legal terms. For example, “ran away from home overnight at least twice while living in parental or parental surrogate home (or once without returning)”—one of the criteria for antisocial personality disorder in DSM-III-R—is a descriptive term that omits considering whether a child is running away from an impossible home with physically abusive parents or from a well-constituted home. Again, “has never sustained a totally monogamous relationship for more than one year”—another DSM-III-R criterion—includes a vast spectrum of late adolescents and early adults, whose dating behavior may be influenced by multiple neurotic inhibitions, culturally determined patterns, and practically any of the personality disorders.
Sexual promiscuity has different implications within different social environments and within the context of different personality structures (masochistic versus narcissistic) (Kernberg, 1988). The presence of obviously marked and chronic delinquent behavior may overshadow such subtleties, but, by the same token, shifts the diagnostic focus to delinquency per se rather than to the specificity of a personality disorder.
I have found that, regardless of the degree of delinquent behavior or even its absence, from a clinical perspective the first indication of the possibility of the existence of an antisocial personality disorder is the presence of a narcissistic personality disorder. In fact, the clinical profile of the antisocial personality described by Cleckley (1941) falls naturally into three categories: first, some basic characteristics that differentiate the antisocial personality from psychosis and organic brain syndromes—“absence of delusions and other signs of irrational thinking” and “inadequately motivated antisocial behavior” (the dominant immediate symptom); second, a series of characteristics found in severe narcissistic character pathology: “sex life impersonal, trivial, and poorly integrated,” “unresponsiveness in general interpersonal relations,” “general poverty in major affective reactions,” “pathological egocentricity and incapacity for love”; third, what amounts to manifestations of severe superego pathology: “unreliability,” “untruthfulness and insincerity,” “lack of remorse or shame,” “poor judgment and failure to learn by experience,” and “failure to follow any life plan.”
Only four of Cleckley’s clinical profile listings, namely, “absence of ‘nervousness’ or psychoneurotic manifestations,” “fantastic and uninviting behavior with drink and sometimes without,” “suicide rarely carried out,” and “superficial charm and good intelligence” are, in my view, questionable. There are many antisocial personalities who do present psychoneurotic symptoms, and impulsive suicide can be observed in these patients (as well as in patients with the syndrome of malignant narcissism, to which I shall return); and inappropriate behavior with drink and sometimes without seems to me rather nonspecific. Many patients with antisocial personality disorder, particularly those within the criminal population, do not show superficial charm, and one finds antisocial personality disorders at all levels of intelligence.
But antisocial behavior linked with a narcissistic personality disorder is not enough to make the diagnosis of an antisocial personality disorder. As I mentioned before, there exists an intermediary group between the narcissistic personality disorder and the antisocial personality disorder, the syndrome of malignant narcissism, characterized by the presence of antisocial behavior in a narcissistic personality structure, while the patient still presents a capacity for non-self-serving investment in others, for authentic concern for others and for himself, for experiencing authentic guilt feelings, and for identification with non–self-serving value systems in some areas while such capacity is lost in others.
Antisocial behavior may emerge in the context of other personality disorders, so that the practically much neglected differential diagnosis among personality disorders becomes highly relevant in evaluating this symptom. This differential diagnosis, in my experience, has fundamental prognostic and therapeutic importance. Antisocial behavior in a non-narcissistic personality structure is prognostically favorable, in contrast to the extremely poor prognosis of antisocial behavior in the antisocial personality proper.
Antisocial behavior also may be a consequence of a normal or pathological adaptation to a highly pathological social environment, such as the “culture of the gang,” and while this is a clinically infrequent condition, the “dyssocial reaction” of DSM-I was a useful reminder of this group of patients. By the same token, sometimes antisocial behavior may be the equivalent of a neurotic symptom: for example, neurotic adolescent rebelliousness may take the form of occasional antisocial behavior.
Antisocial behavior should be explored in the light of a patient’s general level of organization of superego functions. Here we may reexamine the question of the “criminal out of an unconscious sense of guilt.” Antisocial behavior that derives from an unconscious sense of guilt and a corresponding unconscious search for punishment has to be differentiated from the vast majority of cases in which self-destructiveness and self-provoked punishment are a consequence of the antisocial behavior but do not reflect such an unconscious motivation. In fact, the psychoanalytic hypothesis of an unconscious sense of guilt can be demonstrated as valid only if it becomes conscious as a result of psychoanalytic exploration. This is definitely not the case in intensive, long-term efforts of psychoanalytic psychotherapy with most patients presenting severe antisocial behavior. In addition, on purely theoretical grounds, given all the other evidence of severe deterioration or unavailability of basic superego functions in the large majority of patients with antisocial behavior, the assumption of an unconscious sense of guilt in these cases is highly questionable.
In clinical practice, there are patients with neurotic personality organization (in contrast to borderline personality organization), or, in simple terms, with “high level” personality disorders (hysterical, obsessive-compulsive, and depressive-masochistic personalities) (Kernberg, 1984) who may present antisocial behavior unconsciously geared to self-punishment or to obtaining punishment from external sources. The type of the dominant personality disorder points to this rather infrequent etiology.
In this connection, a relatively infrequent symptom, namely, pseudologia fantastica, should also be explored in the light of the personality disorder within which it emerges. Pseudologia fantastica may be found with hysteroid, histrionic, or infantile personalities, prognostically is less severe than both chronic lying and pseudologia fantastica in narcissistic and antisocial personality disorders. Once again, pinpointing the dominant character pathology emerges as a crucial issue in the differential diagnosis of antisocial behavior.
One issue that very frequently complicates the differential diagnosis of antisocial behavior is the presence of alcoholism and / or drug abuse, and of symptoms secondary to these disorders. Another related and often complexly interwoven psychopathology is that of antisocial behavior and a well-structured perversion or sexual deviation, “paraphilia” in DSM-III (American Psychiatric Association, 1980) and DSM-III-R (American Psychiatric Association, 1987) terminology. For practical purposes, here the main issue is the extent to which ego-syntonic aggression is built into the deviant sexual pattern: the more the personality structure shifts from the narcissistic into the antisocial, the more such aggressive behavior may become life threatening, and a subgroup of aggressive antisocial personalities may center their criminal behavior on sexual assaults and murder (Kernberg, 1985, 1986).*
CLASSIFICATION AND DIFFERENTIAL DIAGNOSIS
What follows is a classification of personality disorders in which antisocial features are prominent, from the most severe to the least severe of these disorders. For practical purposes, in all patients presenting antisocial behavior, it is helpful to first rule out the diagnosis of an antisocial personality proper. For this reason, I also investigate systematically the potential presence of antisocial behavior in all patients with narcissistic personality disorder.
The Antisocial Personality Disorder
These patients typically present a narcissistic personality disorder. The typical symptoms of the narcissistic personalities are, in the area of pathological self-love: excessive self-reference and self-centeredness; grandiosity and the derived characteristics of exhibitionism, an attitude of superiority, recklessness, and overambitiousness; overdependency on admiration; emotional shallowness; and severe bouts of insecurity alternating with a predominant grandiosity. Regarding the area of pathological object relations, these patients’ predominant symptoms are inordinate envy (both conscious and unconscious); devaluation of others as a defense against envy; exploitativeness reflected in greediness, appropriation of others’ ideas or property, and entitlement; an incapacity to truly depend on others in a mutual relationship; and a remarkable lack of the capacity for empathy with and commitment to others. The basic ego state of these patients is characterized by a chronic sense of emptiness, evidence of an incapacity to learn, a sense of aloneness, stimulus hunger, and a diffuse sense of meaninglessness of life.
In addition, all of these patients present some degree of superego pathology. Ordinary superego pathology of narcissistic personalities includes the incapacity to experience mournful, self-reflective sadness; the presence of severe mood swings; a predominance of “shame” as contrasted to “guilt” in their intrapsychic regulation of social behavior; and a lack of an integrated adult value system, reflected in the persistence of childlike values. Their self-esteem depends on physical beauty, power, wealth, and admiration from others, in contrast to such adult values as personal capabilities, achievements, responsibility, and relation to ideals.
The antisocial personality disorder proper presents more severe superego pathology. The antisocial behaviors that these patients present include lying, stealing, breaking in, forgeries, swindling, and prostitution—all in a predominantly “passive-parasitic” type—while assault, murder, and armed robbery are typical of the aggressive type (Henderson, 1939; Henderson and Gillespie, 1969). In other words, clinically one may differentiate between the behaviorally aggressive, sadistic, and usually also paranoid orientation of some patients with antisocial personality disorder from the passive, exploitative, parasitic type of others.
It needs to be stressed that, with intelligent patients from a favorable socioeconomic and cultural background who present a predominantly passive-parasitic type of antisocial behavior, the childhood antecedents of such behavior may be apparently mild or even go unnoticed, particularly in some highly pathological yet socially adaptive families. For example, one patient was a brilliant student through elementary school, high school, and college, and was socially successful and well-liked as a young man. His occasional stealing was generously forgiven by his parents, and his lack of a sense of responsibility was adjudicated to his having been spoiled and overprotected by an admiring mother and grandparents. He was able to obtain a postgraduate degree, he married a woman with whom he kept an apparently normal marital relationship for over 15 years, and he was kind to his children. At the same time, he was embezzling funds from associates and from his family business. While running up inordinate debts, he also gave expensive gifts to friends and associates, appeared to be a year-round “Santa Claus,” and was brought to consult by his family only when he was threatened by a potential jail sentence because of tax evasion.
The crucial differentiation of both passive and aggressive antisocial behavior as part of a narcissistic personality disorder from an antisocial personality disorder proper depends on the absence, in the latter, of a capacity for authentic guilt feelings and remorse. Thus, even after being confronted with the consequences of their antisocial behaviors and in spite of their profuse protestations of guilt or regret, there is no change in their behavior toward those they had attacked or exploited, nor any spontaneous concern over this lack of change in their behavior. The absence of guilt is central in this disorder. While the differential diagnosis of the capacity for experiencing guilt and concern requires the inferential step of evaluating a patient’s reaction to confrontation and the breakdown of his omnipotence, other characteristics reflecting this incapacity for guilt and concern may become directly evident in the interviews.
For example, the patient with an antisocial personality disorder is unable to imagine an ethical dimension in others and therefore in the diagnostician’s mind. After reiterating his truthfulness to the therapist, and after subsequently being caught in lying to him, he may react sheepishly but is not able, when asked, to empathize with the therapist’s reaction to him except with a sense that the therapist must feel fooled and angry with the patient. Or an antisocial patient may “confess” his actions but only in those areas where he has been caught, thus entering into a flagrant contradiction with simultaneously professed remorsefulness over his past behavior.
The lack of investment in nonexploitative relations with others may be reflected in transient, superficial, indifferent relations with others, lack of capacity to emotionally invest in people as well as in pets, and the absence of any internalized moral value, let alone the capacity to empathize with such values in others. The deterioration of these patients’ affective experience is expressed in their intolerance of any increase in anxiety without developing additional symptoms or pathological behaviors, their incapacity for depression with reflective mourning or sadness, and their incapacity for falling in love or experiencing any tenderness in their sexual relations.
The lack of a sense of the passage of time, of planning for the future, and of contrasting present experience and behavior with aspired ideal ones are usually striking in these patients, so that planning extends only to an immediate improvement of present discomforts and to a reduction of tension by the achievement of immediately desired goals. Their failure to learn from past experience is an expression of the same incapacity to conceive of their life beyond a short, immediate time span. Their manipulativeness, pathological lying, and flimsy rationalizations are well known. Paulina Kernberg (personal communication) has coined the term holographic man to refer to patients who create a vague, ethereal image of themselves in the diagnostic sessions that seems strangely disconnected from their present reality or their actual past, an image that changes from moment to moment in the light of different angles of inquiry, and leaves the diagnostician with a disturbing sense of unreality.
Again, once the diagnosis of a narcissistic personality structure is obvious, the crucial diagnostic task is to evaluate the severity of any presenting antisocial features, their past history and childhood origins, and then the patient’s remaining capacity for object relations and superego functioning. The practically total absence of a capacity for non-exploitative object relations and of any moral dimension in personality functioning, reflected in the clinical characteristics mentioned before, are the key elements in the differentiation of the antisocial personality proper from the less severe syndromes of malignant narcissism and the narcissistic personality disorder. This diagnosis may be arrived at by taking a complete history, exploring carefully the patient’s narrative, tactfully confronting the patient with contradictory and obscure areas in this narrative, evaluating the patient’s interaction with the diagnostician, and exploring his reactions to being confronted with contradictions between objective information from the patient’s past, his present narrative, and his behavior.
The exploration of the patient’s reactions to inquiry about potential antisocial behavior that might follow from what he has said but has not acknowledged may be very helpful. For example, to raise a question with a patient whose history would show a natural tendency to engage in prostitution: “What prevented you from engaging in prostitution?,” or, similarly, with a patient involved with drugs, “Why would you not be dealing?” may test the patient’s superego functions as well as his honesty in relating to the therapist. Obviously, patients who are lying to the therapist without acknowledging that they are lying (many antisocial personalities may acknowledge to the therapist that they are lying to him but continue doing so after such an acknowledgment) require that we take history from the relatives, sophisticated social work interventions, and reports from institutional settings with which the patient has been involved in the past.
The reasons for consulting a psychiatrist, the manipulative efforts involved in obtaining a “certificate of health” or a certificate for “reinstatement in school,” and, in many cases, the more or less obvious efforts to avoid facing legal procedures by means of psychiatric interventions may serve diagnostic as well as prognostic purposes. Usually the investigation into all these factors requires several interviews, returning again and again to areas of uncertainty and confusion, and repeated evaluation of the patient’s reaction to confrontation with whatever deceptive maneuvers or contradictions he presents.
The countertransference to patients with severe antisocial behavior may provide what might be called a second line of information: the therapist may react with a sense of confusion, the temptation to either accept uncritically the patient’s statements or to reject them with a paranoid stance in the countertransference, a protective “pseudoneutrality” that conceals an underlying devaluation of the patient, or the wish to escape from an intolerable relationship with a patient who implicitly attacks the most basic values of human relations so dear to the therapist. In my view, a therapist’s oscillation between moments of a paranoid stance and others of concern, in other words, a true ambivalence in his reaction to these patients, constitutes a healthy response. It is helpful for the therapist to be able to present himself as moral but not moralizing, as fair but not naive, and as confronting but not aggressive. Confrontation as a technical device implies the tactful bringing together of contradictory or confusing aspects of the patient’s narrative, behavior, and / or past; it is not an aggressive display of criticism or disagreement with the patient.
Usually, a major affective disorder may be ruled out by careful history-taking and mental status examinations, but psychological tests may provide additional help in ruling out an organic mental disorder, such as temporal lobe epilepsy or a limbic lobe syndrome, disorders that may present with explosive aggressive behavior. They may also help to rule out an atypical schizophrenic disorder, such as “pseudopsychopathic schizophrenia.” When antisocial behavior develops in middle or late adulthood in the context of a loss of memory and higher abstract reasoning, many chronic organic mental disorders may have to be ruled out, and in addition to psychological testing, may require neurological, EEG, and radiological studies.
If an antisocial personality proper can be ruled out, the next diagnostic category to be considered is that of a narcissistic personality disorder with the syndrome of malignant narcissism, or an ordinary narcissistic personality with predominantly passive-parasitic antisocial trends.
Malignant Narcissism
As mentioned before, these patients are characterized by a typical narcissistic personality disorder, antisocial behavior, ego-syntonic sadism or characterologically anchored aggression, and a paranoid orientation. In contrast to the antisocial personality proper, patients with malignant narcissism still have the capacity for loyalty to and concern for others or for feeling guilty; they are able to conceive of other people as having moral concerns and convictions; and they may have a realistic attitude toward their own past and in planning for the future.
Their ego-syntonic sadism may be expressed in a conscious “ideology” of aggressive self-affirmation but also, quite frequently, in chronic ego-syntonic suicidal tendencies. These suicidal tendencies do not emerge as part of a depressive syndrome, but rather in emotional crises or even “out of the blue,” with the underlying fantasy that to be able to take one’s life reflects superiority and a triumph over the usual fear of pain and death. To commit suicide, in these patients’ fantasy, is to exercise sadistic control over others or to “walk out” of a world they feel they cannot control.*
The paranoid orientation of these patients (which psychodynamically reflects the projection onto others of unintegrated sadistic superego precursors) is manifest in an exaggerated experience of others as idols, enemies, or fools. These patients have a propensity for regressing into paranoid micropsychotic episodes in the course of intensive psychotherapy, and illustrate most dramatically the complementary functions of paranoid and antisocial interactions in the interpersonal realm (Jacobson, 1971; Kernberg, 1984). Some of these patients may present what, from the outside appears as frankly antisocial behavior, for example, as leaders of sadistic gangs or terrorist groups: an idealized self-image and an ego-syntonic sadistic, self-serving ideology rationalizes the antisocial behavior, and may co-exist with the capacity of loyalty to their own comrades.
Narcissistic Personality Disorders with Antisocial Behavior
These patients present a variety of antisocial behaviors, mostly of the passive-parasitic type, and show remnants of autonomous moral behavior in some areas and ruthless exploitativeness in others. They do not evince the ego-syntonic sadism or self-directed aggression or an overt paranoid orientation typical of the syndrome of malignant narcissism. They have a capacity for experiencing guilt and concern, loyalty to others, an appropriate perception of their past, and they may realistically conceive of and plan for the future; in some cases, what appears from the outside as antisocial behavior is simply a manifestation of lack of capacity for commitment in depth to long-range relationships. Narcissistic types of sexual promiscuity, irresponsibility in work, and emotional or financial exploitation of relatives are prevalent here, while these patients are still able to care for others in some areas and to maintain ordinary social boundaries of honesty in more distant interpersonal interactions.
Other Severe Personality Disorders with Antisocial Features
The next level of pathology, with less negative prognostic and therapeutic implications, is the presence of antisocial behavior in personality disorders other than the narcissistic personality. In terms of the classification of personality disorders that I have proposed in the past (Kernberg, 1975, 1984), these are patients with borderline personality organization and nonpathological narcissism. Typical examples are the infantile, histrionic, hysteroid, or Zetzel type III and IV personality disorder (not to be confused with a hysterical personality proper) (Kernberg, 1986), and the paranoid personality disorder: these are the two most frequent personality disorders of this group that present with antisocial behavior. In the infantile personality, pseudologia fantastica is not infrequent; the “paranoid urge to betray” described by Jacobson (1971) illustrates treacherousness in a paranoid context. In my experience, most patients with factitious disorder with psychological and / or physical symptoms, pathological gambling, kleptomania, pyromania, and malingering, if they do not present a typical narcissistic personality disorder, form part of this group of personality disorders with antisocial features.
Neurotic Personality Disorders with Antisocial Features
Here we find the criminals from (an unconscious) sense of guilt (Freud, 1916). These patients are of great clinical interest because, in spite of what sometimes appears as dramatic antisocial behavior, this behavior occurs in the context of a neurotic personality organization and has an excellent prognosis for psychotherapeutic and psychoanalytic treatment.* As a typical example, I saw a research scientist who compulsively falsified experimental data, only to recheck them again and again until the experiments with the correct results would neutralize and eliminate the findings of the experiments he had tampered with. This dangerous, seemingly purposeless, self-defeating behavior, which gravely threatened his research career, was fully resolved in a four-year psychoanalytic treatment that at the same time also resolved a severe depressive-masochistic personality disorder. The patient presented no antisocial behavior outside the specific pattern I mentioned, and he had a history of pseudologia fantastica in his childhood.
Another patient with an obsessive-compulsive personality disorder would steal minor objects in public places within the organization where he worked, exposing himself to embarrassing and humiliating experiences of being caught and threatened with immediate dismissal. Fortunately, a sophisticated psychiatric evaluation by a colleague provided the information that protected this patient’s future while treatment was initiated. While such cases are relatively rare, the enormous difference in their prognosis from that of the groups previously mentioned warrants a careful assessment of the personality structure in each case of antisocial behavior.
Antisocial Behavior as Part of a Symptomatic Neurosis
This category refers to occasional antisocial behavior as part of adolescent rebelliousness, in adjustment disorders, and / or in the presence, in many cases, of a facilitating social environment that fosters channeling psychic conflicts into antisocial behavior.
Dyssocial Reaction
This clinically relatively infrequent syndrome refers to the normal and / or neurotic adjustment to an abnormal social environment or subgroup. In clinical practice, most of these patients do present some type of personality disorder that facilitates their uncritical adaptation to a social subgroup with antisocial behaviors.
PROGNOSTIC AND THERAPEUTIC CONSIDERATIONS
The treatment of antisocial behavior is essentially psychotherapeutic, except, of course, when it is symptomatic of an organic mental disorder or of a psychotic illness. The levels of severity of antisocial behavior I have described correspond to the prognosis for psychotherapeutic treatment, with the first of these levels, the antisocial personality disorder proper, having the poorest prognosis to the extent that practically all of these patients are not responsive to ordinary psychotherapeutic approaches. The treatment of the antisocial personality disorder in childhood, however, the “conduct disorder” in DSM-III-R (American Psychiatric Association, 1987), has a more favorable prognosis, and encouraging results with treatment of these children in specialized residential settings (Diatkine, 1983) have been reported. “Unsocialized aggressive conduct disorder,” however, seems to have the least favorable prognosis. This diagnosis corresponds to what is called “solitary aggressive type” in DSM-III-R.
Regarding adult patients, outpatient psychotherapy with antisocial personality disorders has been very discouraging. I believe that it is too early to conclude whether specialized therapeutic community settings for patients with antisocial personality disorders may be effective in the long run. Extended inpatient treatment in specialized closed hospitals or prison systems would seem to be effective in some cases, particularly if a firm and incorruptible environmental control is combined with the opportunity for group therapy in groups constituted by delinquent patient-prisoners (Kernberg, 1985).
The first task of the psychiatrist evaluating patients with antisocial behavior under ordinary outpatient conditions is to establish carefully the differential diagnosis elaborated before, and then to separate out the prognostically more favorable personality disorders with antisocial behavior from the antisocial personality proper. The second task for the psychiatrist is to protect the immediate social environment of the patient with an antisocial personality disorder from the consequences of his antisocial behavior, help the patient’s family protect themselves, and provide tactfully but openly full information and counsel regarding the nature of this psychopathology and its prognosis to the family. The fact that, as many researchers and clinicians have pointed out, the antisocial personality disorder tends to “burn out” in middle and later adult years may provide some long-range hope, or at least some consolation to the family (Glueck and Glueck, 1943).
The psychiatrist’s third task is to create realistic conditions for whatever treatment is attempted, eliminating all secondary gains of treatment—treatment used to escape from the law, for example, or for ongoing parasitic dependency on parents or other social support systems. The therapist needs to establish reasonable minimal preconditions that will safeguard any treatment effort from secondary exploitation by the patient.
The prognosis for the treatment of malignant narcissism, while reserved, is significantly better than that of the antisocial personality proper, and, in the course of intensive, long-term, psychoanalytic psychotherapy some of these patients may achieve a gradual transformation of their antisocial behavior and the corresponding manipulative, exploitative behavior in the transference into predominantly paranoid resistances. Such paranoid resistances may even lead to a paranoid transference psychosis, but also, if and when such regression can be contained and managed in the psychotherapy, to further gradual transformation into more ordinary transferences characteristic of severe narcissistic personality disorders. One potential limit to such treatment efforts is presented by patients whose aggressive behavior is potentially threatening to others, including the psychotherapist, so that the possibility of dangerous violence connected with severe paranoid transference reactions should be evaluated before an intensive psychotherapy is undertaken.
The treatment of patients with narcissistic personality and antisocial features may follow the ordinary stages of intensive psychotherapy with this personality disorder. These patients usually have an indication for psychoanalytic psychotherapy rather than psychoanalysis proper, which is also true for the next category, namely, other severe personality disorders with antisocial features. Antisocial behavior as an expression of unconscious guilt, that is, in neurotic personality organization, has an indication for psychoanalytic treatment.
THE PSYCHODYNAMICS OF MALIGNANT NARCISSISM AND OF THE ANTISOCIAL PERSONALITY
In my view, the psychodynamic findings of patients with malignant narcissism (Kernberg, 1984) open the way for a psychoanalytic understanding of the intrapsychic structure and the internal world of object relations of the antisocial personality disorder proper.
The transferences of patients with malignant narcissism reflect the vicissitudes of both faulty early superego formation and the failure to consolidate total object relations in the context of integration of ego identity. In essence, these patients are so dominated by the earliest sadistic superego precursors that the subsequent idealized superego precursors cannot neutralize them, superego integration is blocked, and the more realistic superego introjects of the oedipal period are largely unavailable. These patients convey the impression that their world of object relations has been transformed malignantly, leading to the devaluation and sadistic enslavement of potentially good internalized object relations on the part of an integrated yet cruel, omnipotent, and “mad” self (Rosenfeld, 1971). This pathological grandiose and sadistic self replaces the sadistic precursors of the superego, absorbs all aggression, and transforms what would otherwise be sadistic superego components into an abnormal self-structure, which then militates against the internalization of later, more realistic superego components.
These patients experience external objects as omnipotent and cruel. They feel that loving, mutually gratifying object relations not only can easily be destroyed but contain the seeds for an attack by the omnipotent, cruel object. One way to survive is by total submission. A subsequent route is to identify with the object, which brings to the subject a sense of power, freedom from fear, and the feeling that the only way to relate to others is by gratifying one’s aggression. An alternative route to escape is by adopting a false, cynical way of communication and to totally deny the importance of object relations, to become an innocent bystander rather than to identify with the cruel tyrant or to submit masochistically to him.
The limited experiences I have had in attempting a psychodynamic exploration of patients with antisocial personality proper, together with the findings derived from the intensive psychotherapy and psychoanalysis of patients with malignant narcissism, lead me to propose the following tentative considerations regarding the psychodynamics of the antisocial personality proper.
These patients convey past experiences of savage aggression from their parental objects, and frequently report violence both observed and experienced in their early childhood. They also convey a dramatic conviction of the impotent weakness of any good object relation: the good are weak and unreliable by definition, and the patient shows rage, devaluation, and contempt against those vaguely perceived as potentially good objects. The powerful, in contrast, are needed to survive, but are unreliable in turn; and they are invariably sadistic. The pain experienced in having to depend upon powerful, desperately needed but sadistic parental objects is transformed into rage, and expressed as rage mostly projected, thus worsening the sadistic image of powerful bad objects who become towering sadistic tyrants. In this world, which is reminiscent of Orwell’s (1977) novel 1984, aggression is prevalent but unpredictable, and this unpredictability precludes even a secure submission to the sadistic tyrant and prevents the patient from idealizing the sadistic value system of the aggressor.
This failure to achieve any idealization of objects differentiates the antisocial personality proper from the “self-righteous” aggression of the patient with malignant narcissism who has at least found some possibility of condensing sadism and idealization by identifying himself with an idealized, cruel tyrant. The failure of this idealization also prevents the antisocial patient from attempting a masochistic submission to a predictable although sadistic authority. The patient is deeply and totally convinced that only his own power itself is reliable, and the pleasure of sadistic control the only alternative to the suffering and destruction of the weak. In such a world, there exists the need (to paraphrase Paul Parin) to “fear thy neighbor as thou fearst thyself” and to devalue all the weakening linkages with them.*
So far, I have focused on dynamics of the predominantly aggressive antisocial personality disorder. The passive-parasitic antisocial personality disorder, in contrast, has found a way out of gratification by means of sadistic power into the denial of the importance of all object relations, and into the regressive idealization of the gratification of receptive-dependent needs—food, objects, money, sex, privileges—and symbolic power exerted over others by extracting such gratifications from them. To extract the supplies needed while ignoring others as persons and protecting oneself from revengeful punishment is the meaning of life. To eat, to defecate, to sleep, to have sex, to feel secure, to take revenge, to feel powerful, to be excited—all without being discovered by the surrounding dangerous though anonymous world—permits an adaptation of sorts to life. This adaptation is the adaptation of the wolf disguised to live among the sheep while the real danger comes from other wolves similarly disguised, against whom a protective “sheepishness” has been erected. This psychological structure permits the denial of aggression and its transformation into ruthless exploitation.
In malignant narcissism, some idealized superego precursors have been drawn into the aggressively infiltrated, pathological grandiose self, facilitating at least a consolidated sense of self, of self-continuity throughout time, and, by means of projection, a sense of stability and predictability of the world of powerful and dangerous others as well. The pathological narcissism, ego-syntonic grandiosity, antisocial behavior, and paranoid alertness of these patients jointly permit them to control their internal world of object relations. At the same time, this same pathological grandiose self protects them from the unbearable conflicts around primitive envy that torment the less pathologically protected narcissistic personality. The antisocial personality proper, in contrast, is protected from rageful envy only by aggressive, violent appropriation or passive-parasitic exploitation of others.
Dicks’s (1972) study of SS killers illustrates the facilitation and induction of criminal behavior under particular social circumstances. Zinoviev (1984) has made a study of the moral characteristics of social groups and institutions in totalitarian political regimes whose moral authority images are projected onto the top hierarchy of the system as external “persecutory” figures.* He stresses the generalized social corruption that is a consequence of such a social structure and that may affect the public behavior of large segments of the population. His dramatic descriptions of the general corruption of public life under such circumstances illustrate the dependency of the individual’s moral behavior upon the social structure that surrounds him. Milgram’s (1963) famous experiments indicate how uncritical obedience to authority may easily bring about guiltless participation in sadistic behavior even at high levels of psychological organization and in an atmosphere of social freedom. The antisocial personality’s reality is the normal person’s world of nightmares; the normal person’s reality is the nightmare of the psychopath.
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*Editor’s Note: Dr. Kernberg’s criticism is no less relevant to DSM-IV.
**Editor’s Note: In fact, most self-report and structural interview measures of personality disorder show higher rates of specificity (true negatives) than of sensitivity (true positives).
*Editor’s Note: See R. Stoller (1975). Perversion: The Erotic Form of Hatred. Washington, DC: American Psychiatric Press; and J. R. Meloy (2000). The nature and dynamics of sexual homicide: An integrative review. Aggression and Violent Behavior, 51–22.
*Editor’s Note: I have described this phenomenon as an acute dysphoric plunge in which suicide represents a final, rageful act of omnipotent control. The life and death of Andrew Cunanan, the killer of Gianni Versace, captured this psychopathic attitude (see M. Orth [ZOOO]. Vulgar Favors. New York: Dell).
*Editor’s Note: See J. R. Meloy and C. B. Gacono (1994). A neurotic criminal:“I’ve learned my lesson …” Journal of Personality Assessment, 63:27–38.
*Editor’s Note: Kernberg’s clinical theory is bolstered by recent empirical findings of the strength of the relationship between various measures of sadism and psychopathy. See, for example, S. Holt, J. R. Meloy, and S. Strack (1999). Sadism and psychopathy in violent and sexually violent offenders. Journal of the American Academy of Psychiatry and the Law, 27:23–32.
*Editor’s Note: Jerold Posfs work on malignant narcissism and national leadership is also relevant and instructive. See, for example, J. Post (1993). Current concepts of the narcissistic personality: Implications for political psychology. Political Psychology, 14:99–121.