 Dear colleagues, I am honored and delighted to participate in the seventh International Conference on Psychiatry and Psychological Disorders. This presentation is a part of my series on Malignant Fantasy Defenses. Today I'm going to discuss a proposed differential diagnosis between borderlines and covert narcissists. In other words, borderline personality disorder is often misdiagnosed as covert narcissism, and it would behoove us to delineate a few critical differences between the two disorders. My name is Sam Batnin, I'm a professor of psychology in Southern Federal University or Stov-on-Don in Russia, and I'm a professor of psychology and a professor of finance in the outreach program of the CS Consortium of Universities, CSAPS, Center for International Trans and Professional Studies and Disintroduction out of the way we can get to business. A small percentage of people diagnosed with borderline personality disorder are high-functioning. In other words, they perform impeccably and perfectly in a variety of areas of life, in interpersonal relationships, in the workplace, in church, as pillars of the community. High-functioning borderlines succeed to regulate their emotions to control the labile moods. They do so for certain periods of time, could be days, could be weeks. In rare cases, it could even be years. So these borderlines do not present with emotional dysregulation. They don't present with mood swings up and downs. It's very difficult to tell that these people are borderlines, because if you observe them casually, for example, in therapy, with presenting symptoms on the first session, you wouldn't be able to tell. You couldn't tell that these people have borderline personality disorder, emotional dysregulation disorder. Even the School of Psychology which suggests that borderline personality disorder is a form of post trauma, complex trauma. Even this School fails to offer us a differential diagnosis between high-functioning borderline personality disorder and other personality disorders masquerading as borderline. For example, covert narcissism. These high-functioning borderlines give the impression that they're actually grandiose covert narcissists. Borderlines are as grandiose as narcissists and as grandiose as psychopaths. Actually, again, the cutting edge or the bleeding edge research is that borderlines are actually secondary psychopaths and grandiosity is common to all these cluster B personality disorders. So when you remove the emotional dysregulation, when you put aside the moodlability, what is left? The grandiosity. Confronted with the grandiosity of the patient, a diagnostician could be excused for misdiagnosing the patient as a covert or an overt narcissist. All that is left is the tip of an iceberg, the grandiosity. Now, just a short reminder, what is covert narcissism? Covert, fragile, shy or vulnerable narcissists had first been described in 1989 by Akhtar and the late Cooper. They had suggested the diagnosis. A bit later, a few years later, I contributed to the diagnosis by proposing a subtype of covert narcissists known as inverted narcissists or narcissists codependent. At any rate, covert narcissists are actually full-fledged narcissists who are unable to obtain supply, narcissistic supply, independently. They can't garner attention because they're a bit introverted and a lot shy. They're much more fragile and compensatory than the overt narcissists, so they don't dare go out into the world and become hunter-gatherers of victims and targets and narcissistic supply and so on. They're not go-getters, they're not dare-doers, they're not dare-devils, they're not happy-go-lucky. Instead, they sit in the corner, seething with envy and resentment and feeling that the world is poised against them, that they are discriminated against and treated unjustly. They become passive-aggressive. Covert, fragile, shy, vulnerable, and from now on I will use just the phrase covert narcissists, are absolutely distinct from and different to borderline personalities, so that there's nothing in common except the grandiosity. And today I want to propose to the best of my knowledge for the first time a differential diagnosis. Here is how to tell the difference between the two. Covert narcissists never experience suicidal ideation, they never attempt suicide. Covert narcissists externalised aggression, externalised aggression, and in this sense they are no different to overt narcissists and to psychopaths. Covert narcissists are typically negativistic, in other words passive-aggressive. Borderlines tend to internalise aggression, they would of course act out. Once the aggression is internalised, they go through decompensation, the internalised aggression destroys the defences of the borderline, and once the defences are down, the psychopathic self-state of the borderline takes over and then the borderline becomes technically or clinically a psychopath with externalised aggression. She will break things, she will cheat, she will act recklessly, she will shop or gamble or drive under the influence or whatever. So I repeat, the borderline's aggression is first internalised. The internalised aggression creates a depressive state where all the defences are down. Once the borderline's defences are down, she switches to a psychopathic self-state, secondary psychopathic self-state, facto 2 psychopath. She then externalises aggression verbally, through behaviour, recklessly and so on. The covert narcissist always externalises aggression, there's no internalisation of aggression. Even literature shows that mood disorders, which are a form of internalised aggression, are very rare with covert narcissists. Number two, covert narcissists do not experience separation in security, also known as abandonment or separation anxiety. They don't have this. They are not anxious about being abandoned or rejected by, for example, the intimate partner. They are very sensitive to humiliation, they are very attuned and hyper-vigilant when it comes to shame, to insults, to being ridiculed. But that's not the same as abandonment anxiety. Abandonment anxiety is about being abandoned or rejected by the intimate partner. Now abandonment anxiety, or the clinical term is separation in security, is much more common in borderline personality disorder than in all other disorders that we know of. Actually it's a defining feature. It's one of the criteria, the diagnostic criteria of borderline. And it's nowhere to be seen with covert narcissists. Covert narcissists maintain object constancy. In other words, even when people in the lives of the covert narcissist are not present physically, the covert narcissist still has a stable inner representation of these people. The borderline doesn't. The borderline has object inconstancy or object impermanence. She is unable to maintain a stable representation, a stable inner object, which corresponds to an outer object to people in her life. So when these people are out of sight, they're out of mind. This generates enormous anxiety in the borderline. Very similar to a toddler or an infant's reaction to an absent mother. Now this is a main distinguishing feature between the two disorders. Next, because there is a difference in object constancy between borderlines and covert narcissists, they behave differently. Covert narcissists are not clinging, they are not needy, and they don't emotionally blackmail. Borderlines and co-dependence, people with dependent personality disorder, are clinging, they are needy, and they use a variety of manipulative techniques, especially emotional blackmail, to obtain object permanence, to secure the presence of the intimate partner in their lives in an uninterrupted manner, and to fend off abandonment and rejection. Next, covert narcissists are self-efficacious. They are able to extract favorable outcomes from the environment through a series of coping strategies. So they are agentic, they have agency, they are largely autonomous and independent, and they are self-efficacious. Borderlines are self-defeating, self-destructive, self-sabotaging, self-loathing, self-hating. Covert narcissists are exactly the opposite. They are like overt narcissists, they love themselves. So it's a major difference between borderlines and covert narcissists. Borderline personality disorder is about self-annihilation, is about finally merging with the emptiness inside. Kernberg described the borderline as an emptiness, there's an empty schizoid core, and so the borderlines seek to kind of remove the outer layers and become that emptiness, become that void. Covert narcissists seek to add layers, while the borderlines seek to remove layers. The covert narcissists and the overt narcissists, they seek to add layers. By garnering attention, narcissistic supply from the environment, they actually construct additional layers, additional firewalls, separating them from reality. Ironically, the reality testing of both disorders is impaired, but owing to totally different reasons. Borderlines are dissociative, covert narcissists and overt narcissists are divorced from reality because it's too painful. Borderlines going on to the next element in differential diagnosis, borderlines are self-critical. They tend to criticize themselves. As I said, they're self-loathing, they're self-hating, they see themselves in negative terms. They have a very harsh inner critic, a sadistic super ego to borrow from Freud and others in psychoanalysis. So borderlines are highly self-critical and very similar to neurotics. Borderlines have auto-plastic defenses. They would tend to blame themselves. They do experience shame and guilt. They also have access to empathy, full-fledged empathy. And they have dichotomous thinking, borderlines. They have dichotomous thinking, also known as splitting. They divide everyone to good and bad, black and white, totally right, totally wrong, positive and negative. So I repeat, borderlines have a harsh inner critic, they are self-critical. They always blame themselves. They have auto-plastic defenses and they have dichotomous thinking. They divide the world in two camps. Covert narcissists have none of this. They don't have splitting or dichotomous thinking. They are not self-critical on the very contrary. They are other critical. They never criticize themselves. They always criticize other people. The boss, the wife, the pastor, the government, the CIA, you name it. In a sense, there's a lot of paranoid ideation in covert narcissism. And they have auto-plastic defenses. They tend to blame others for everything that goes wrong, for every defeat, for every failure, for every failed attempt to obtain supply or any sign of recognition. They blame other people. They have auto-plastic defenses. Now I mentioned paranoid ideation. Paranoid ideation is common to both borderlines and to covert narcissists. And paranoid ideation in both cases is imbued with grandiosity, colored by grandiosity. But there's a big difference when it comes to the etiology. The borderline's paranoia emanates from her experience of her own disintegration. As the borderline crumbles and falls apart, she becomes more and more paranoid because she realizes that she is at risk. In this sense, the borderline's paranoid ideation is not far removed from reality. The covert narcissists' paranoid ideation resembles very much a conspiracy theory. The world is against me. I'm discriminated against. Everyone envies me. Everyone is out to get me. Borderlines, finally, are highly emotive. Highly emotive and dysregulated. I mentioned before that borderlines are skinless. They are overwhelmed by emotions. They drown in emotions. Covert narcissists, on the other hand, display only negative affectivity. They don't have access to positive emotions, similar to overt narcissists. Both types of narcissists don't have access to positive emotions, such as love. But they have access to a monopoly of negative emotions, for example rage or envy. And so covert narcissists display negative affectivity while borderlines display the whole gamut, the whole smuggler's board of emotions, positive and negative. Covert borderlines also have usually reduced effect display. They appear to be a bit numb, a bit with a poker face. Borderlines are highly expressive, too expressive actually, and can be easily conflated and confused with histrionics because they are so emotionally expressive. So these are the differential criteria. This is a differential diagnosis between borderlines and covert narcissists. Now some of these things are easily observable as presenting signs and symptoms. Some of them take a bit more time to uncover and discover, and they are an integral part of the anamnesis or anamnetic process. But ultimately, within a simple session, there is no reason not to come across all these elements and to decide whether the patient facing you has borderline personality disorder, which essentially is a cross between psychopathy and psychosis, or covert narcissism, which is a grandiosity fantasy defense, gun malignant, gun awry. Thank you for listening, and I'm now open to questions.