Misdiagnosing Personality Disorders as Anxiety Disorders

What is Anxiety

Anxiety is uncontrollable and excessive apprehension, a kind of unpleasant (dysphoric), mild fear, with no apparent external reason. Anxiety is dread in anticipation of a future menace or an imminent but diffuse and unspecified danger, usually imagined or exaggerated. The mental state of anxiety (and the concomitant hypervigilance) has physiological complements. It is accompanied by short-term dysphoria and physical symptoms of stress and tension, such as sweating, palpitations, tachycardia, hyperventilation, angina, tensed muscle tone, and elevated blood pressure (arousal). It is common for anxiety disorders to include obsessive thoughts, compulsive and ritualistic acts, restlessness, fatigue, irritability, and difficulty concentrating.

Personality Disorders and Anxiety

Patients with personality disorders are often anxious. Narcissists, for instance, are preoccupied with the need to secure social approval or attention (Narcissistic Supply). The narcissist cannot control this need and the attendant anxiety because he requires external feedback to regulate his labile sense of self-worth. This dependence makes most narcissists irritable. They fly into rages and have a very low threshold of frustration.

Subjects suffering from certain personality disorders (e.g., Histrionic, Borderline, Narcissistic, Avoidant, Schizotypal) resemble patients who suffer from Panic Attacks and Social Phobia (another anxiety disorder). They are terrified of being embarrassed or criticized in public. Consequently, they fail to function well in various settings (social, occupational, interpersonal, etc.).

Narcissism, Obsession-Compulsion, and Anxiety

The personality disordered often develop obsessions and compulsions. Like sufferers of anxiety disorders, narcissists and compulsive-obsessives, for instance, are perfectionists and preoccupied with the quality of their performance and the level of their competence. As the Diagnostic and Statistical Manual (DSM-IV-TR, p. 473) puts it, GAD (Generalized Anxiety Disorder) patients (especially children):

"… (A)re typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries."

This could apply equally well to subjects with the Narcissistic or the Obsessive-Compulsive Personality Disorder. Both classes of patients - those suffering from anxiety disorders and those tormented by personality disorders - are paralyzed by the fear of being judged as imperfect or lacking. Narcissists as well as patients with anxiety disorders constantly fail to measure up to an inner, harsh, and sadistic critic and a grandiose, inflated self-image.

From my book "Malignant Self Love - Narcissism Revisited"

"The narcissistic solution is to avoid comparison and competition altogether and to demand special treatment. The narcissist's sense of entitlement is incommensurate with the narcissist's true accomplishments. He withdraws from the rat race because he does not deem his opponents, colleagues, or peers worthy of his efforts.

As opposed to narcissists, patients with Anxiety Disorders are invested in their work and their profession. To be exact, they are over-invested. Their preoccupation with perfection is counter-productive and, ironically, renders them underachievers.

It is easy to mistake the presenting symptoms of certain anxiety disorders with pathological narcissism. Both types of patients are worried about social approbation and seek it actively. Both present a haughty or impervious facade to the world. Both are dysfunctional and weighed down by a history of personal failure on the job and in the family. But the narcissist is ego-syntonic: he is proud and happy of who he is. The anxious patient is distressed and is looking for help and a way out of his or her predicament. Hence the differential diagnosis."

Bibliography

Goldman, Howard G. – Review of General Psychiatry, 4th ed. – London, Prentice-Hall International, 1995 – pp. 279-282

Gelder, Michael et al., eds. – Oxford Textbook of Psychiatry, 3rd ed. – London, Oxford University Press, 2000 – pp. 160-169

Klein, Melanie – The Writings of Melanie Klein – Ed. Roger Money-Kyrle – 4 vols. – New York, Free Press – 1964-75

Kernberg O. – Borderline Conditions and Pathological Narcissism – New York, Jason Aronson, 1975

Millon, Theodore (and Roger D. Davis, contributor) – Disorders of Personality: DSM IV and Beyond – 2nd ed. – New York, John Wiley and Sons, 1995

Millon, Theodore – Personality Disorders in Modern Life – New York, John Wiley and Sons, 2000

Schwartz, Lester – Narcissistic Personality Disorders – A Clinical Discussion – Journal of Am. Psychoanalytic Association – 22 (1974): 292-305

Vaknin, Sam – Malignant Self Love – Narcissism Revisited, 8th revised impression – Skopje and Prague, Narcissus Publications, 2006