#pd comorbidity

[hauntedselves]

Poll Results: Personality Disorder Comorbidity

In these polls I asked people with PDs which comorbid disorders they had. If they had more than one, I told them to choose the one that impacts their daily life the most. The options were taken from the DSM-5-TR entry for the specific PD.

Note: It’s important to remember and take into account that A) this is a tumblr poll, not a formal study, and the sample sizes are very small; B) there was no “other” option or write-in option; C) I asked for the one that impacts the most, so while someone could have many comorbidities, the one that makes their life the hardest will have been chosen - this is more reflective of the chosen disorder, not the PD.

Antisocial PD

NPD won with 42.9%, which agrees with the literature on AsPD. C/PTSD came second, and most other options got no votes, from 14 votes total.

Avoidant PD

C/PTSD won by miles with a huge 45.5%! Makes sense when we consider the etiology of AvPD and the effects of C/PTSD in daily life. Interestingly, SzPD came 2nd, though not with a huge amount of votes.

Borderline PD

Dissociative disorder won with 31.3% of 32 votes; that lines up fairly well with literature, as does C/PTSD in second place.

Dependent PD

Surprisingly, autism won with 28% of 25 votes. C/PTSD was second with 24%.

Histrionic PD

BPD won with 33.3% of 9 votes, and C/PTSD came second. NPD, PPD, DPD and depression each tied for 3rd place, and the other options got no votes.

Narcissistic PD

BPD won with 33.3%! C/PTSD was second, followed interestingly by bipolar disorder.

Obsessive-Compulsive PD

OCD won, at 37.5%. This is in line with the literature on OCPD, which notes OCD as a frequent comorbidity. Interestingly, C/PTSD was 2nd, and most other options didn’t get any votes at all. There was only 8 votes, a very small size.

Paranoid PD

NPD won, though there were only 8 votes. AvPD came second, and SzPD, StPD, and BPD tied for third. Other options got no votes.

Schizoid PD

Autism and C/PTSD tied at 25%. Depression was 2nd, then Avoidant PD, and Paranoid PD, Borderline PD, and paraphiliac disorder didn’t get any votes, out of 24 votes total. Interesting that autism & C/PTSD got so many votes!

Schizotypal PD

Dissociative disorder won by 18% with 31.8%! Autism and Avoidant PD tied for 2nd place. Interestingly, C/PTSD was the only option to not get any votes at all, from 22 votes. These results are pretty much agreeing with what the literature says on Schizotypal PD comorbidities.

[hauntedselves]

Another thing, do you have any resources on NPD+BPD comorbidity? I looked and could only find "how to spot an abuser" articles.

people with NPD & BPD both need attention and validation from others, and have very fragile self-esteem

the reasons behind the need for attention is different: narcissists need to be reminded they’re important; borderlines need to be reminded they’re not going to be abandoned

someone with both would be very easily jealous

people with NPD are internally focused, while borderlines are externally focused

people with NPD have low empathy, people with BPD may have hyperempathy or fluctuating levels of empathy; someone with both will probably have low and/or fluctuating empathy

borderlines are impulsive, narcissists aren’t (though they may be when it comes to their self-image)

narcissists are prone to grandiosity & manipulation, and can have delusions of grandeur

both can have a need to be in control & are prone to eating disorders, depression, anxiety and emotional dysregulation

people with BPD have chronic feelings of emptiness, narcissists don’t outside of shame spirals (”narc crash”)

people with BPD have intense, volatile relationships, while people with NPD don’t; someone with both may have unstable relationships exacerbated by NPD superiority

both struggle a lot with keeping anger in check

narcissists put people in hierarchies, and borderlines tend to think they’re beneath people, so someone with both may think they are low on their hierarchy

people with BPD have difficulty planning for the future

both can have depression, suicidal thoughts, restlessness, and difficulties with self-identity and social relationships

shame is a hallmark of NPD, but also pops up in BPD a lot (thanks to trauma, splitting, mood swings, etc)

needing to see yourself as superior is more NPD, but again could also be part of mood swings & splitting in BPD

+ see also this post

[hauntedselves]

I know you've covered AsPD/NPD, PPD, and SzPD comorbidity but what would SzPD and NPD comorbidity look like? (Please feel free to redirect me to it if you've already covered it)

Here is what one person has said about NPD and SzPD:

"I think schizoid and narcissistic comorbidity is a very interesting dynamic! In my opinion there can be a decent amount of overlap, and it’s one of the reasons I’m suspicious about the possibility of me having narcissistic traits in addition to SzPD. There’s a webpage produced as a project from Appalachian State University (though it’s from 2001) which talks about a variety of PDs versus NPD in the context of differential diagnosis. Of SzPD in this framework, it says: “Emotional aloofness and lack of mutual interpersonal relations or genuine deep interest in other people are common characteristics in both schizoid and narcissistic personality disorders” … which I thought was a good description of overlapping traits. (Link) It’s definitely true that both are described as involving lack of empathy, so it makes sense to have such similarities."

And some other quotes from other posts I've written:

SzPD is completely different from that need for (perfect) relationships/perception of themselves as perfect - although both NPD & SzPD use superiority as self defence, SzPD has no need for people to see them as perfect/admirable/etc, and no hypersensitivity to criticism

both SzPD & NPD will value things other than relationships, but NPD will seek out relationships for validation

[Both] use fantasy as an escape method (+ self-esteem booster in NPD). Fantasies are often linked to a need to feel in control, which is also common in [both]

someone with NPD will find it difficult to manage anger. SzPD tends to see (any) emotions as dramatic and distasteful, so won’t express anger readily

Greenberg theorises a subtype of SzPD with NPD features (the “Narzoid”)

I think the biggest similarity between [both] is relationship fear. This presents itself in vastly different ways: [...] NPD “uses” people, and avoids revealing their true self for fear of their flaws being seen (again, rejection and criticism); and SzPD avoids for fear of engulfment/control.

All may idealise people they see as safe (+ superior, in NPD)

SZPD & NPD also have similarities [...], particularly grandiosity and idealising people they see as superior (may be “safe” people, as in PPD & SZPD). all of these also have “not feeling like a ‘real’ person”/having a “false self” that they use to interact with the world (masking).

the two NPD traits that are conflicting with SZPD [...] are fragile self-esteem and needing admiration. [SzPD doesn't have] particularly low self-esteem, and [...] may be uncomfortable with admiration/praise [...] due to fear of engulfment/control

so someone with [NPD & SzPD] would have their NPD low self-esteem and need for admiration conflict with their [...] SZPD, but overall would feel grandiose, idealise people (to a lesser extent than someone with just NPD), [&] mask their true self

[hauntedselves]

Hello! I was wondering if you could describe what a comorbidity of avpd and npd, and a comorbidity of avpd, npd, and szpd, would look like?

Here's a post on NPD & AvPD, and another post here.

All of them are fairly similar to each other (NPD & AvPD are the most different). There's a fair bit of overlap. AvPD & SzPD are similar, SzPD & NPD are similar, and AvPD & NPD aren't similar but do have their similarities here and there

NPD & AvPD both have low self-esteem & are hypersensitive to rejection and criticism

someone with both AvPD & NPD said "i avoid most public situations unless i’m certain i can make myself look cool and confident and admirable to the people around me, because if they think i’m cool and confident and admirable, then that must be what i am. if they, in turn, think i’m weak and pathetic, then i’m weak and pathetic, and that’s a no-no for me. so i avoid most situations where there’s a risk to my self-image (note that my self-image is almost fully reliant in how i believe others perceive me)"

SzPD is completely different from that need for (perfect) relationships/perception of themselves as perfect - although both NPD & SzPD use superiority as self defence, SzPD has no need for people to see them as perfect/admirable/etc, and no hypersensitivity to criticism

both SzPD & AvPD can come with identity disturbances, though it's lesser in AvPD

both SzPD & NPD will value things other than relationships, but NPD will seek out relationships for validation

AvPD on the other hand will only seek out relationships if they're sure they're safe, and SzPD struggles with the fear of engulfment so may not seek out relationships at all

All use fantasy as an escape method (+ self-esteem booster in NPD)

Fantasies are often linked to a need to feel in control, which is also common in all 3

AvPD will find it very difficult to express anger, while someone with NPD will find it difficult to manage anger. SzPD tends to see (any) emotions as dramatic and distasteful, so won't express anger readily

Greenberg theorises a subtype of SzPD with NPD features (the "Narzoid"); in that post, the "Cat Lady" subtype seems like it could feasibly be SzPD with AvPD features. Greenberg's "Covert Narcissist" NPD subtype also seems feasibly AvPD. Millon's Remote Schizoid subtype has AvPD features.

I think the biggest similarity between all 3 is relationship fear. This presents itself in vastly different ways: AvPD avoids, for fear of rejection & criticism; NPD "uses" people, and avoids revealing their true self for fear of their flaws being seen (again, rejection and criticism); and SzPD avoids for fear of engulfment/control.

All may idealise people they see as safe (+ superior, in NPD)

Summary: Seems to be on a kind of continuum of AvPD -> SzPD <- NPD in terms of similarities. Low self-esteem + hypersensitivity to rejection & criticism in NPD & AvPD clash with SzPD indifference. NPD & SzPD use superiority as self-defence, AvPD feels inferior. Fantasy is a major coping mechanism in all 3. Relationship fear is the common thread between the three - fear of engulfment/control, & rejection/criticism + flaws being revealed.

[hauntedselves]

Hi! If you don’t mind, could you maybe explain a bit about what the comorbidity between NPD, BPD, and ASPD would be like?

people with NPD & BPD both need attention and validation from others, and have very fragile self-esteem, while people with ASPD don’t, so that would be a conflicting symptom

the reasons behind the need for attention is different: narcissists need to be reminded they’re important; borderlines need to be reminded they’re not going to be abandoned

someone with all 3 would be very easily jealous

people with NPD & ASPD are internally focused, while borderlines are externally focused

people with NPD & ASPD have low empathy, people with BPD may have hyperempathy or fluctuating levels of empathy; someone with all 3 will probably have low and/or fluctuating empathy

borderlines & antisocials are impulsive, narcissists aren’t (though they may be when it comes to their self-image)

narcissists and antisocials are both prone to grandiosity & manipulation, and can have delusions of grandeur

all can have a need to be in control & are prone to eating disorders, depression, anxiety and emotional dysregulation

people with BPD & ASPD have chronic feelings of emptiness, narcissists don’t outside of shame spirals (”narc crash”)

people with BPD have intense, volatile relationships, while people with ASPD & NPD don’t; someone with all 3 may have unstable relationships exacerbated by ASPD manipulation & NPD superiority

all 3 struggle a lot with keeping anger in check

antisocials & narcissists put people in hierarchies, and borderlines tend to think they’re beneath people, so someone with all 3 may think they are low on their hierarchy

people with BPD & ASPD have difficulty planning for the future

all can have depression, suicidal thoughts, restlessness, and difficulties with self-identity and social relationships

[hauntedselves]

How does SZPD and ASPD traits would interact ?

ASPD & SZPD share boredom, focusing on themselves, wanting to be in control of a situation/relationship, & valuing autonomy. antisocials value relationships, unlike schizoids, so that could be a conflicting point. i can see the schizoid apathy and the ASPD dislike for social norms combining to make it very hard for the person to stay out of trouble, as they wouldn’t care about consequences to an even greater degree than is usual for ASPD.

[hauntedselves]

How would Autism, StPD (positive symptoms and stress triggered psychosis) and ASPD (conduct disorder in childhood present) with the addition of PPD traits interact?

I have a couple of posts on all of those, except PPD & ASD which I'll discuss below.

Autism + StPD (and PDs in general) is a really complicated and tricky subject from a diagnostic standpoint, so for the differences and similarities between them I'll just point you to my directory section on autism + PDs.

This post covers StPD + AsPD (as well as SzPD).

This post talks about AsPD + PPD.

This post is about suspicion in StPD vs PPD. StPD is also more associated with strange beliefs and behaviour and a more autistic-like presentation, while PPD revolves entirely around paranoia (which may lead to strange behaviours, but there's a motive behind it, unlike in StPD).

As for PPD and ASD, they're pretty different:

PPD is defined by "a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent" (i.e. paranoia that others are acting against them).

ASD is defined by a) communication problems, & b) restricted repetition (stimming, special interests, need for routine etc.).

It's possible that communication problems in autism could lead to misunderstandings of people's intent, and possibly cause paranoid ideation. But paranoia in PPD is pervasive (always there in many different contexts), not situational.

Paranoia may cause a need for routine, or compulsions (but that's more OCD territory), but there's a clear motive behind it (the paranoid belief that any deviation from your normal routine will make people hurt you, for example). In autism the need for routine is about the inability to deal with change and unpredictability; paranoia doesn't come into it.

So while a clinician treating someone presenting with symptoms of both PPD and ASD would need to do a bit of digging to find the reasons behind the symptoms, the difference between the two is distinct.

Another difference is that autism is neurodevelopmental and present from birth (though may not become obvious until later on), while PDs generally form in early adulthood.

[hauntedselves]

any idea on how dpd and avpd would show up like??

they're pretty similar and are often comorbid.

here's a venn diagram showing DPD & AvPD symptoms and overlap.

AVPD and DPD are difficult to distinguish

Both are shy, lack confidence and self-esteem, are afraid of criticism and disapproval, and need approval and support

People with DPD try to encourage others to take control of their lives, and this requires trust and openness to relationships

People with AVPD withdraw from relationships because they fear rejection and humiliation

People with DPD struggle with making their own decisions, while people with AVPD don’t if there isn’t a chance of judgement and rejection

AVPD and DPD both result in the person feeling inadequate, but their response to this feeling is different: people with DPD seek people who they can depend on, while people with AVPD avoid for fear of their negative self-view being voiced by others

People with AVPD do well on their own, while people with DPD tend to feel increasingly helpless

When faced with criticism, people with AVPD avoid the situation, while people with DPD stay and try to please

Millon has a DPD subtype with AvPD traits (the "disquieted dependent"):

> Like other people with DPD, rely on others for guidance and support, but their anxiousness makes them avoid autonomy and initiative

> Easily disconcerted, feel a general sense of dread and foreboding

> Separation anxiety, sometimes expressed with anger

> Withdraws from social life, causing loneliness and isolation

> Tend to be pleasant and agreeable, but feel sad and guilty, overwhelmed by fear of abandonment

> Depressed, fatigued, “life is seen as empty but heavy”