In our paper we discuss the existence of narcissism as instinct; a Mendelian trait that can be inherited from either parent. This instinct is an essential component of five different personalities in our model and these personalities can be classified into two groups: Narcissistic and Obsessive. How these personalities manifest in individuals and how the individual interacts with the healthcare system is described. Narcissistic instincts are kept in check by the superego. When the superego starts to fail, the Narcissist goes through three stages ending with the development of narcissistic personality disorder (NPD); where the person is not capable to hear, speak, and see in sensible ways. Reversal of NPD symptomology is unlikely once NPD is fully developed. We recommend prevention as a strategy to reduce the incidence of NPD.

Narcissistic personality disorder, Obsessive,  Instinct, HIV, Narcissist, Superego

Afacan Y, Chaudhry F, Santangelo V, Shkolnik A (2017) Narcissism is Genetic and the Superego Keeps it in Check. JSM Anxiety Depress 2(1): 1021

NPD: Narcissistic Personality Disorder; PD: Personality Disorder; HIV: Human Immunodeficiency Virus

We described biologic existence of narcissistic, masochistic, and neutral instincts in our paper They Cannot Hear, Talk, and See in Sensible Ways: The Impact of Personality Disorders on HIV and other Sexually Transmitted Infection, with three key premises: a) personality instincts are biologically-based Mendelian traits; b) the ego consists of social and executive brain; and c) the superego is a physiologically dynamic entity maintained and positively reinforced with altruistic behaviors and can be weakened to the point of failure by ongoing deceptive behaviors against others.

Our team developed a personality model (2011) and published it in a peer-reviewed medical journal (2015). The rationale and explicit knowledge for this model is detailed in our original article [1]. In our personality model the question of what happens to our brain function under stress acts like a litmus test. If the individual replies that his/her brain function improves under stress, this implies the individual has narcissistic instinct. The phrase “nothing makes me more productive than the last minute itself” clearly defines the individual with narcissistic instinct. This instinct orients the individual towards success. As a next step, we look at the individual’s body language and also ask him to describe his personality in one word. The narcissist appears hyper alert, eyes sharp, with keen awareness of his surroundings; and his posture can be described as vigilant, almost as if ready to respond to any situation. The words narcissists tend to use to describe themselves are: “winner,” “fighter,” and “positivethinker.” The obsessive’s body language appears as low energythe opposite of the narcissist. He will have difficulty describing his personality in one word. When confronted with a description of themselves as passive, they will tend to agree, but will add that they have a more aggressive side that comes out when they are pushed into the corner. Another defining characteristic of the obsessive is that they tend to seek perfection and analyze the people around them. Decrease in brain function under stress is the typical response of the masochist. The neutral reports no change in brain function during stress; and if they can use stress as a motivator they will be able to complete the task. If the stress becomes distractive, they will fail the task.

The general categorization of the personality type can be determined by the screening methods described above. However, determining the subtype (e.g., body vs. mental narcissist) requires additional interviewing time. Through proper open-ended questions, the clinician will be able to interpret the responses and pinpoint the personality type.

The opinions expressed in this brief communication mainly represent the culmination of five years’ experience working with and observing the personalities of the more than 1300 patients who seek care at our HIV center.

Based on our observations, every individual has two instincts. Instincts inherited from the father innervate the executive brain and instincts from the mother innervate the social brain. These instincts combine to form distinct personality groups.  The narcissist can be expressed in three ways Narcissistic Personality (NN), Body Narcissist (ON), and Mental Narcissist (NO); b) masochist can be expressed in three ways Masochistic Personality (MM), Social Masochist (OM), and Mental Masochist (MO); c) obsessive can be expressed in two ways Positiveoriented perfectionist (MN), and Negative-oriented perfectionist (NM); and neutral can be expressed only as (OO)

The instinct, by definition, a way of behaving, thinking or feeling that is not learned and in our model the instinct is also a substance with extensive hard wiring in the brain and body. It is inherited from our parents and interact with each other to shape our personality and affects our minds. They are instrumental in determining our fight-or-flight response and body language [1].

Treatments are not one size fits all. The interaction of personality and outcome is mediated by the message and how it is delivered. Although all patients should receive a balanced message, each personality type responds differentially to it. When the provider is treating the narcissist it is essential to highlight the positive, underscoring actions to be taken, e.g. “we will bring the viral load to undetectable”, or “this medication will have the best possible outcomes for you.” In contrast, the masochist responds best when the clinician is focused on the prevention of negative outcomes, like “this medication is necessary to keep you from developing opportunistic infections and avoid hospitalizations.” The obsessive needs a balanced picture to best respond. Here the clinician should lay out both positive and negative outcomes, engaging the patient; enabling an informed choice regarding their treatment. The neutral personality requires the argument to be supported with lots of evidence. Presentation of findings from published articles will facilitate the neutral patient’s engagement in treatment.

In our model the narcissistic instinct makes one naturally click with positive events and motivates him/her to duplicate them. The Narcissist focuses on high quantity or extraordinary outcomes. He/she is proactive and this instinct helps the individual to reach these goals by increasing effective IQ under stress. Negative manifestations of the narcissist include an inflated self-image, lack of empathy, and selfishness. Narcissistic instinct in our model is an essential part of five different personalities which can be categorized into two distinct groups: Narcissistic vs. Obsessive. This classification of Narcissism into two groups is in agreement with the psychiatric literature which has similar dichotomous classifications such as grandiose vs. vulnerable and overt vs. covert [2].

The narcissistic group has three different personality types associated with it. First is classified as the body narcissist, who inherited narcissistic instinct from the mother and neutral instinct from the father. The social brain is narcissist and he/she tries to use his/her body and personality to become prominent in social interactions. They tend to build their bodies, seek the best cars, and other status symbols. They are “all form and no substance.” Second is the mental narcissist; they acquire narcissistic instinct from the father and inherit neutral instinct from the mother. They like to dominate their personality in mental areas; they tend to choose careers that rely on intellectual matters such as medical professions, academics, and science

Third is the narcissistic personality, inheriting narcissistic instincts from both parents. Armed with only narcissistic instincts they can only present as narcissistic and are noticeable in social settings. They tend to see things in extremes (black and white). They tend to have communication issues with others. They are prone to addiction and under the influence of alcohol or other drugs, combined with stress, will result in the individual striking out, either verbally or physically. They tend to become winners in even the most one-sided situations due to their persistent focus on the positive and significant increase in their baseline IQ under stress. They will snatch victory from the jaws of defeat. Approximately one third of most genius pools consist of the people with the narcissistic personality. Historically leaders such as Alexander the Great and the prophet David had narcissistic personalities, and they greatly contributed the good of society. It is essential to nurture these leaders, ensuring access to intellectual stimulation and equip them with strategies to control their narcissistic instincts and avoid substance abuse to maximize the likelihood of their success in life.

The narcissist, in general, is challenged by our current healthcare system which tends to highlight both the positive and negative, equally. Their personality is in sync with the positive, discounting the negative. They are more aligned with holistic medicine which tends to highlight the positive, ignoring the negative. It would be a pitfall to diagnose a narcissist with a potentially terminal illness without addressing the futility of holistic medicine in these situations. Otherwise they will tend to gravitate toward the holistic approach without taking into account the risks to their own wellbeing. They have a tendency to be non-adherent to complex medication regimens, rejecting many medications as a symbol of a weakened state. They also place themselves and their partners at risk for HIV and other STI’s through an inconsistent use of condoms during sex. The condom represents a barrier to pleasure and control. Lack of consistent condom use is especially high during periods of alcohol and other drug use.

The obsessive personality group consists of two different personality types: the negative-oriented perfectionist and the positive-oriented perfectionist. The negative-oriented perfectionist gets narcissistic instincts from the father and masochistic instincts from the mother. This type of personality is very good at noticing the negative and tries to make the negative perfect, subconsciously. This type of person would take a rundown company and make it whole and profitable. The positiveoriented perfectionist inherits narcissistic instincts from the mother and masochistic instincts from the father. They are very good at noticing the positive and will try to make positive perfect. Example, they can make a well-run company the leader in their field.

The co-existence of narcissistic and masochistic tendencies, such as postulated in our view of the obsessive personality, has been documented in psychiatric literature as a narcissisticmasochistic character [3]. The obsessive as patient tends to adjust well to our current healthcare system. They use reasoning in their actions, and comply provided they are given a rationale for their treatment regimens. They are able to hide their narcissistic side during social interactions. Hence, the “Covert Narcissist” fits this description.

Narcissists exhibit an NPD when the superego fails to function properly. Personality disorder (PD) starts to develop when the person cannot function in a normal environment without deceiving others. When the superego starts to fail the person first is unable to pick up on social cues (hearing goes wrong); second, they are unable to communicate in an altruistic manner (speaking goes wrong). Finally, the failure of the superego eventually leads to a dysfunctional relationship with the real world. It is as if their “vision” goes wrong and finally they begin to see other people in sync with their own narcissistic view and can become hostile when those around them cannot read their minds. It is as though the basic senses (hearing, speaking, and vision) are failing the individual most of the time due to dysfunctional or weakened superego created through his deceptive responses to other human beings

When NPD fully develops, the individual with NPD masters deceiving others. He/she starts to recognize the existence of masochistic instincts in others, within three (3) seconds. They even are able to differentiate masochists from obsessive within a few minutes based on body language. An informant described the masochist as an individual from which he could easily take what he wants; and the obsessive as a more difficult, but doable, target. An HIV-positive person with NPD can recognize and convince a partner with masochistic personality to have unprotected sex. The sexual interaction between the person with NPD/Narcissist and Masochist is an ideal breeding ground for HIV and other STI’s. Often the Masochist who has been abused by a person with NPD will think the abuse resulted “by coincidence” and not realize they were a target from the beginning.

Based on the author’s observations, it usually takes four to five years to weaken the functional superego with egoistic or selfish behaviors without balancing with altruistic behaviors. In an HIV setting we were seeing lots of PD, especially NPD. These observations are well documented in the literature [4,5]. Initially we attributed this partially to the virus, but the control of the virus has not resulted in a reduction in the incidence of PD. Regardless of the origin of PD in the HIV population, it is important to note that HIV is an illness that creates significant stress for the individual. For example, to reveal one is HIV infected could result in not obtaining what he/she wants (sex). In order to obtain what he/she wants the individual reverts to deception, which could be instrumental in further weakening the superego and exacerbating the PD. This could account for why PD is more common in the HIV setting.

To date we have not observed a case of NPD reverse to normal healthy narcissism. If NPD is the result of a biologically suppressed superego, it implies alteration of the brain tissue. As we have learned in endocrinology, we can suppress the hypothalamo-pituitary-adrenal (HPA) axis by using exogenous corticosteroids. Suppression is achieved within three weeks; however it may take up to 72 weeks to reverse it [6]. Likewise, three to four IV heroin episodes can result in lifelong addiction. In essence, neuroplasticity is a major stumbling block in reversing symptomology of NPD once it is fully developed. We believe that trying to cure NPD with the current psychiatric methods available is akin to trying to cure stage-4 cervical cancer. Effective strategy for managing NPD, as for cancers in general, is in prevention.

Early identification of the narcissist and helping him/her control their narcissistic instincts and observation for early signs of dysfunctional superego and immediate intervention can keep the person from developing a full-blown NPD

For the person with obsessive personality, who has both narcissist and masochistic instincts, when their superego fails, they develop obsessive personality disorder, which can be described as perfectionist, driven, preoccupied, rigid, and irritable (1). This is consistent with a person who exhibits a hybrid or the mixed symptomology of masochistic personality disorder and the NPD.

The etiology of narcissism and NPD became a Gordian knot for the researchers in this field. How a person becomes a narcissist and develops NPD is unknown. Further, it is unknown if subtypes of NPD exist, and even the argument has been made that NPD should it be a part of DSM-V [7,8]. We suspect this Gordian knot has two loopholes. First, narcissists present in all cultures in more or less the same way and have not changed for centuries. Why is that? The simple answer is that it is genetic. The literature accepts narcissism as the most commonly inherited personality type and NPD has a genetic component [9-12]. In our models unless one inherits narcissistic instinct from either parent he has no potential to become narcissistic or develop NPD. Second, a person with NPD is a perfect poster boy for a con artist and deceiving others always co-exists with NPD. What does deception have to do with NPD? In our model, deception, with negative reinforcement, weakens the superego and results in the development of PD. Recent research has identified a structural abnormality in the brains of those with NPD, specifically noting less volume of gray matter the left anterior insula [13]. Another study has associated the condition with reduced gray matter with deficits in the right prefrontal and bilateral medial prefrontal/ anterior cingulate cortices and decreased fractional anisotropy in right frontal lobe white matter [14]. This could be supportive of our assertion that ongoing deception causing brain atrophy due to neuroplasticity. Obviously time will tell, but my team and I believe we came a long way in undoing this Gordian knot once and for all.

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