Narcissists, sociopaths et al: Loved on screen, loathed (and misunderstood) in life

For six years now, fresh horror stories have arrived in my inbox every week. One woman writes to tell me about her relationship with a man who told her he was a wealthy senior IT executive but who turned out not to have had a job in two years, nor a fixed address. Another says she tried to kill herself after she discovered her partner’s grandiose deceits. A young mother reaches out to share her story about a deep friendship with a woman living with terminal cancer. After a decade of intricate and credible stories about symptoms and surgeries, the truth came out: the woman self-harmed to create the wounds of operations, inserted intravenous cannulas into her own arms and faked seizures. An elderly man emails to tell me about a woman who befriended him and his wife then, using complex and dramatic sob stories over years, borrowed money and racked up debts in their name. “She has left us with no home, no business, no money and mentally exhausted trying to keep up with her activities, lies, deceit and fraud. She is narcissistic, a pathological liar, shows no empathy and blames everyone but herself.”

Since 2017, when I revealed my own story of a traumatic relationship with a narcissistic man who lied about everything – first in a Good Weekend story and later in a book, Fake – several hundred people have contacted me to relate terrible experiences with partners, friends, family members and sometimes strangers who have behaved in extraordinarily self-centred and callous ways, displayed a complete lack of empathy, and engaged in often criminal levels of deception. Every time I decide I must move on from the subject matter, a batch of new messages arrives from traumatised people pouring out their stories – of fantastical deceit, of psychological abuse and manipulation, of trails of financial chaos and fraud, of emptied bank
accounts and hidden debts, of vindictive Family Court battles, ongoing mental health struggles and lives damaged. Frequently, the same sentences appear – “I thought I was losing my mind”, “literally everything he/she told me was a lie”, “he lied even when lying made no sense”, “I will never trust anyone again”.

It doesn’t take too much research to identify that the types of people causing such distress have patterns of behaviour typically associated with personality disorders (PDs). A rare phenomenon, you might think: the stuff of Hollywood thrillers such as The Talented Mr Ripley and Single White Female, of Dirty John and Inventing Anna and The Tinder Swindler. But some of the world’s foremost experts in the field confirm what the weight of my inbox suggests: people with a PD are way more prevalent than most of us might imagine, and they have a substantial impact in both private and public spheres.

“It’s a vastly under-recognised problem,” says Dr Roger Mulder, a New Zealand-based psychiatrist and professor at Otago University and an international leader in the field. Mulder believes about 10 per cent of people have at least a mild PD – “some quite significant, prolonged problems”. Others, including English specialist Professor Peter Tyrer, believe the figure could be as high as 14 per cent in Western societies. (Rates are believed to be lower in low- and middle-income countries and some experts think the individualistic and status-hungry nature of contemporary Western society might contribute to their higher prevalence.) Andrew Chanen, Melbourne-based chief of clinical practice and head of personality disorder research at Orygen, the National Centre of Excellence in Youth Mental Health, says PDs are among the most common and severe mental health problems occurring in young people. Adds Brin Grenyer, professor of psychology at the University of Wollongong and director of the Project Air Strategy for Personality Disorders: “This is not a boutique area, this is high-prevalence.”

The societal cost and impact of PDs is substantial and wide-ranging. “It’s a major source of burden in the community,” says Chanen. He says those affected are more than eight times more likely to be receiving a disability support pension than those without and have a two-decade reduction in life expectancy. People with a PD are over-represented in mental health settings (one in every three or four patients, says Grenyer), emergency departments, doctors’ surgeries, alcohol and drug treatment centres and jails. (The only available research within the corrective services system, a 2003 paper, Mental illness among New South Wales’ prisoners, reported that 41 per cent of a group of inmates had a personality disorder.) It’s widely believed that in civil court settings such as the Family Court, PD is often the underlying pathology of vexatious, high-conflict litigants. Financial scammers, con artists, domestic violence perpetrators with coercive behaviours, manipulative parents and toxic bosses frequently have PD traits.

Yet while we casually appropriate the familiar terminology of the field – “psychopathic”, “narcissistic” or “sociopathic” – it is a subject that is little understood, even among psychiatrists and psychologists. “As a whole, the profession has not really, certainly in public mental health, got a great handle on personality disorders,” says Melbourne forensic psychiatrist Andrew Carroll. Notable German psychiatrist Sabine Herpertz tells me in a Zoom interview from Heidelberg that “it really is a neglected area, also in psychiatry.” Roger Mulder says clinicians frequently fail to recognise and diagnose PDs, or don’t have the language to describe it. “They just say ‘difficult patient’ … but they’re not quite sure why they’re difficult. They know their heart sinks when [these people] come into the room and they’re thinking, ‘Why is that?’ ”

Not only is there a lack of understanding about such a significant issue, in the past few years there has been a sea change in how the field’s foremost experts look at personality and its disorders. “There’s an issue that needs to be talked about – there is a more contemporary approach to personality disorders that most practitioners are not following,” says Mulder.

In the raw and difficult early days after the breakdown of my relationship with a man whose behaviour was so cruel, so duplicitous, so inexplicable – when I thought I might be the only one ever to have had such an encounter – I longed to understand his mysterious other mind. I wanted to wander its corridors, illuminate its dark corners. I needed to understand “why” – why would anyone behave in such a way? I looked for a label with which I could tag the man, a box to put him in. But as I’ve learnt in the years since, human personality and the science surrounding it is boundlessly complex. None of us fits neatly in boxes.

When Sue* first emailed me in 2019, she had just had the locks on her Sydney apartment changed after ending a feverish three-month relationship with a man she’d met online. “I thought I had lived through every dating scenario possible, that I was pretty wised up,” she wrote. “Then I got conned.” Michael* was 45, good-looking, charming and, he said, worked at a major bank in a senior role. He took Sue out for meals where they locked eyes and marvelled over shared interests – arthouse films, independent music, left-wing politics. “We’re two peas in a pod,” Sue thought.

Soon Michael was spending most of his time at her apartment, where he cooked for her, scrubbed her shower and fixed her washing machine. She comforted him when he shared the story of his mother’s cancer battle. He told her he hadn’t wanted to have children but now, with her, he could imagine having a family. “We started house-hunting,” Sue, a PR executive, tells me on the phone. Michael told her he could spend about $3 million, more if he sold one of his other properties. But odd things niggled at her. He interrogated her about her past relationships. His mood swings were fierce. He hadn’t introduced her to his friends or family. And, while his LinkedIn page matched what he’d told her, for someone with such a senior position, nothing else came up when she Googled him.

Michael’s house of cards tumbled when Sue dug more deeply. She discovered he had faked a document he’d shown her when she questioned his employment story. He didn’t work at the bank in question and never had. He didn’t have a job or own properties. His mother didn’t have cancer. Sue tracked down one of his former fiancées, who said it had taken her eight months to eject Michael from her home after discovering he was living a double life with another woman. The fiancée’s research had uncovered other facts: Michael refused to grant his wife of 20 years a divorce; he’d been in at least 12 long-term and overlapping relationships over a decade, had three children with three different women, was in a Family Court dispute with one woman, had been the subject of multiple AVOs and was several years older than he said he was.

For a few weeks, even with new locks on her apartment, Sue stayed at her mother’s place, too frightened to return home. When she finally did go back, she discovered Michael had even more hidden parts than she’d realised. “I found hair dye, Viagra and women’s make-up in a bag he had stashed in my bathroom.” Sue’s anger crackles as we talk. “If only I’d known sooner how narcissistic sociopaths worked, I would have seen this guy coming.”

Like tourists in a foreign country stumbling over basic phrases, most of us speak broken DSM-5 – the language of what is frequently described as the “bible of psychiatry”, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, which lists 10 PDs. Following the lead of pop culture and social media, we toss around terms such as “narcissistic personality disorder” and “borderline personality disorder” (aka BPD), alongside “psychopath” and “sociopath”, neither of which are actually official diagnoses (they are generally considered to fall under the DSM-5’s “antisocial” category). And social media is crowded with amateur psychologists: on TikTok, the hashtag #BPD has 10.9 billion views; #narcissist, 10.7 billion; #narctok, 5.1 billion. On Instagram, among dozens of similar accounts, you can follow @narcabusecoach, @understandingthenarc and @borderlinepd_awareness.

But leading experts consider the DSM-5 to be obsolete and not fit for purpose (more on that later). They say its catchphrases and categories do nothing to help us understand what a PD actually is. “One useful way of looking at it is that everyone has a personality and some people’s personalities are a little unusual and towards one extreme in one particular trait,” says Andrew Carroll. Some traits are useful; experts talk about “adaptive” behaviours which allow us to function in our daily lives. “If you’re a bit obsessive, that can be quite helpful if you’ve got diabetes,” says Roger Mulder. “I’d like my accountant to be a bit obsessive – if you look at it as dimension [a continuum], it’s not all negative.” Similarly, in the context of narcissistic behaviours, we all need some self-regard and self-centredness to survive.
A degree of callousness and exploitative behaviour might contribute to a CEO’s success and, says Mulder, are traits well-matched to a capitalist society.

On TikTok, the hashtag #BPD has 10.9 billion views; #narcissist, 10.7 billion; #narctok, 5.1 billion.

It’s when the expression of a personality style is so extreme and maladaptive that it causes recurrent dysfunction and difficulty in a person’s thought patterns, emotional self-regulation and relationships – so compromising their capacity to function in the world – that a PD exists, says Andrew Chanen.

Clinical psychologist Carla Sharp, a PD specialist at the University of Houston, Texas, uses an analogy to explain it. “If you think about interpersonal relationships as ping-pong games and we serve, and we return, and we serve and return, there’s a lot of skill that goes into that.” In interactions we need to understand each other, understand and manage the impact we have on others, understand and manage the impact others have on us, manage ourselves and our emotions. Someone with a PD, Sharp says, struggles with the serve and return. They choke, their game collapses, things can go very awry.

In early July, Alice* sends me a message about a former friend: “Today marks two years to the day since my best friend Sarah* admitted that for the
previous decade her experience of having terminal cancer had been a fabrication,” she writes. “I am feeling very alone and there is little content online about psychologically abusive friendships, so any insight you have would be really helpful.” I reply to tell her that I’ve heard from many people deceived on a grand scale by friends and from several others who were victims of cancer counterfeiters. I remind her of Belle Gibson, the cancer-faking wellness blogger.

Alice and Sarah met in 2011 at work in a small media company in Perth. Each was living interstate, away from their families, and their friendship blossomed.

A few months later, Sarah made a dramatic announcement: she had been diagnosed with leukaemia. Not long after, cancer was found in her lungs and then her brain. Over the next decade she presented with a cascade of supposed symptoms and claimed to be having surgeries and treatments. She offered multiple plausible reasons for refusing Alice’s offer of physical assistance or hospital visits, including that she had to travel interstate for many of her surgeries, or she had an infection so needed to be in isolation. She sent Alice photographs of herself: one with a bandaged head and black eye lying in what was clearly a hospital bed, another with an ugly stitched wound in her forehead, and a third lying in bed, attached to a cannula, head swathed in bandages. “The overarching sentiment was that she was private about her medical issues and wanted to do it her way,” Alice tells me, “and when someone with terminal cancer sets the tone, you fall in line.”

The grandiosity of Sarah’s stories escalated. She said the tumours on her brain caused psychotic episodes during which her behaviour was violent and unpredictable. At one point, according to calls from a woman claiming to be Sarah’s sister, she wasn’t expected to live for much longer. The “sister” asked Alice to write a eulogy in readiness for the funeral; Alice read it out to her on the phone. Some time later, Sarah told Alice that she was going to Luxembourg for medically assisted dying and that her father would accompany her; there were traumatic goodbye phone calls, purportedly from overseas. Then Alice heard that a legal hitch meant things hadn’t been able to proceed. For Alice, it was an emotionally roiling decade: there was the joy of what she thought was a deep friendship but also the burden of being someone’s constant emotional crutch. Her phone pinged constantly with calls and texts with updates from Sarah and, she thought, Sarah’s family members. And after each claimed psychotic episode, Alice would spend hours comforting her – “for her to tell me about the incidents and for me to support her through the shame and distress”.

In July 2021, out of the blue, Sarah confessed to Alice that it had all been a fabrication. She had had different phones for the messages and calls from other family members – which were all, in fact, from Sarah. She had used fake blood capsules. She had self-harmed to create wounds. She had bought medical supplies online as props for her photographs. When, in a phone call, Alice read out the eulogy she’d written celebrating her friend, it had been Sarah at the other end of the line listening to it, not her “sister”. “I can now see that I was psychologically abused by someone whose fabricated life was designed to steal my time and attention,” says Alice, who remains irreparably hurt and haunted by the experience. When she considers her ex-friend now, all she can think is that Sarah had created a prison for herself, “took a pocket knife to her own life”.

Why, in a succession of relationships, does a man elevate his fakery almost to the point of performance art?

I am not a psychiatrist, I haven’t met Sarah or Michael or any one of the other subjects people have written to me about; I can’t say that any one of them has a PD. I can say, though, that their behaviours show signs of maladaptive self and interpersonal functioning and traits associated with personality disorders. I can also point out the inestimable number of criminal
defendants and inquest subjects who have been deemed to have PDs in their most extreme form.

The NSW Deputy State Coroner’s findings earlier this year into the disappearance and suspected death of Melissa Caddick, who faked her financial qualifications and swindled family and friends, noted a forensic psychiatrist’s opinion that Caddick likely “met criteria for a person with a narcissistic personality disorder”. A psychiatrist’s report tendered during the trial of Richard Pusey, who filmed dead and dying police officers after a freeway crash in Melbourne in 2020 then shared the images, said he had “a complex mixture of core antisocial, borderline, narcissistic and paranoid personality subtypes”. A psychologist told the Supreme Court of Victoria that James Gargasoulas, who killed six pedestrians and seriously injured 27
others when he drove his car down the Bourke Street Mall in 2017, fitted “diagnostic criteria for both antisocial and narcissistic personality disorders”.

The inquest into the 2014 Sydney Lindt Cafe siege deaths heard that the gunman Man Haron Monis had a “severe, longstanding complex personality disorder with antisocial and narcissistic features and some paranoid features”.

But while the diagnosis of a PD in cases such as these seems incontrovertible, the foremost experts in the field believe it’s vital to jettison categorical, DSM-5-driven language to describe people like them and other non-criminal people with PD traits. Human beings and psychopathology are complex and categories don’t reflect “how abnormal mental phenomena are structured”, says Andrew Chanen. A person can have characteristics from multiple DSM-5 PD categories and so be diagnosed with multiple disorders. “I’ve written articles saying that DSM stands for ‘diagnoses for simple minds’,” says Peter Tyrer on a Zoom call from London. “It has a tick-box mentality to it.“

The new, more nuanced thinking about PD is codified in the ICD-11 (the World Health Organisation’s International Classification of Diseases 11th revision), which came into effect as the official diagnostic system in dozens of countries, especially in Europe, in 2022. It stipulates that severity (mild, moderate or severe) is the primary factor to be considered in diagnosis. A clinician can then augment that by drawing on a list of “trait domains” – negative affectivity, dissociality, detachment, disinhibition and anankastia (a focus on a rigid standard of perfection and right and wrong, while controlling one’s own and others’ behaviour to conform to those standards). According to the ICD-11, the “dissociality” trait encompasses narcissistic and antisocial-type behaviours and has core features including a disregard for the rights and feelings of others, self-centredness, a lack of empathy, a sense of entitlement, manipulative, deceptive and exploitative conduct, callousness and physical aggression. As with the DSM-5, the terms “psychopath” and “sociopath” are not used, although some specialists believe psychopathy is a distinct disorder with its own extreme set of features. “Borderline” is included as “a pattern specifier”.

“This is the big shift: that personality disorder is not a number of discrete disorders, it’s one thing,” says Andrew Chanen. “There’s broad agreement in the field that there’s no such thing as personality disorders. There’s just personality disorder with degrees of severity and flavours. It’s not even like there’s the difference between sorbet and ice-cream, there’s just ice-cream and you can have different flavours.”

For all of the ICD-11’s apparent elegant simplicity, PD science remains strewn with complications. For example, Roger Mulder, who sat on a panel of international experts who formulated the ICD-11 approach, says “detachment”, which is mostly seen in men, can appear to overlap with autism spectrum disorder (a developmental disorder, not a personality trait). Dissociative identity disorder (aka multiple personalities) and bipolar disorder (formerly known as manic depression) are often mistaken as PDs but are actually mental health conditions.

In violent crimes such as the Lindt Cafe siege and James Gargasoulas’s Bourke Street murders, other factors pile in. “Neither was fully explicable on the basis of personality disorder alone,” says Andrew Carroll. “Obviously in Bourke Street there were significant substance-use issues and clear evidence of active psychosis as a result of that. It gets to be a very messy area.” Additionally, perpetrators often have coexisting mental illness such as schizophrenia.

Perhaps the field’s most vexed and complicated issue is borderline personality disorder (BPD). According to ICD-11, borderline personality disturbance is “characterised by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity” and can include “frantic efforts” to avoid abandonment (real or imagined), self-harm, feelings of emptiness, difficulty controlling anger and “transient dissociative symptoms or psychotic-like features”. It is the most visible disorder because people with its features are heavy users of health services and their behaviour can be extreme and distressing for themselves and others. Yet some members of the ICD-11 working group, including Mulder and Tyrer, argued for its deletion from the classification. (Its eventual inclusion as a “pattern specifier” was a political compromise, says Mulder, partly to appease members from European countries where health insurers cover BPD.)

Mulder and Tyrer, who co-authored the 2022 book Personality Disorder: From Evidence to Understanding, believe the inclusion of borderline in ICD-11 is “a gremlin in the system”. They argue that there is no scientific
evidence that BPD is a condition and things listed as borderline traits such as self-harming are not underlying personality traits but symptoms. They and others believe BPD as a term should be abandoned, that it would be more accurate and less stigmatising for it to be considered a trauma-spectrum disorder or complex PTSD, although Mulder says that people with BPD have similar rates of childhood trauma to people with other PDs – higher than the general population. And, he says, many people with “so-called borderline personality disorder don’t have histories of trauma, so it’s not as simple as a cause-and-effect model”.

Wrexham-based clinician Keir Harding, an executive committee member of the British and Irish Group for the Study of Personality Disorder, believes the terminology is deeply harmful. “Our current insistence on labelling people as disordered is a poor start to any therapeutic relationship,” he noted in a 2020 letter to the UK medical journal The Lancet, adding, “It is a label that leads to closed minds rather than open arms.” On the phone from Wales, Harding tells me that 80 per cent or more of people diagnosed with BPD have experienced neglect, abandonment and/or trauma, yet society brands them as at fault. He says that some people who arrive at emergency departments after self-harming are told, “well, you’ve done it to yourself” and, if they need stitches, are refused anaesthetic. “We know that if health professionals are meeting someone they’ve never met before, if they’ve got ‘personality disorder’ written on their notes, they’re going to have a more judgmental, pessimistic experience than if they had nothing written on their notes.” Additionally, Harding believes diagnosis is riddled with gender bias. More women are diagnosed with BPD than men and, he says, “you’ve got to wonder if some of the criteria around borderline personality disorder are actually a way of judging women who do not fit with how society wants women to behave.”

Says Orygen’s Andrew Chanen: “The biggest problem we have in personality disorder is not about classification, it’s about bigotry. You see it in the health system every day; you see people talk about people with personality disorder in a way they would never talk about any other mental health problem or physical health problem. Particularly when labelled with ‘borderline personality disorder’, [people] get ... treated as second-class citizens, it’s a reason to reject people from services.” Chanen says clinicians have the same expectations of people with personality disorder that they would have of people who are mentally healthy. “They expect them to wait patiently in line, they expect them to be able to turn up on time to appointments … [but] the very nature of the disorder means that it’s difficult for those people to live their lives. They wouldn’t send someone away from an emergency department because they have poor personal hygiene, yet they will send people away because they have poor interpersonal skills.”

Research into the origin of PDs remains limited. Roger Mulder says there’s no consensus about the importance of what brain-scanning technology has found; studies haven’t established consistent or substantial differences between the brains of people with a PD and those of control subjects. Others believe people with severe antisocial and aggressive behaviour have a reduced volume in frontal brain regions. Research led by Sabine Herpertz, the professor in the University of Heidelberg’s department of psychiatry and psychotherapy, has looked at impulse control and the regulation of “affect”, the experience and expression of emotions or feelings. “You find a misconnection between some special parts in the prefrontal cortex, which are responsible for control, for inhibition … there are functional impairments concerning brain circuits involved in the controlling of affect and behaviour.”

Substantially, all the experts I interview concur with Carla Sharp’s view that a PD is “a complex confluence of nature and nurture”. Its origins, she says, lie in an interaction between biological and temperamental vulnerabilities and, as people interact with their environments in their early years, those factors are either exacerbated or contained. Evidence generally suggests they emerge in early teenage years but, says Mulder, some behaviours such as neuroticism appear in childhood. “There are some children, for example, who are terrified their parents are going to die, or really find it difficult to go to school, and that carries on through their life.“

Treatment for PDs is relatively unexplored territory, in part because aside from those with borderline traits, few who might have a disorder think they have an issue. A parent concerned about a son’s lack of friends or partner, indicators of detachment traits, might drag them to a specialist. “But the person himself doesn’t see it as a problem,” Mulder says. Similarly, those with dissocial/narcissistic-style behaviours rarely recognise or acknowledge the issues they cause for themselves and others and so are only likely to see a psychiatrist after landing in a criminal justice or corrective services setting. “[They] are the hardest to change,” says Carla Sharp. “The only way you can … is to help them see when change in their best interest.“

“Our interest is in this being a red flag for people who are likely to do badly in life.”

Professor Andrew Chanen, personality disorder specialist

The most researched and successful treatments are in people with features of borderline personality disorder, who tend to be open to change because of their terrible distress. Many approaches are based on cognitive
behaviour theory and techniques. Primarily, though, experts agree that people seeking assistance should be treated with compassion, and that identifying potential issues early in teenagers and young adults is vital.

At Orygen in Melbourne, Andrew Chanen has pioneered an early-intervention program. “It’s not all this classification stuff that’s important, it’s the fact that they have high levels of distress, high levels of other mental health problems, educational dropout, sexual and reproductive health problems, other physical health problems and substance-use problems,” Chanen says. “Young people who have ever met the criteria for severe personality disorder live two decades less than the rest of the population; they are vastly over- represented among the long-term unemployed, on the disability support pension, they’re the people who turn up to hospitals with severe and enduring physical health problems. They’re likely to be both perpetrators and victims of crime in the future. There’s a raft of terrible consequences that are associated with this. And so our interest is not narrowly in personality disorder; it’s in this being a red flag for people who are likely to do badly in life.“

Science will likely never fully decode human personality and behaviour. Every mind is mysterious, a wild and singular frontier, shaped by an inestimable number of genetic variations, epigenetic shifts, life forces and experiences. “We’re talking about the human condition in all its diversity,” says Andrew Carroll. “It’s hugely complex.“

And it’s hard to imagine we will ever stop asking “Why?” when we hear stories of the cruel and/or unusual behaviour of other human beings, behaviour which so often runs counter to their own best interests. Why, in a succession of relationships, does a man elevate his fakery and pretence almost to the point of performance art? Why does a woman spend a decade and waste countless hours telling her best friend she has cancer? And what can we understand about these types of behaviours if we consider them through the prism of ICD-11?

Take Melissa Caddick, whose story gripped the nation: her disregard for the rights and feelings of others, a core feature of the dissociality trait, is clear throughout the inquest findings into her disappearance and suspected death. And in life, she exhibited another characteristic trait – grandiosity. Caddick wore designer clothing and expensive jewellery; one person told the inquest into her disappearance that Caddick would show off new art acquisitions when they visited her home, she told others she owned an Aspen condo and a New York apartment block. (She didn’t.) Caddick’s friends said she always wanted to be better than she actually was. Meanwhile, grandiosity can come in different forms; it can, as in the case of cancer con artists, emerge in tall tales and fantastical stories designed to feed an insatiable and dysfunctional hunger for attention and sympathy.

When I ask the University of Wollongong’s Brin Grenyer about grandiosity and deceit, he returns a question: “What is the function of that behaviour?” What if, he asks, a person feels empty inside or small and inconsequential? “Are they trying to create a false image of themselves to feel bigger and more important?”

Carla Sharp explains it in another way: she describes it as a defence mechanism, “a way of creating a world you can cope with”.

* Names have been changed.
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