My name is Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.

Phineas Gage was twenty-five years old, construction foreman. He lived in Vermont in the 1860s. While working on a railroad bed, he packed powdered explosives into a hole in the ground using tamping iron. The powder heated and blew in his face. The tamping iron rebounded and pierced the top of his skull, ravaging his frontal lobes.

In 1869, his doctor, a chap by the name of Harlow, reported the changes to Phineas Gage’s personality following this horrible accident.

The doctor wrote, ’93Phineas Gage became fitful, irreverent, indulging at times in the grossest profanity, which was not previously his custom, manifesting, but little deference to his fellows, impatient of restraint or advice when it conflicts with his desires, at times, pertinaciously obstinate, yet capricious, vacillating.

He said that Phineas Gage was devising many plans for future operation, which are no sooner arranged than they are abandoned for other, more appealing, but equally feasible alternatives.

Phineas Gage’s mind was radically changed, so that his friends and acquaintances said that he was no longer Phineas Gage, concluded the doctor.

In other words, his brain injury turned Phineas Gage into a psychopathic narcissist.

Is this possible? Can a head trauma or brain injury induce a full-fledged personality disorder?

Well, not really.

Similarly, startling transformations have been recorded among soldiers with penetrating head injuries suffered in World War I. Ortopalial wounds made people pseudo-psychopathic. They suddenly became grandiose, euphoric, disinhibited, and purile. When the dorsolateral convexities were damaged, those affected became lethargic, apathetic, or in the lingo of their time, pseudo-depressed.

A doctor by the name of Gishvin noted that in many cases both syndromes appeared. Wounded soldiers became both pseudo-psychopathic and pseudo-depressed.

But the Diagnostic and Statistical Manual is absolutely clear. People with brain injuries may acquire traits and behaviors which are typical of certain personality disorders, but head trauma never results in a full-fledged, long-term personality disorder.

I’m quoting from page 689 of the DSM.

The enduring pattern of personality disorder should not be due to the direct physiological effects of a substance, such as a drug or a medication, or to a general medical condition, such as head trauma.

In my book Malignant Self-Love, Narcissism Revisited, I wrote, It is considerable that the third unrelated problem causes chemical imbalances in the brain, metabolic diseases such as diabetes, pathological narcissism, and other mental health syndromes. There may be a common cause, a hidden common denominator, or perhaps a group of genes.

Certain medical conditions can activate a narcissistic defense mechanism. Chronic ailments are likely to lead to the emergence of narcissistic traits or a narcissistic personality style. Traumas, such as brain injuries, have been known to induce states of mind akin to full-blown personality disorders.

Such narcissism is irreversible and tends to be ameliorated or disappear altogether when the underlying medical problem goes away. Other disorders, like bipolar disorder, formerly known as mania depression, are characterized by mood swings that are not brought about by external events. These mood swings are endogenous, not exogenous. They are the outcome of biochemical processes in the brain.

But the narcissist mood swings, by comparison, are strictly the results of external events, not internal ones. The narcissist perceives and interprets certain events, for instance, the obtaining of narcissistic supply or the lack of narcissistic supply.

And this cause is mood swings.

But phenomena which are often associated with narcissistic personality disorders, such as depression or obsessive compulsive behaviors, can and are treated with medication.

Rumor has it that SSRIs, such as fluoxetine, known as Prozac, might have adverse effects if the primary disorder is narcissistic personality disorder. They sometimes lead to a serotonin syndrome, which includes agitation and exacerbates the rage attacks, typical of a narcissist.

The use of SSRIs is associated at times with delirium and the emergence of a manic phase, even with psychotic microepisodes. This is not the case, luckily, with heterocyclics, MAOs, and other mood stabilizers, such as the lithium. Blockers and inhibitors are regularly applied without discernible adverse effects as far as narcissistic personality disorder is concerned.

Not enough is known about the biochemistry of narcissistic personality disorder. There seems to be some vague link to serotonin, but no one knows for sure. There isn’t a reliable, non-intrusive method to measure a brain and central nervous systems surrounding levels, so it’s mostly guesswork at this stage.

Head injury induces temporary narcissistic behaviors and traits. Brain biochemistry and genetic makeup may encourage the formation of narcissistic personality disorder. That’s all we know at this stage.