The following article began as a discussion over Sunday brunch with three close friends who are all active or retired psychotherapists. One of them, whom I’ll call Mary, had recently seen a former patient of mine and was asking me about his diagnosis. She was struck by features that suggested Obsessive-Compulsive Personality Disorder (OCPD), whereas I had seen far more evidence of Narcissistic Personality Disorder (NPD). As she talked about the anger he felt towards his girl friend for failing to say and do things “perfectly” for him, I thought of “Perfectionism in Service of Self” (PISS) as a way to explain how NPD could look like OCPD. She and the others encouraged me to write something about it. The idea of adding “with Extreme Demandingness” (PISSED) occurred to me as soon as I started. I sent the draft to Mary and the others. She was especially appreciative of its educational value and encouraged me to make it available to trainees and colleagues.
The PISSED Syndrome
Perfectionism In Service of Self with Extreme Demandingness (PISSED) describes a narcissistic variant sometimes confused with Obsessive Compulsive Personality Disorder (OCPD). People with both conditions can be very difficult in relationships, but there are important differences. OCPD is characterized by:
- Rigid adherence to rules and regulations
- An overwhelming need for order
- Unwillingness to yield or give responsibilities to others
- A sense of righteousness about the way things “should be done” 
Narcissistic Personality Disorder (NPD) involves:
- Exaggerated feelings of self-importance
- Excessive need for admiration
- Lack of understanding of others’ feelings 
The PISSED Syndrome is not about perfectionism except as applies to meeting the extreme emotional needs of the person with the syndrome. It is how narcissists react to people who don’t give them the admiration, love, nurturance or sexual responses that they crave. It is manifested by:
- Extreme emotions triggered by unsatisfied desires
- Inability to recognize that others have legitimate needs
- Impulsive behaviors aimed at satisfying demands
Here are examples of how OCPD and PISSED differ:
OCPD: Dr. Wright, a 48 year old surgeon, spends hours reading everything written about the work he does. He insists that his O.R. run like clockwork and that his operating team perform flawlessly. He doesn’t delegate important tasks to his assistants because he doesn’t trust anyone but himself to do them correctly. He loudly berates and dismisses staff from his O.R. for failing to live up to his standards. He is neither pleased by flattery nor wounded by criticism, because he is not particularly interested in what other people think of him. His entire focus is on adherence to the highest possible standards in work and in life.
PISSED: Mr. Needham is a 38 year old unmarried investor from a wealthy family. He spends less and less time working because he is obsessed with being sought after by women. He has a 27 year old girlfriend, whom he alternates between idealizing and devaluing. In the first state he says he loves her and buys her expensive gifts. In the second he attacks her verbally for “disrespecting” him by spending time with her friends when he wants to be with her. He grabs her phone away to see if she has lied to him. After she alleviates his concerns for the moment, the process repeats itself, but he becomes progressively more vicious as she becomes worn down by his attacks, seeks affection elsewhere and is less convincing in her apologies.
In short, people with OCPD are obsessed and compelled to make sure that neither they nor anyone else contaminates the world they care about with imperfection; whereas PISSED people demand without exception that no one in their world ever contaminates them personally with feelings of imperfection.
How is PISSED different from NPD? They are just two sides of the same coin, sometimes called the grandiose and vulnerable types of NPD. People with grandiose NPD are among the happier individuals in the DSM. Their grandiosity often leads them to feel better about themselves than they would if they saw themselves more accurately. In some cases they can even persuade others to believe their pretensions. In more intimate relationships, however, the truth typically emerges. The initial positive impression that they create is replaced with disillusionment, particularly when their blindness to the needs of the other person becomes apparent. Somewhere between the initial encounter and that moment of truth, they will start to feel that the other person isn’t meeting their needs, and that is the moment when NPD becomes PISSED.
In extreme cases PISSED people can become aggressive or lethal. Here, the last word in the name of the disorder changes from “Demandingness” to “Dangerousness.” These are the worst examples of the disorder, in which narcissistic rage erupts into violence. Mr. Needham did not physically harm his girl friend, because rational self-interest prevented him from crossing the line; however, with less impulse-control or more sociopathy, some narcissists do hurt or even kill those who make them feel imperfect. With an added component of depression, homicide-suicides may result. In the case of mass murderers, a perverted quest for negative fame may motivate becoming one’s own last victim.
Fortunately, the PISSED syndrome is treatable, Pharmacological agents can increase impulse-control and reduce negative affect. Psychotherapy can help people become more aware of their narcissistic tendencies, more forgiving of their imperfections and more understanding of the mental lives of others. These changes can help make relationships more fulfilling and can create a level of contentment that replaces the drug of grandiosity with the stability of self-acceptance.
DSM-5 (2013), American Psychiatric Association.
Krizan, Z., & Johar, O. (2015). Narcissistic rage revisited. Journal of Personality and Social Psychology, 108(5), 784-801.
The value of naming things is to help identify them and distinguish them from different entities. The PISSED syndrome differs from “vulnerable” narcissism by virtue of its cyclic rather than “separate” relationship with grandiose narcissism. My 50 years of clinical experience has presented countless examples of narcissists who could be either grandiose or PISSED depending on circumstances. There may be some who are primarily one or the other, but most cycle between the two, leading to the ever more common misdiagnosis of NPD as bipolar disorder.