top of page

Clinical Labels

If It Walks Like a Duck

Can you distinguish between common domestic abusers and pathological abusers? Both engage in abusive behavior within intimate relationships, but there is a significant difference in the nature and complexity of their abuse. It is often said that if something walks like a duck, quacks like a duck, and swims like a duck; then it's probably a duck. Similarly, if the abusive behavior goes beyond the typical patterns and exhibits a higher level of manipulation, intricacy, and lasting impact, it may indicate the presence of a pathological abuser.

While domestic abusers may exhibit mean, hurtful (psychological and/or psychical) abusive behavior, pathological abusers take the abuse to a more extreme level. These individuals not only exhibit abusive traits, but also indicate the possibility of having a clinical personality disorder or displaying all the associated traits and behaviors.  Their manipulation tactics are skillfully employed, making it challenging to detect their true nature. Additionally, they often avoid seeking therapy, further complicating their identification and intervention.

Severe Consequences

The consequences of the actions of pathological abusers are severe and have long-lasting effects on survivors. Their abuse goes beyond mere manipulation, encompassing a range of tactics designed to control, dominate, and exploit their victims. Recognizing the distinction between domestic abusers and pathological abusers is crucial in raising awareness about the complexities of pathological abuse. 

Although qualified clinicians are the ones who can formally diagnose pathological abusers, it is important to create awareness about their existence. Pathological abusers are a hidden reality within domestic abuse, and in order to unveil the truth, it is crucial to understand their nature and distinguish them from common abusers.

Conditions like Antisocial Personality Disorder (ASPD) and Narcissistic Personality Disorder (NPD) are examples of disorders that can manifest in pathological abusers. Diagnosing these disorders can be challenging because individuals with ASPD and NPD typically resist therapy and mask their true selves through manipulation and deceit.

Nevertheless, the DSM-5 and ICD-11 serve as invaluable diagnostic manuals, providing a framework to unravel personality disorders and pathological abuse. While they share a common goal, these manuals diverge in their approaches and terminology. These variations show that experts are continually working to understand better and classify personality disorders, giving healthcare professionals different viewpoints to assess and diagnose.


The American Psychiatric Association publishes the DSM-5, which is widely used in the United States and other countries. It uses a categorical approach, which means that disorders are defined based on a set of specific criteria that must be met for a diagnosis to be made.


The ICD-11 is published by the World Health Organization and is used internationally. It uses a dimensional approach, and meaning disorders are defined based on the severity and number of symptoms present. The ICD-11 also includes information on the context and functional impairment caused by the disorder.

Narcissistic Personality Disorder (NPD)

NPD is diagnosed when a person consistently displays traits such as grandiosity, a need for admiration, and a lack of empathy. People with NPD often have an inflated sense of self-importance and exploit others for their own benefit.

To diagnose NPD, the DSM-5 outlines specific criteria, requiring the presence of at least five out of the following traits: a grandiose self-view, fantasies of unlimited success, a belief in their own uniqueness, a strong need for admiration, a sense of entitlement, a tendency to exploit others, a lack of empathy, the envy of others or the belief that others envy them, and arrogant behaviors or attitudes.

In contrast, the ICD-11, a diagnostic manual used internationally, takes a unique approach. It assesses personality disorders based on specific symptoms and their severity. Individuals with narcissistic traits may receive a diagnosis under different categories, depending on their overall symptoms and impairments in self-functioning and interpersonal relationships.

Antisocial Personality Disorder (ASPD)

ASPD is characterized by a disregard for others' rights, including callousness, impulsivity, and manipulation. While sociopathy and psychopathy are not separate disorders, they can be seen as different expressions of ASPD.

The DSM-5 provides specific criteria for diagnosing ASPD, requiring a history of conduct disorder before the age of 15 and the presence of at least three out of the following traits: deceitfulness, impulsivity, irritability, aggressiveness, reckless disregard for safety, consistent irresponsibility, and lack of remorse.

In contrast, the ICD-11 focuses on evaluating enduring patterns of behavior and inner experiences that significantly deviate from societal norms. It assesses impairments in self-functioning, including self-identity and self-direction, as well as interpersonal functioning, such as empathy and intimacy, to diagnose ASPD.

These diagnostic guidelines help professionals in understanding and identifying individuals with narcissistic and antisocial traits, providing a framework for assessment and intervention.

Robert Hare's Psychopathy Checklist (PCL)

Robert Hare's Psychopathy Checklist is a diagnostic tool for assessing psychopathy, often considered a more severe form of ASPD. The checklist includes 20 items that are scored based on the individual's history and behavior, such as a lack of empathy, pathological lying, and impulsivity. The score on the checklist can be used to determine the degree of psychopathic traits an individual exhibits.

It's important to note that the Psychopathy Checklist is not an official diagnostic tool but can help identify individuals with psychopathic traits. The DSM-5 and ICD-11 recognize psychopathic traits as part of the diagnostic criteria for ASPD, but the severity and extent of these traits can vary among individuals.

Dual Diagnoses

Pathological abusers may present with complex diagnoses that involve a combination of traits from multiple personality disorders. This adds an extra layer of complexity in addressing their symptoms and underlying issues. For example, Antisocial Personality Disorder (ASPD) co-occurs with Narcissistic Personality Disorder (NPD) or Obsessive-Compulsive Personality Disorder (OCPD) (distinct from Obsessive-Compulsive Disorder or OCD). It is crucial to differentiate these disorders to understand the unique challenges they pose in navigating dual diagnoses.

Summary of Clinical Diagnostic Guidelines

I am not a clinical therapist, but as a survivor of over two decades of pathological abuse, I have dedicated significant time to making sense of it all. Through extensive reading, taking numerous classes and courses in psychology, and personal therapy experiences, I have gained valuable knowledge. This information is not intended for clinical diagnoses but aims to provide a concise and easily understandable summary. I have explained the concepts in my own words, breaking them down for better comprehension.

Understanding the intricacies of these diagnostic guidelines and their distinctions can contribute to a clearer understanding of the behaviors exhibited by pathological abusers. By delving into these concepts, it can enhance knowledge and recognize the importance of tackling these complex personality disorders in the context of pathological abuse and how they significantly differ from 'common' domestic abuse.

Therapy Closeup
bottom of page