Narcissistic Personality Disorder

NARCISSISTIC PERSONALITY DISORDER

Saundra E. Burleson

Wake Forest University

February 14, 2016

Narcissistic Personality Disorder

Narcissistic Personality Disorder (“NPD”), of which 50%-75% of those diagnosed (according to DSM-V) are male, is a disorder that is characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy. Typically beginning by early adulthood; this disorder presents the potential for suffering not only to those diagnosed, but also to those who find themselves in a relationship with them.

Introduction

In Metamorphoses, a fifteen-book, epic Latin narrative poem by Roman poet Ovid, Narcissus the hunter, who was known for his beauty, was so vainly in love with himself, that he lost his will to live, and died by a pool of water, staring at his own reflection. Narcissistic Personality Disorder was first introduced in the DSM-III in 1980. People with this disorder selfishly disregard the wants and needs of others and exploit relationships. They are “prone to infidelity and both verbal and physical aggression.” (Dhawan, Kunik, Oldham, & Coverdale, 2010)

Background Provided By Existing Literature

In a study conducted in 2010 and reviewed in Prevalence and treatment of narcissistic personality disorder in the community: a systematic review, the authors reported that an average of less than 10 studies per year were conducted on NPD. This is evidence of the fact that more research is needed in reference to this disorder. The authors conducted research using a structured or semi-structured interview and found that of the 49,812 participants, 2,169 met the diagnostic criteria for NPD. This result of 4.35% falls within the range of 0% to 6.2% in community samples reported in the DSM-V.

There has been some interest in researching the psychological effects that parents with NPD have on their children. Seth Myers, Psy.D. reports in Psychology Today that children of NPD parents suffer similar psychological bruises at the hands of their parents. “The child of the narcissist realizes early on that he exists to provide a reflection for the parent and to serve the parent – not the other way around.” (Myers, 2014)

Diagnostic criteria for NPD is listed in DSM-V as follows:

Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
Requires excessive admiration.
Has a sense of entitlement (i.e. Unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of him or her.
Shows arrogant, haughty behaviors or attitudes.

(American Psychiatric Association, 2013)

Individuals with this disorder generally have a very fragile self-esteem, although their external behaviors convey something much different. They may expect to be treated with excessive admiration and their sense of entitlement, combined with their lack of compassion and empathy for, and their lack of sensitivity to the wants and needs of other people, sometimes manifests as conscious or unconscious exploitation of others. Because they often assume that others are totally concerned about their welfare, people with NPD tend to talk about themselves with excessive, inappropriate detail.

Because of their very fragile self-esteem, people with NPD are very sensitive to criticism and/or defeat. A simple criticism, that would be acknowledged and let go of by most people, can leave a person with NPD feeling “humiliated, degraded, hollow, and empty.” (American Psychiatric Association, 2013) Their reaction to criticism may present as rage, disdain, or a defiant counterattack. These episodes can often lead to social withdrawal. To protect their grandiosity, a person with NPD might also present an appearance of humility.

People with NPD are oblivious to how their behaviors affect/impact others. They talk as though they are speaking to anyone within earshot instead of directly to one person. They are not aware of the fact that they are alienating others with their boastful and arrogant mannerisms, and “their tendency to refer to themselves repeatedly reflects their need to be the center of everyone else’s attention.” (Gabbard, 2009) They come across as insensitive because of their inability to comprehend the experience of others. They are often perceived as having a sender but no receiver.

Personal and professional relationships are often difficult for people who suffer with NPD because of their sense of entitlement, disregard for the feelings of others, and excessive need for admiration. Individuals with NPD may be high achievers because of their high level of ambition; but they may also lack in performance because of their inability to accept criticism or defeat. According to the DSM-V, NPD “is also associated with anorexia nervosa and substance use disorders (especially related to cocaine. Histrionic, borderline, antisocial, and paranoid personality disorders may be associated with NPD.” (American Psychiatric Association, 2013)

Causes of Narcissistic Personality Disorder

There are various theories about the possible causes of NPD, but further research is needed to confirm a true root cause of this disorder. The cause of NPD is likely very complex. Most professionals subscribe to a biopsychosocial model of causes and believe that NPD is caused by a combination of factors such as individual temperamental patterns and early life experiences such as excessive pampering or harsh or negative parenting. This would mean that a complex, intertwined nature of a person’s early developmental, environmental, social, and psychological experiences, combine to cause NPD. There is also research that suggests that if a person suffers with NPD, they are likely to pass this on to their children; whether through genetics or modeling of the various NPD traits, is not yet confirmed.

Treatment Options for Narcissistic Personality Disorder

There is no known cure for NPD, but counseling might help the person learn to relate to others in a more positive and rewarding way. One goal in counseling is to provide the client with deeper insight into his/her difficulties and attitudes in hope that behaviors will change. Another goal of therapy might be to help the client develop less inflated self-esteem and more realistic expectations of others. It is important to note that medication can be used to alleviate distressing symptoms such as the anxiety and sadness that often co-occur with NPD. Psychotherapy outcome studies on NPD are scarce and experts typically recommend the use of methods that have been useful in the treatment of other personality disorders.

Treatment of NPD typically involves long-term psychotherapy and is possibly combined with medications that can help with persistently troubling symptoms. It is usually considered a difficult-to-treat disorder and patients with this disorder rarely seek therapy because of the extreme sensitivity to criticism and/or need for admiration. More likely, a person with NPD will seek treatment for surface issues such as anxiety, depression, substance abuse and psychosomatic disorders, without considering possible links to personality aspects and interpersonal functioning related to NPD. There are useful treatments for NPD, but individuals “often find it difficult to engage.” (Kramer, Berthoud, Keller, & Caspar, 2014)

Much of the difficulty in treating NPD also arises from the challenging patterns of transference and countertransference that develop in the course of treatment. These patterns can also be considered a priority in treating NPD since those who suffer with NPD have significant difficulty in maintaining gratifying relationships. Counseling sessions can be considered a place where the “clinician can directly observe how the patient relates to others outside” (Gabbard, 2009) of therapy. Much of the knowledge about NPD comes from psychoanalysis and intensive psychoanalytic psychotherapy. “Recent empirical data has helped illuminate those characterological features that are hallmarks of narcissistic personality disorder.” (Gabbard, 2009)

Hypervigilant NPD patients are extremely sensitive to how others react to them and tune into facial expressions and listen intently to others in search of evidence of a critical reaction. They will often feel slighted by others when there was no intention of criticism whatsoever. Oblivious narcissists will use their therapist as a sounding board that exists solely to enhance the patient’s self-esteem according to Dr. Glen O. Gabbard in his article, Transference and Countertransference: Developments in the Treatment of Narcissistic Personality Disorder. These clients don’t connect with their counselor in the way that most clients do. They talk at length about themselves without any curiosity about the therapist. To an outside observer, this interaction might be characterized by an “apparent absence of transference. The astute clinician, however, knows that this apparent absence is the transference.” (Gabbard, 2009)

It is important for therapists to remember that those suffering with NPD are plagued by feelings of inadequacy related to inability to regulate their self-esteem. One common defensive strategy that these clients use is to devalue others as a way to make themselves feel superior and less inadequate. They may initially treat their therapist with contempt as a way to level the playing field in a situation where they are dealing with feelings of inferiority. NPD clients are prone to feelings of shame and humiliation and may scan the their therapist’s reactions (body language and facial expressions) as a way to avoid exposing their vulnerability by guarding against the experience of humiliation.

Therapists working with NPD clients should be aware of their own need to be needed because NPD clients may strive to deprive them of fulfilling this need. They will often talk “at” the therapist instead of “’to” the therapist and without preparing for these types of interactions, the therapist may begin to feel ineffectual. Untrained or unprepared therapists may react to this type of behavior by becoming bored or disengaged. Being aware of “common experiences of transference/counter-transference developments (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014) alerts the therapist to potential impasses and resistances in the treatment that must be taken into account.” (Gabbard, 2009)

It is essential in the treatment of NPD that therapists use efficient therapeutic procedures from the very beginning. Constructive work on the individual’s core issues, including “vulnerable self-image, difficulties in reflecting on mental states, lack of empathy, problems related to shame as central emotional state, along with problematic emotion regulation, destructive interpersonal patterns related to grandiosity and dominance or aggressivity, superficiality, and interpersonal avoidance processes”,(Kramer, Berthoud, Keller, & Caspar, 2014) is extremely important.

One therapeutic approach that is used for patients with severe personality disorders is transference-focused psychotherapy (TFP). This manualized evidence-based treatment which integrates contemporary object relations theory with attachment theory and research, is used to attempt a “gradual integration of disparate, split-off self and object representations into a more integrated stable concept of the self and objects, which in turn fosters reflective capacity in that it provides a more integrated, consistent working model of self and others against which momentary mental states, including those that devolve from the grandiose self, may be more systematically reflected upon and their defensive function understood.” (Diamond & Meehan, 2013) The use of TFP in treating individuals with NPD allows for a systematic analysis of the grandiose self in hopes of affecting a shift from a “grandiose, dismissive to a more vulnerable, preoccupied narcissistic presentation.” (Diamond & Meehan, 2013)

Motive-oriented therapeutic relationship (MOTHER) is referred to by several therapy models as a useful intervention principle for use with NPD. MOTHER is a prescriptive concept based on an integrative form of case conceptualization and is considered to be particularly relevant to the treatment of individuals with personality disorders.

“Cognitive-Behavior therapy methods of teaching problem solving and social skills and modification of underlying dysfunctional schemas on self-worth is recommended.” (Kramer, Berthoud, Keller, & Caspar, 2014) The psychodynamic therapy approach of interpreting transference and counter-transference within the therapeutic relationship, particularly components of aggression, hate, and jealousy; can also be useful in working with individuals with NPD.

Metacognitive Interpersonal therapy targets characteristics of NPD such as an “intellectualizing narrative style, poor metacognition, maladaptive interpersonal schemas, a restricted set of states of mind, impaired agency and perfectionism” (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014) and can therefore be a treatment option. These dysfunctions are targeted with a series of formalized procedures “aimed at first forming a shared formulation of functioning which patients and therapists can then use to plan change.” (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014) Continuous awareness of the therapeutic relationship is necessary to minimize misunderstandings

Important in the treatment of those with NPD is therapeutic alliance building, which should be the focus from the beginning of treatment. Therapists employing this method of treatment will validate clients’ subjective experience and monitor their own tendencies toward behaving as an aggressive authority figure. Therapists working with NPD clients should try not to react to the narcissistic tendencies to use them as an audience and should instead invite the client to be “active and reflect jointly on any problems occurring in the therapy room so as to make meaning out of them and repair alliance ruptures.” (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014)

Due to the long-term difficulties and distress caused by living with NPD, people with this disorder could be at risk for other emotional and behavioral disorders. Drug/alcohol abuse often co-occur because they are used as a way to cope with the symptoms of NPD. The outlook for people with NPD depends greatly on the degree of their commitment to engaging in honestly identifying behaviors/emotions and more positive ways of relating to others. Individuals who seek help and work toward change can improve their lives.

Case Conceptualization

Client Demographics

Frank is a Caucasian, 45 year old, divorced male. He comes to therapy dressed as if he is prepared for a business meeting. He is approximately 5’10 and weighs approximately 195 pounds. Frank reports that he has “several” master’s degrees but is very vague about where he went to school and what he studied. He has had difficulty finding a job since becoming unemployed and shares that he was let go from his most recent job (not his fault of course) as a result of being “misunderstood” by his “idiot” supervisor who “lacked the capacity to understand depression.” He says he has lost touch with his former colleagues and friends because they “just don’t understand serious mental illness.”

It is apparent, by Frank’s interpersonal style and narrative, thathe wants to be perceived as successful, wealthy, and educated, although he provides no evidence of these attributes. His vocabulary and language style contradict his report of “extensive higher education.” He becomes frustrated when asked for specifics and begins to ask for evidence of the counselor’s education and training. It is important to note that Frank’s ability to give an accurate and cohesive account of his historical information may be affected by his personality disorder.

Presenting Problem

Frank’s physician referred him for counseling, reporting that he was seeking assistance for depression. Frank shares that his own extensive research led him to believe he is depressed even though he is not exhibiting typical symptoms. He says he believes that this large stack of research documents may be helpful for the counselor. Frank’s responses to the counselor’s probing questions about depression keep going back to a sense that he is not achieving what he would like to achieve and is having difficulty with people. He reports feeling dissatisfied with life and physically run down. When the counselor asks Frank questions like: “are you feeling sad” he answers with one-word answers and is very vague. He makes generalized statements about having a happy family life when he was growing up and now with his daughter, but provides no evidence of close relationships.

History

Frank takes the lead in conversation and does not allow the counselor to make the introductory statements for the initial session until he has finished his narrative about how he has seen many counselors previously and has found them all to be inadequate. Frank says that he has seen “several” but can’t remember exactly how many counselors, psychologists, psychiatrists, etc. he has seen for depression. He also cannot remember their names.

Frank has a somewhat forced and authoritative quality to his affect. He is happy to tell his story when asked open-ended questions, but frequently talks over the counselor when she tries to re-direct the session or clarify. He is vague with his answers and provides statements such as “just not myself” and “want more from life. Frank continues on to describe himself as “complicated” and says (while smiling) that other people have not been “smart enough to figure him out either.” His other answers are inconsistent. For example, when asked if he has stopped doing things he enjoys, he answers “yes.” When asked what he has stopped doing, he answers that he is not working anymore. When asked if this was a source of enjoyment, he answers that it was not a very good place to work because they didn’t know how to “utilize me to my full potential.”