Narcissistic PD

Narcissistic PD

a pervasive pattern of:

grandiosity need for admiration lack of empathy

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Narcissistic PD

Highly controversial Uncertain validity Literature is theoretical/clinical Not a solid research base

Epidemiology

less than 1% of general population 2-16% of clinical

Huge variation across studies

Why differences? How NAR assessed, by whom and when

Narcissism as style

NarcissismSelf-confident, asserting

Style Disorder

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Narcissistic PD - History

Narcissus – mythological figure Fell in love with own reflection Was unable to leave Eventually died

NPD in Media

often cast as main characters does not see effect on others plot sets to correct this flaw

CARS

Media Examples The Fisher King (Jeff Bridges) Apocalypse Now (Robert Duvall) Star Trek (Q - TNG) Rain Man (Tom Cruise)

Movie Review

Review the Movie “Malice” Study Dr. Jed Hill How does he meet the criteria for NPD?

Review the Movie “A Few Good Men” Study Colonel Jessup How does he meet the criteria for NPD?

History

History Havelock Ellis (1898)

First to invoke the myth clinically Case study of a man Excessive masturbation Individual becomes object of own desire

History Freud (1914)

Primary narcissism – occurs early Secondary narcissism – occurs later

Waelder (1925) Narcissistic personality first described

Freud (1931) Narcissistic personality type

History Nemiah (1961)

narcissistic character disorder

*Kernberg (1967) Narcissistic personality structure Primitive defense mechanisms Higher Ego functioning

*Kohut (1968) – coined Narcissistic personality disorder

NAR PD - History large body of literature on this disorder

from a psychodynamic perspective

NAR first appeared in the DSM-III

Narcissism has different meanings

no ICD equivalent for NAR...

Essential DSM – 5/9 Criteria

Grandiose sense of self Preoccupied with the fantasies Is special, Excessive Admiration Sense of Entitlement, Interpersonally

Exploitive Lacks Empathy, Envious Arrogant

Part IIPart I Part III

In addition to DSM view…

Westen and Shedler (1999)

Survey of clinicians suggests NAR.. More controlling Power Struggles More Competitive

Associated Features

Exaggerate abilities Don’t like others to succeed Seeks affirmation of special status Ambitious Leaders, act decisively Persuasive, lack of reciprocity Angry if not reinforced

Gender

More common in men Not clear why

Could reflect diagnostic criteria

Differential Diagnosisand Co-morbidity

Looks like delusional disorder Grandiose type

Dysthymia or Major Depression

Bulimia, Substance Abuse (cocaine)

Borderline PD

No single Axis I disorder is consistent

Interview Considerations

Interview Considerations

Verbal, likes attention A rehearsed quality to information Talk at you, not to you Rapport sometimes difficult

If challenged or not validated Narcissistic injury or rage

Interview Considerations

Condescending Blames others for disappointment Hypersensitive to criticism The world revolves around them Aspirations don’t match their

discipline

Interview Themes very sensitive to injury or self-defeat fragile self-esteem aging is handled poorly

shallow lonely person, lacks emotional depth

insensitive to others, preoccupied with self tries to impress interviewer pathological rivalry

Interview Themes

arrogant, attention-seeking trouble taking criticism, feel

entitled they do not follow rules

trouble getting along with others sarcasm, devaluation respond in defensive ways

Other themes Headline Intelligence A learning disability among NPD Assimilate catch phrases but are not

well-versed on a topic

Incapable of thorough studying in a given area

Other themes Narcissistic dialoguing

Use communication to regulate self-esteem rather than for true communication

In other words, the person is talking to themselves.

The NPD Cycle 1. Identify with another Person 2. Exploit Person 3. Person becomes exhausted 4. Person then is devalued 5. Person is rejected 6. Find another Person, cycle starts again

Cause

Cause Not extensively studied

Why? – does not have huge impact on society

Lacks a clear genetic link to Axis I

Explanations sometimes appear contradictory

NAR - Cause

giftedness from an early age "god-like" praise from parents Narcissistic extensions of parents

Nobel Prize Complex feelings of superiority destined for greatness

Cause - Psychosocial

Mom Was Good, Dad was Bad strong supportive mother absent or weak father

Mom Was Bad, Dad was Bad Children are Narcissistic

Extensions

Cause – blame the parents Lack of “selfless” modeling

Or

The Incomplete Lesson Observed “selfless” without reinforcing the

responsibility of selflessness in the child Expectation of being served without ever

having to serve others.

Cause – Blame the mother Mahler; Modell; Kinston

During critical periods, the mother was unavailable, unresponsive or insensitive to needs of child

NAR – Cause - Kernberg

spiteful or indifferent parenting causes oral rage or psychic hunger

sets stage for using people and/or consuming things beyond realistic limits

severe frustration causes “borderline personality organization”

use of splitting, not a well developed superego, poor relationships

NAR - Cause Heinz Kohut

narcissism is the result of the self being damaged during early psychological development (due to inadequate parenting)

Parents do not validate child’s concerns

Cause - Cognitive

Beck and Freeman (1990)

Each PD has unique beliefs “I am special” “I am superior” ”I am above the rules”

Cause - Cognitive

Young (1994) Cause is early maladaptive schemas

Key areas Entitlement Emotional deprivation Defectiveness

Cause - Fonagy

Narcissism is a disorder of self.

How is the self developed?

Due to mirroring of the parent of child’s emotions – overtime a stable sense of self and emotions is developed

Cause - Fonagy If the parent acknowledges child, but does not

properly mirror feedback, the child develops a dual representation of self

1) child’s experience 2) false self as mirrored by parent

Child does not have a stable self representation and manifests itself as poor affect regulation

Types of NAR PD

Types - Gabbard Type I Thick skinned Egotistical,

grandiose Arrogant, craves

attention Disregards

feelings of others

Type II Hypervigilant Thin-skinned Self-effacing Diverts attention Highly sensitive

Types - Millon Unprincipled – NAR + ANT Amorous – NAR + HIS Compensatory – NAR + AVD Elitist - NAR

Unprincipled Antisocial Drug problems, in prison Confidently amoral Deceptive Exploit others

Elitist Pure variant Self-assured, arrogant, impressive Amplified superior self-image Fear being ordinary “Phallic” types Flaunt symbols of achievement Compare themselves to others

Compensated

A paradox… Confident outside, insecure inside Plaques on the wall Sensitive to reactions of others Façade of superiority

Amorous

Skilled at erotic seduction Skilled at tempting the “needy” Sexual exploitation Body narcissism

Physical appearance Clothes

Hollywood Multiple Marriages 8 Times Mickey Rooney Elizabeth Taylor Lana Turner

7 Times Larry King Stan Laurel Martha Raye

Turkat – Three Types

acceptance-oriented impression management narcissists

ruthless impression management narcissists

self-centered impulsive narcissists

Type I - Turkat life is about creating an impression

hard to maintain close relationships

desires close relationships

best prognosis

Type II - Turkat

ruthless impression management

skilled at manipulating others’ impressions of him or her

not interested in close relationships

Type III - Turkat

self-centered impulsive type

key difficulty here is the impulsivity of their actions

a great deal of overlap with ANT

Assessment

Assessment

Broad measures MCMI-III PDQ-R SNAP OMNI PIQ

Assessment

Specific Narcissistic PD scale

Ashby et al. 1979 *Narcissistic Personality Inventory

Raskin & Hall, 1979 MMPI based Inventories

Diagnostic Interview for Narcissism

Gunderson and Ronningham Semistructured interview Assesses 33 narcissism areas

Grandiosity – fantasies Interpersonal Relations – attention seeking Reactive – sensitive Mood States – boredom, hallow Moral Adaptation – superficial, corruptible

DIN - Gunderson et al.

Key features Boastful, pretentious Self-centered, self-referential Belief that others envy them

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0 11 SDFPAR

AVD

HIS

DEPSZD

ANT

NAR

Assured-Dominance

Unassured-Submissive

Warm-Agreeable

Cold-Hearted

Gregarious-Extraverted

Unassuming-Ingenuous

Aloof-Introverted

Arrogant-Calculating

unprincipled amorous

elitist

compensated

N E O A C

SZD L

AVD H L

DEP H

HST H

NAR H h l

ANT L L

COM h

SZT H L l

BDL H l l

PAR h L

See commentary below slide to understand letters and numbers

Therapy

NAR – Reasons for Therapy

Turkat troubled by depression they want something

Therapy

Rapport Strategies Need for clients to be dominant Don’t criticize

Therapy

Cognitive Therapy Schema issues “I am the only one who is special” Beliefs need to be challenged

Therapy

Need to learn to empathize To become Rogerian Therapists

Self-sacrifice exercises Anonymous giving Charity work

Therapy Judeo-Christian Bible has many

references to “pride”

Difference between: Internal pride Comparison pride

“pride comes before a fall”