Narcissistic Personality Disorder Research Paper
Narcissistic personality disorder
Last reviewed: November 14, 2010.
Narcissistic personality disorder is a condition in which people have an inflated sense of self-importance and an extreme preoccupation with themselves.
Causes, incidence, and risk factors
The causes of this disorder are unknown. An overly sensitive personality and parenting problems may affect the development of this disorder.
Symptoms
A person with narcissistic personality disorder may: * React to criticism with rage, shame, or humiliation * Take advantage of other people to achieve his or her own goals * Have excessive feelings of self-importance * Exaggerate achievements and talents * Be preoccupied with fantasies of success, power, beauty, intelligence, …show more content…
or ideal love * Have unreasonable expectations of favorable treatment * Need constant attention and admiration * Disregard the feelings of others, and have little ability to feel empathy * Have obsessive self-interest * Pursue mainly selfish goals
Signs and tests
Like other personality disorders, narcissistic personality disorder is diagnosed based on a psychological evaluation and the history and severity of the symptoms.
Treatment
Psychotherapy (for example, talk therapy) may help the affected person relate to other people in a more positive and compassionate way.
Expectations (prognosis)
The outcome depends on the severity of the disorder.
Complications
* Alcohol or other drug dependence * Relationship, work, and family problems
References
1. Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA. Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Clinical Psychiatry. 1st ed. Philadellphia, Pa: Mosby Elsevier;2008:chap 39
DSM-IV-TR 301.81
The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines narcissistic personality disorder (in Axis II Cluster B) as:[1]
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal …show more content…
love 3. 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) 4. Requires excessive admiration 5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations 6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 8. Is often envious of others or believes others are envious of him or her 9. Shows arrogant, haughty behaviors or attitudes
It is also a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Etiology
The etiology of this disorder is unknown.
Researchers have identified childhood developmental factors and parenting behaviors that may contribute to the disorder: * An oversensitive temperament at birth * Overindulgence and overvaluation by parents * Valued by parents as a means to regulate their own self-esteem * Excessive admiration that is never balanced with realistic feedback * Unpredictable or unreliable caregiving from parents * Severe emotional abuse in childhood * Being praised for perceived exceptional looks or talents by adults * Learning manipulative behaviors from parents
Phenomenology and Diagnosis
The challenge of understanding and treating narcissistic personality disorder has been compounded by the multiple, wide-ranging, and often ambiguous meanings of the terms narcissism and narcissistic pathology. As Cooper (1984) has written, "The fuzziness of the term reflects the complexity of the concepts, while the persistence of the term reflects their central importance" (p. 39). At the same time, he continues, "[W]e remain with more ambiguity than is desirable or useful" (p. 43).
The history of the concept of narcissism has been reviewed elsewhere(Cooper 1986; Pulver 1970). Recent literature recognizes that narcissism is a healthy, normal, and necessary component of psychological development and psychic life, thereby avoiding the pejorative connotation that the term narcissistic has often assumed (Stone 1997). Narcissistic traits, moreover, appear in all forms of character pathology. A constellation of certain pathological traits that dominate the life history and the transference relationship distinguishes narcissistic personality disorder from other forms of personality disturbance.
Narcissistic pathology assumes a wide range of clinical and functional forms. Clinically, these forms range from the arrogant, boastful individual who steals the spotlight to the shy, easily slighted person who avoids center stage (Akhtar 1989; Cooper 1982, 1997; Gabbard 1989). Functionally, they may range from the prominent businessperson and political leader to the malignant narcissist and premeditating murderer (Kernberg 1989; Stone 1989).
Three overlapping systems have evolved for diagnosing narcissistic personality disorder, differentiating it from other character pathology, and capturing the diversity of its clinical presentation.
Narcissistic personality disorder can be diagnosed 1) according to DSM criteria; 2) according to a pattern of intrapsychic affects, defenses, and object relationships; and 3) according to the forms of transference that develop in therapy. Clearly, the linear model of first formulating a diagnosis and then planning and implementing a treatment cannot always be followed with patients with narcissistic personality disorder because the diagnosis may become apparent only after a period of psychotherapy or an extended
evaluation.
Clinical Manifestations
History and Mental Status Examination
People with narcissistic personality disorder demonstrate an apparently paradoxical combination of self-centeredness and worthlessness. Their sense of self-importance is generally extravagant, and they demand attention and admiration. Concern or empathy for others is typically absent. They often appear arrogant, exploitative, and entitled. However, despite their inflated sense of self. below their brittle facade lies low self-esteem and intense envy of those whom they regard as more desirable, worthy, or able.
Narcissistic Personality Disorder Treatment
The diagnosis of narcissistic personality disorder does not in and of itself imply a given treatment. Because the range of narcissistic character pathology is broad, the reasons for seeking treatment multiple, and the capacities and circumstances of the patients varied, treatment must be tailored to each individual case. Motivation, insight, and life circumstances need to be taken into account in formulating a realistic treatment plan and treatment goals. Narcissistic personality disorder presents in a full range of severity, from episodically troublesome dysphoria to crippling existential emptiness and lack of meaningful relationships and goals, and treatment is prescribed accordingly.
No controlled comparative treatment studies for narcissistic personality disorder have been conducted, and treatment recommendations therefore are based on clinical experience. Although some form of individual psychotherapy is generally recommended, couples, family, and group therapy are useful modalities in certain cases.
Pharmacotherapy is indicated for treatment of comorbid Axis I conditions such as dysthymia, other affective disorders, or anxiety disorders, but no known pharmacological treatment is effective for the character disorder itself. Similarly, hospitalization of patients with narcissistic personality disorder may be of use in the treatment of comorbid Axis I disorders but is not known to have any direct benefit in the treatment of the personality disorder.
Individual Therapies
The capacities and motivations of the patient are important considerations in choosing and recommending a form of individual therapy. The patient’s general ego strength (as measured by the quality of personal relationships, historical capacity for love and feelings of guilt, anxiety tolerance and impulse control, and potential for sublimatory commitment in an area of life such as work or a passionate hobby) is an important guide to the choice of treatment. Kernberg highlighted the “quality of internalized object relations,” meaning “the depth of the patient’s internal relationships with others, rather than the extent to which he [or she] is involved in social interactions” as perhaps the most critical indicator for type of treatment.
Psychoanalysis or exploratory psychotherapy at least twice a week may be indicated for narcissistic patients who have adequate ego strength and object relations but significant life impairments. For narcissistic patients with overt borderline or antisocial features, psychoanalysis or intensive exploratory psychotherapy must be approached with caution. A supportive-expressive psychotherapy with clear limit setting and less potential for regression is probably preferable in treating such narcissistic patients. Recently, treatments that combine the directive aspects of cognitive-behavioral therapy with interpretive, transference-based psychodynamic techniques have been formally studied and proposed as an additional model in the range of approaches to narcissistic personality disorder. In clinical practice, such eclectic approaches are often used, and we believe that such treatments are likely in the future to take their place alongside psychoanalytically derived psychotherapies.
BriefTherapy
Patients with narcissistic personality disorder who are troubled by limited neurotic symptoms and maintain apparent satisfactory adaptation in other areas of their lives are unlikely to be sufficiently motivated to tolerate the demands of psychoanalysis or psychoanalytic psychotherapy. Short-term psychotherapy is probably the best treatment in such cases. The goal of such treatment is generally to improve adaptation rather than to alter character. These patients, who are generally young and whose narcissism is often well compensated by their life circumstances, may return for treatment later in life as their narcissistic pathology makes further inroads into their interpersonal relationships, their professional endeavors, or their general sense of pleasure. At these later times, they may be capable of greater insight into their need for more intensive psychotherapy.
Oldham, for example, described a 24-session, once-weekly psychotherapy for a 50-year-old surgeon who came to treatment under threat of divorce from his wife and in the setting of his daughter’s hospitalization for depression. The patient’s chronic rage attacks, periods of dysphoria, and tyrannical style at work and in the home came to the boiling point under the stress of his daughter’s illness and were threatening to destroy the family.
Oldham diagnosed narcissistic personality disorder based on DSM criteria, along with an adjustment disorder with mixed emotional features. His treatment choice and strategy of a time-limited psychotherapy were based on “a dynamically informed directive approach”. Recognizing that narcissistic character structure is “especially ego-syntonic, and unlikely to be altered in brief treatment”, he also understood that midlife deterioration represented a window of opportunity for insight and change on the part of the patient. He therefore set the treatment goal as increased insight and modification of destructive behavior patterns. He approached the patient empathically, acknowledging that the patient’s “survivor mentality” grew out of the circumstances of his upbringing. At the same time, he did not endorse the patient’s view of his problems as stemming from a lack of appreciation and mistreatment by others. Instead, he consistently pointed out the patient’s role in generating and perpetuating his life problems and defined the patient’s task to be “refraining from acting on impulse, and deliberately trying to see things from the point of view of the other person”. These behavioral efforts were gradually reinforced by the family’s more positive responses to the patient. The treatment ended with the patient asking to be able to return at a future date to touch base with the therapist. Highlighting the masochistic side of the narcissistic coin, Oldham concluded that “the narcissistic patient whose pathology leads to dismantling his own success may be highly receptive to treatment at such a critical point.”
Psychoanalysis and Psychoanalytic Psychotherapy
When character change is the goal and ego strength is adequate, psychoanalysis or intensive psychoanalytic psychotherapy is indicated. There are two dominant paradigms for the psychoanalytic treatment of narcissistic personality disorder. One is associated with self psychology and the work of Kohut; the other is associated with the ego psychology-object relations theory and the approach of Kernberg.
Where Kohut sees structural deficits in the self, Kernberg discovers pathological defensive organization; where Kohut finds hidden elements of positive transference, Kernberg perceives latent negative transference; and where Kohut advises the unimpeded efflorescence and empathic encouragement of narcissistic idealization, Kernberg insists on its early interpretation. If for Kohut and his students it is above all the narcissist’s overwhelming and hidden shame that must be recognized and understood, for Kernberg envy lies like a minotaur at the heart of the narcissistic labyrinth and must be gotten at in therapy (Table 85-2).
Although for heuristic purposes it is useful to contrast sharply these two perspectives on pathological narcissism and its treatment, it is important to recognize that at times they also complement each other. Taken together, they create a dual perspective on narcissistic personality disorder and furnish the therapist with a complex and comprehensive way of listening to, understanding, and treating these patients. Moreover, they offer the therapist treatment options that can be used and assessed for appropriateness and therapeutic effect with each narcissistic personality disorder patient. We urge a flexible and individualized approach to each patient with narcissistic personality disorder, in which the therapist uses conceptualizations and recommendations from both Kohut and Kernberg, to the extent that they fit the therapist’s overall theoretical biases and personality traits. One cannot treat narcissistic personality disorder without the conviction concerning one’s therapeutic activity and without the therapist’s inner sense of honesty, of being true to himself or herself as a therapist. Without this, the therapist will collude with the patient’s “false self” and will engage in a sham treatment that can only be ineffective.
Medication
As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms. There are anecdotal reports in the medical literature that the selective serotonin reuptake inhibitors, or SSRIs, which are frequently prescribed for depression, reinforce narcissistic grandiosity and lack of empathy with others.
Hospitalization
Low-functioning patients with NPD may require inpatient treatment, particularly those with severe self-harming behaviors or lack of impulse control. Hospital treatment, however, appears to be most helpful when it is focused on the immediate crisis and its symptoms rather than the patient's underlying long-term difficulties.
Prognosis
The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older within a youth-oriented culture and lose their looks and overall vitality. The retirement years are especially painful for patients with NPD because they must yield their positions in the working world to the next generation. In addition, they do not have the network of intimate family ties and friendships that sustain most older people.
Prevention
The best hope for prevention of NPD lies with parents and other caregivers who are close to children during the early preschool years. Parents must be able to demonstrate empathy in their interactions with the child and with each other. They must also be able to show that they love their children for who they are, not for their appearance or their achievements. And they must focus their parenting efforts on meeting the child's changing needs as he or she matures, rather than demanding that the child meet their needs for status, comfort, or convenience.
Causes of Narcissistic Personality Disorder
Narcissistic personality disorder has no known cause. Personal upbringing may be a factor, such as excessive pampering, harsh discipline or neglect.
Background
A personality disorder, as defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV-TR), is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances. Ten personality disorders, grouped into 3 clusters (ie, A, B, C), are defined in the DSM-IV-TR.1
Case study
Ms. A is a 28-year-old woman with a history of mood instability dating back to adolescence. She varies from depressed to irritable to cheerful rapidly, several times each day. Usually, her mood shifts are related to perceived affection, rejection, praise, or criticism from others. She has attempted suicide at least 5 times, though none of the attempts have been lethal.
Ms. A is the product of a broken home. Her father was verbally and physically abusive; he left when the patient was aged 9 years. Her mother is addicted to alcohol and cocaine and has always been unreliable. The patient has had intense relationships with a number of men, none of which has lasted more than 6 months. She has experimented with homosexual relationships, and “cannot decide if I am bisexual.”
She has taken antidepressants from several different chemical classes. Usually there has been moderate initial relief, inevitably followed by return of her depression. She has found benzodiazepines to be more helpful. She has been hospitalized twice for her suicide attempts. She has tried psychotherapy several times but has always terminated prematurely when she perceived her therapist to be unhelpful.
Pathophysiology
The origin of personality disorders is a matter of considerable controversy. Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early environments that prevent the evolution of adaptive patterns of perception, response, and defense. A body of data points toward genetic and psychobiologic contributions to the symptomology of these disorders; however, the inconsistency of the data prevents authorities from drawing definite conclusions.
Last reviewed: November 14, 2010.
Narcissistic personality disorder is a condition in which people have an inflated sense of self-importance and an extreme preoccupation with themselves.
Causes, incidence, and risk factors
The causes of this disorder are unknown. An overly sensitive personality and parenting problems may affect the development of this disorder.
Symptoms
A person with narcissistic personality disorder may: * React to criticism with rage, shame, or humiliation * Take advantage of other people to achieve his or her own goals * Have excessive feelings of self-importance * Exaggerate achievements and talents * Be preoccupied with fantasies of success, power, beauty, intelligence, …show more content…
or ideal love * Have unreasonable expectations of favorable treatment * Need constant attention and admiration * Disregard the feelings of others, and have little ability to feel empathy * Have obsessive self-interest * Pursue mainly selfish goals
Signs and tests
Like other personality disorders, narcissistic personality disorder is diagnosed based on a psychological evaluation and the history and severity of the symptoms.
Treatment
Psychotherapy (for example, talk therapy) may help the affected person relate to other people in a more positive and compassionate way.
Expectations (prognosis)
The outcome depends on the severity of the disorder.
Complications
* Alcohol or other drug dependence * Relationship, work, and family problems
References
1. Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA. Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Clinical Psychiatry. 1st ed. Philadellphia, Pa: Mosby Elsevier;2008:chap 39
DSM-IV-TR 301.81
The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines narcissistic personality disorder (in Axis II Cluster B) as:[1]
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal …show more content…
love 3. 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) 4. Requires excessive admiration 5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations 6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 8. Is often envious of others or believes others are envious of him or her 9. Shows arrogant, haughty behaviors or attitudes
It is also a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Etiology
The etiology of this disorder is unknown.
Researchers have identified childhood developmental factors and parenting behaviors that may contribute to the disorder: * An oversensitive temperament at birth * Overindulgence and overvaluation by parents * Valued by parents as a means to regulate their own self-esteem * Excessive admiration that is never balanced with realistic feedback * Unpredictable or unreliable caregiving from parents * Severe emotional abuse in childhood * Being praised for perceived exceptional looks or talents by adults * Learning manipulative behaviors from parents
Phenomenology and Diagnosis
The challenge of understanding and treating narcissistic personality disorder has been compounded by the multiple, wide-ranging, and often ambiguous meanings of the terms narcissism and narcissistic pathology. As Cooper (1984) has written, "The fuzziness of the term reflects the complexity of the concepts, while the persistence of the term reflects their central importance" (p. 39). At the same time, he continues, "[W]e remain with more ambiguity than is desirable or useful" (p. 43).
The history of the concept of narcissism has been reviewed elsewhere(Cooper 1986; Pulver 1970). Recent literature recognizes that narcissism is a healthy, normal, and necessary component of psychological development and psychic life, thereby avoiding the pejorative connotation that the term narcissistic has often assumed (Stone 1997). Narcissistic traits, moreover, appear in all forms of character pathology. A constellation of certain pathological traits that dominate the life history and the transference relationship distinguishes narcissistic personality disorder from other forms of personality disturbance.
Narcissistic pathology assumes a wide range of clinical and functional forms. Clinically, these forms range from the arrogant, boastful individual who steals the spotlight to the shy, easily slighted person who avoids center stage (Akhtar 1989; Cooper 1982, 1997; Gabbard 1989). Functionally, they may range from the prominent businessperson and political leader to the malignant narcissist and premeditating murderer (Kernberg 1989; Stone 1989).
Three overlapping systems have evolved for diagnosing narcissistic personality disorder, differentiating it from other character pathology, and capturing the diversity of its clinical presentation.
Narcissistic personality disorder can be diagnosed 1) according to DSM criteria; 2) according to a pattern of intrapsychic affects, defenses, and object relationships; and 3) according to the forms of transference that develop in therapy. Clearly, the linear model of first formulating a diagnosis and then planning and implementing a treatment cannot always be followed with patients with narcissistic personality disorder because the diagnosis may become apparent only after a period of psychotherapy or an extended
evaluation.
Clinical Manifestations
History and Mental Status Examination
People with narcissistic personality disorder demonstrate an apparently paradoxical combination of self-centeredness and worthlessness. Their sense of self-importance is generally extravagant, and they demand attention and admiration. Concern or empathy for others is typically absent. They often appear arrogant, exploitative, and entitled. However, despite their inflated sense of self. below their brittle facade lies low self-esteem and intense envy of those whom they regard as more desirable, worthy, or able.
Narcissistic Personality Disorder Treatment
The diagnosis of narcissistic personality disorder does not in and of itself imply a given treatment. Because the range of narcissistic character pathology is broad, the reasons for seeking treatment multiple, and the capacities and circumstances of the patients varied, treatment must be tailored to each individual case. Motivation, insight, and life circumstances need to be taken into account in formulating a realistic treatment plan and treatment goals. Narcissistic personality disorder presents in a full range of severity, from episodically troublesome dysphoria to crippling existential emptiness and lack of meaningful relationships and goals, and treatment is prescribed accordingly.
No controlled comparative treatment studies for narcissistic personality disorder have been conducted, and treatment recommendations therefore are based on clinical experience. Although some form of individual psychotherapy is generally recommended, couples, family, and group therapy are useful modalities in certain cases.
Pharmacotherapy is indicated for treatment of comorbid Axis I conditions such as dysthymia, other affective disorders, or anxiety disorders, but no known pharmacological treatment is effective for the character disorder itself. Similarly, hospitalization of patients with narcissistic personality disorder may be of use in the treatment of comorbid Axis I disorders but is not known to have any direct benefit in the treatment of the personality disorder.
Individual Therapies
The capacities and motivations of the patient are important considerations in choosing and recommending a form of individual therapy. The patient’s general ego strength (as measured by the quality of personal relationships, historical capacity for love and feelings of guilt, anxiety tolerance and impulse control, and potential for sublimatory commitment in an area of life such as work or a passionate hobby) is an important guide to the choice of treatment. Kernberg highlighted the “quality of internalized object relations,” meaning “the depth of the patient’s internal relationships with others, rather than the extent to which he [or she] is involved in social interactions” as perhaps the most critical indicator for type of treatment.
Psychoanalysis or exploratory psychotherapy at least twice a week may be indicated for narcissistic patients who have adequate ego strength and object relations but significant life impairments. For narcissistic patients with overt borderline or antisocial features, psychoanalysis or intensive exploratory psychotherapy must be approached with caution. A supportive-expressive psychotherapy with clear limit setting and less potential for regression is probably preferable in treating such narcissistic patients. Recently, treatments that combine the directive aspects of cognitive-behavioral therapy with interpretive, transference-based psychodynamic techniques have been formally studied and proposed as an additional model in the range of approaches to narcissistic personality disorder. In clinical practice, such eclectic approaches are often used, and we believe that such treatments are likely in the future to take their place alongside psychoanalytically derived psychotherapies.
BriefTherapy
Patients with narcissistic personality disorder who are troubled by limited neurotic symptoms and maintain apparent satisfactory adaptation in other areas of their lives are unlikely to be sufficiently motivated to tolerate the demands of psychoanalysis or psychoanalytic psychotherapy. Short-term psychotherapy is probably the best treatment in such cases. The goal of such treatment is generally to improve adaptation rather than to alter character. These patients, who are generally young and whose narcissism is often well compensated by their life circumstances, may return for treatment later in life as their narcissistic pathology makes further inroads into their interpersonal relationships, their professional endeavors, or their general sense of pleasure. At these later times, they may be capable of greater insight into their need for more intensive psychotherapy.
Oldham, for example, described a 24-session, once-weekly psychotherapy for a 50-year-old surgeon who came to treatment under threat of divorce from his wife and in the setting of his daughter’s hospitalization for depression. The patient’s chronic rage attacks, periods of dysphoria, and tyrannical style at work and in the home came to the boiling point under the stress of his daughter’s illness and were threatening to destroy the family.
Oldham diagnosed narcissistic personality disorder based on DSM criteria, along with an adjustment disorder with mixed emotional features. His treatment choice and strategy of a time-limited psychotherapy were based on “a dynamically informed directive approach”. Recognizing that narcissistic character structure is “especially ego-syntonic, and unlikely to be altered in brief treatment”, he also understood that midlife deterioration represented a window of opportunity for insight and change on the part of the patient. He therefore set the treatment goal as increased insight and modification of destructive behavior patterns. He approached the patient empathically, acknowledging that the patient’s “survivor mentality” grew out of the circumstances of his upbringing. At the same time, he did not endorse the patient’s view of his problems as stemming from a lack of appreciation and mistreatment by others. Instead, he consistently pointed out the patient’s role in generating and perpetuating his life problems and defined the patient’s task to be “refraining from acting on impulse, and deliberately trying to see things from the point of view of the other person”. These behavioral efforts were gradually reinforced by the family’s more positive responses to the patient. The treatment ended with the patient asking to be able to return at a future date to touch base with the therapist. Highlighting the masochistic side of the narcissistic coin, Oldham concluded that “the narcissistic patient whose pathology leads to dismantling his own success may be highly receptive to treatment at such a critical point.”
Psychoanalysis and Psychoanalytic Psychotherapy
When character change is the goal and ego strength is adequate, psychoanalysis or intensive psychoanalytic psychotherapy is indicated. There are two dominant paradigms for the psychoanalytic treatment of narcissistic personality disorder. One is associated with self psychology and the work of Kohut; the other is associated with the ego psychology-object relations theory and the approach of Kernberg.
Where Kohut sees structural deficits in the self, Kernberg discovers pathological defensive organization; where Kohut finds hidden elements of positive transference, Kernberg perceives latent negative transference; and where Kohut advises the unimpeded efflorescence and empathic encouragement of narcissistic idealization, Kernberg insists on its early interpretation. If for Kohut and his students it is above all the narcissist’s overwhelming and hidden shame that must be recognized and understood, for Kernberg envy lies like a minotaur at the heart of the narcissistic labyrinth and must be gotten at in therapy (Table 85-2).
Although for heuristic purposes it is useful to contrast sharply these two perspectives on pathological narcissism and its treatment, it is important to recognize that at times they also complement each other. Taken together, they create a dual perspective on narcissistic personality disorder and furnish the therapist with a complex and comprehensive way of listening to, understanding, and treating these patients. Moreover, they offer the therapist treatment options that can be used and assessed for appropriateness and therapeutic effect with each narcissistic personality disorder patient. We urge a flexible and individualized approach to each patient with narcissistic personality disorder, in which the therapist uses conceptualizations and recommendations from both Kohut and Kernberg, to the extent that they fit the therapist’s overall theoretical biases and personality traits. One cannot treat narcissistic personality disorder without the conviction concerning one’s therapeutic activity and without the therapist’s inner sense of honesty, of being true to himself or herself as a therapist. Without this, the therapist will collude with the patient’s “false self” and will engage in a sham treatment that can only be ineffective.
Medication
As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms. There are anecdotal reports in the medical literature that the selective serotonin reuptake inhibitors, or SSRIs, which are frequently prescribed for depression, reinforce narcissistic grandiosity and lack of empathy with others.
Hospitalization
Low-functioning patients with NPD may require inpatient treatment, particularly those with severe self-harming behaviors or lack of impulse control. Hospital treatment, however, appears to be most helpful when it is focused on the immediate crisis and its symptoms rather than the patient's underlying long-term difficulties.
Prognosis
The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older within a youth-oriented culture and lose their looks and overall vitality. The retirement years are especially painful for patients with NPD because they must yield their positions in the working world to the next generation. In addition, they do not have the network of intimate family ties and friendships that sustain most older people.
Prevention
The best hope for prevention of NPD lies with parents and other caregivers who are close to children during the early preschool years. Parents must be able to demonstrate empathy in their interactions with the child and with each other. They must also be able to show that they love their children for who they are, not for their appearance or their achievements. And they must focus their parenting efforts on meeting the child's changing needs as he or she matures, rather than demanding that the child meet their needs for status, comfort, or convenience.
Causes of Narcissistic Personality Disorder
Narcissistic personality disorder has no known cause. Personal upbringing may be a factor, such as excessive pampering, harsh discipline or neglect.
Background
A personality disorder, as defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, Text Revision (DSM-IV-TR), is an enduring pattern of inner experience and behavior that differs markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances. Ten personality disorders, grouped into 3 clusters (ie, A, B, C), are defined in the DSM-IV-TR.1
Case study
Ms. A is a 28-year-old woman with a history of mood instability dating back to adolescence. She varies from depressed to irritable to cheerful rapidly, several times each day. Usually, her mood shifts are related to perceived affection, rejection, praise, or criticism from others. She has attempted suicide at least 5 times, though none of the attempts have been lethal.
Ms. A is the product of a broken home. Her father was verbally and physically abusive; he left when the patient was aged 9 years. Her mother is addicted to alcohol and cocaine and has always been unreliable. The patient has had intense relationships with a number of men, none of which has lasted more than 6 months. She has experimented with homosexual relationships, and “cannot decide if I am bisexual.”
She has taken antidepressants from several different chemical classes. Usually there has been moderate initial relief, inevitably followed by return of her depression. She has found benzodiazepines to be more helpful. She has been hospitalized twice for her suicide attempts. She has tried psychotherapy several times but has always terminated prematurely when she perceived her therapist to be unhelpful.
Pathophysiology
The origin of personality disorders is a matter of considerable controversy. Traditional thinking holds that these maladaptive patterns are the result of dysfunctional early environments that prevent the evolution of adaptive patterns of perception, response, and defense. A body of data points toward genetic and psychobiologic contributions to the symptomology of these disorders; however, the inconsistency of the data prevents authorities from drawing definite conclusions.