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Narcissistic personality disorder. Narcissism refers to self-love, and loving self regard is something that is both desirable and necessary in ones inner world. It is only when the absorption of the self impairs one’s ability to form lasting relationships do we call it pathological. And crippling self-doubt and insecurity that is involved in pathological narcissism is a far cry from what we would consider simple self-regard. People with narcissistic personality disorder have severe problems in maintaining a realistic sense of their own worth. And that’s thought to lie at the core of this disorder, and all symptoms seem to build upon that.
They will often then feel inadequate and helpless when they don’t meet those standards. They constantly crave love and attention and admiration from other people as a means of bolstering their unstable self-esteem. Their demands for love and praise can be insatiable. They are likely to fly into a rage when these demands are not met.
The narcissistic person struggles with a tenuous balance between the intensity to be admired by other people and the rage that he or she feels when people are disappointing and don’t provide the admiration that is needed. The narcissistic individual often starts out by idealizing other people only to come to devalue them when they reveal themselves to have feet of clay. Of course, this is something you have all experienced if you work with these people long-term. Narcissistic individuals, as you know, have great difficulty recognizing how other people feel. They feel entitled to special favors, to special treatment. They are more concerned about how they look to other people than with genuine feeling. And they tend to use other people to their own ends. The narcissistic person has a very fragile self-esteem, although that many narcissists present as haughty and totally self-assured.
The defenses that the narcissistic individual uses include; projection, and splitting into all good and all bad, and along with that, idealization.
The diagnostic criteria emphasizes ideas of having a grandiosity is fantasy or behavior, lack of empathy, and hypersensitivity to the evaluation of other people. Now one of the things that you’ll notice is that not all narcissistic individuals present as grandiose. Many of them present as quite self-loathing and self-critical. Often you will find the flip side of that when you dig deeper. But usually what you see are both sides of this coin. Overly inflated self-esteem and some unrealistic self-criticism and devaluation.
In terms of the etiology, there have been no genetic or environmental factors, so far, indicated. There is a lot of psychoanalytic theory that postulates that parents didn’t encourage or appreciate the child’s efforts at self-assertion, they didn’t help the child take realistic pride in accomplishments and also whether realistic disappointments. So that the child is left unable to judge him or herself and unable to maintain a realistic sense of self-esteem without constant evaluation from the outside. There is no good data on the prevalence of this disorder. The diagnosis is made much more frequently in men than in women. It’s more common in outpatient practices.
There is no good data on the course and prognosis of the disorder. It is found in all stages of adult life. Many of these individuals can be quite high-functioning so that while some individuals are crippled and cannot work, cannot maintain any relationships, others are extremely high-functioning. They can be presidents, CEO’s, department chairmen.
Differential diagnosis; four main possibilities. The first is histrionic personality disorder. Narcissists can also be seductive and self-dramatizing. But the histrionic individual is generally more playful and more warm, while the narcissistic person is more likely to be more haughty and removed, and obviously exploitive in dealing with others. Borderline personality disorder needs to be distinguished from narcissistic personality disorder. Borderline individuals have terrible problems maintaining self-esteem. But borderline individuals usually have poorer impulse control. They are more self-destructive. They function less well. And borderline individuals often appear to be quite emotionally needy while the whole signet of the narcissistic population appears to be self-sufficient. You also want to think about antisocial personality disorder. Antisocial individuals are more impulsive and more persistently disregarding of cultural norms. Narcissistic people either don’t recognize that they are violating social norms or they feel that they are deserving to be above society’s rules. Antisocial people typically just
Obsessive-compulsive personality disorder needs to be distinguished from narcissistic personality disorder because both narcissists and people who are obsessive-compulsive set very high standards for themselves. The narcissistic person often sets these standards to maintain an idealized self-image while the obsessive-compulsive person strives for perfection in order to maintain a sense of
Treatment of narcissistic personality disorder. Individual and group psychotherapies are the treatments of choice. Usually psychodynamic in orientation. Cohat sees narcissism as a developmental defect that results from inadequate parenting. So for Cohat the therapists job is to encourage people to reveal their untamed grandiose self, to really reveal all their grandiose fantasies and to allow an idealized view of the therapist because someone needs to have those views of self and the therapist for a long time, and then gradually weather the disappointments that come inevitably when
Kernberg, on the hand, sees this grandiose self-view and narcissistic idealization as defenses to protect against the narcissists underlying rage and envy and sense of inferiority. So for Kernberg what is important is to interpret this grandiosity, interpret the patient’s idealization of you as the treater early on instead of treating them as part of the normal developmental phase. What I find in my own practice is that certain patients response to one set of techniques and other patients respond to the
The treatment is fraught with difficulties because of this vacillation between idealizing others and devaluing others. And the bouts of rage that ensue when the therapist is seen as disappointing. So the aim of therapy is to provide a consistent, caring relationship and help people develop more realistic concepts of self. There have been no rules delineated for pharmacologic treatment, although it