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Block 5 Unit 2 Narcissistic Personality Disorder

1. Prepare a clinical picture of narcissistic personality disorder.

A clinical picture of narcissistic personality disorder involves an individual displaying an exaggerated sense of self-importance, a deep need for admiration, and a lack of empathy. These individuals may have a grandiose view of their own abilities and accomplishments and expect to be recognised as superior without commensurate achievements. They often fantasize about unlimited success, power, brilliance, beauty, or ideal love and see themselves as special and unique, believing they can only be understood by other high-status people. They demand excessive praise and admiration, have a sense of entitlement, exploit others for their own gain, and lack the ability to recognise or identify with the feelings of others. They may also exhibit arrogance and envy when confronted with other successful people. These behaviours are consistent and cause significant problems in their personal and professional life. It is important to note that these behaviours often conceal a deep sense of insecurity and fragile self-esteem.

2. How does narcissistic personality disorder differ from borderline personality disorder?

While both narcissistic and borderline personality disorders fall under Cluster B (dramatic, emotional, or erratic disorders), they differ significantly in their presentation and underlying mechanisms. Key differences include:

• Self-image: Individuals with narcissistic personality disorder have a grandiose sense of self-importance, whereas those with borderline personality disorder have an unstable self-image.
• Need for attention: Narcissistic individuals seek admiration and praise, while those with borderline personality disorder have unstable relationships and extreme emotionality.
• Empathy: Narcissistic individuals lack empathy for others, whereas those with borderline personality disorder may have difficulties with empathy but also struggle with their own intense emotional experiences.
• Relationships: Narcissistic individuals often exploit relationships, whereas borderline individuals have intensely unstable relationships, and are prone to alternating idealization and devaluation of others.
• Emotional Instability: While both can have emotional instability, it is more of a central feature of Borderline Personality Disorder than Narcissistic Personality Disorder. Those with Borderline Personality disorder are highly reactive to mood shifts and feelings of abandonment, whereas those with Narcissistic Personality disorder may display irritability or rage if they do not receive the praise or attention they desire, but not with the same reactivity as those with BPD.

3. Discuss the diagnostic features of narcissistic personality disorder.

The diagnostic features of narcissistic personality disorder, as specified in DSM-IV-TR, include:

• Grandiose sense of self-importance: Exaggerating achievements and expecting to be recognised as superior without commensurate achievements.
• Fantasies of unlimited success: Preoccupation with fantasies of power, brilliance, beauty, or perfect love.
• Belief of being "special": Considering themselves unique and only understood by other high-status individuals.
• Need for admiration: Requiring excessive amounts of praise and attention from others.
• Sense of entitlement: Expecting preferential treatment and automatic compliance from others.
• Exploitative behaviour: Taking advantage of others to achieve their goals.
• Lack of empathy: Inability to recognise or identify with the feelings and needs of others.
• Envy of others: Feeling envious of others or believing others are envious of them.
• Arrogant behaviour: Exhibiting haughty or arrogant behaviours and attitudes.

To meet the diagnostic criteria, an individual must exhibit at least five of these features.

4. Discuss the causes of narcissistic personality disorder.

The causes of narcissistic personality disorder are complex and not fully understood. Several theories attempt to explain its development:

• Psychoanalytic Theories:
  • Freud's Libido Theory: Freud proposed that narcissism results from the libido being directed back to the ego rather than toward others, which may result in a lack of interest in the external world and delusions of grandeur.
  • Kohut's Self-Psychology: Kohut suggests that narcissism arises from a lack of adequate parental mirroring and idealisation, leading to a fragile sense of self.
  • Kernberg's Object Relations Theory: Kernberg views narcissism as a defense mechanism against cold and unempathetic parenting, usually from the mother.

• Childhood Experiences: Some theories link narcissistic personality disorder to specific child-rearing practices such as extremes in parenting.
• Bio-psychosocial Model: This model proposes that genetic predispositions, early childhood experiences, and individual personality factors can all contribute to the development of this disorder.
• Empty or Hungry Sense of Self: Some theorists believe the narcissistic individual has an 'empty' or 'hungry' sense of self while others suggest they have a disorganised sense of self.
• Inability to Test Reality: Some theorize that the individual with NPD struggles to test reality and accurately understand themselves.

5. Explain the treatment and prognosis of narcissistic personality disorder.

• Treatment: The main treatment approach for narcissistic personality disorder is psychotherapy. There are no medications specifically for the disorder but medications such as antidepressants or anti-anxiety medications may be used to manage co-occurring symptoms such as depression or anxiety.

  • Psychotherapy: This aims to help the individual develop a more realistic self-esteem and relate to others more positively. Different approaches include psychoanalysis, Adlerian therapy, rational emotive therapy and Gestalt therapy. The consensus is that therapists should set modest goals for treatment with patients as they can struggle to form a deep bond with a therapist.
  • Group therapy: This approach may reduce the intensity of emotional experiences and allow for better confrontation and clarification.
  • Family therapy: This approach might be beneficial in some cases.
  • Long-term treatment: Since personality traits are difficult to change, therapy may be a long-term process, lasting several years.

• Prognosis: The prognosis for narcissistic personality disorder is mixed:

  • Short term: The short term goals of therapy are to deal with related problems such as substance abuse, depression or low self esteem.
  • Long term: The long-term goal is to reshape the patient's personality to some degree so the patient can change distorted thinking and create a more realistic self image.
  • Younger persons: For younger individuals, the prognosis is more hopeful if the disturbances are due to a lack of life experience.
  • Long-standing NPD: Long-standing cases of the disorder have a more negative outlook.
  • Midlife acceptance: Some narcissists may accept their limitations, resolve issues of envy and accept their mortality as they approach midlife.
  • Retirement difficulties: Retirement can be especially challenging due to the loss of their work positions and a lack of a close support system.

In summary, narcissistic personality disorder is characterised by a grandiose sense of self, a need for admiration, and a lack of empathy. Treatment is often challenging, and while some individuals may improve with therapy, others may not.