Sunday, November 1, 2015

Narcissistic Personality Disorder--Diagnosis and Treatment

NOTE: This post has been edited since originally published. I've noticed that Narcissistic Personality Disorder is increasingly being used as an epithet in the media and by the general public. It is actually a serious disorder with a lack of effective treatment protocols, and it is on the increase.

The Diagnostic and Statistical Manual of Mental Disorders' checklist of NPD symptoms for diagnosis is the following. Only five symptoms need be present to diagnose the disorder:

1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love.
3. Believes that he or she is "special" and unique and can only understood by or should associate with, other special or high-status people or institutions.
4. Requires excessive admiration.
5. Has a sense of entitlement.
6. Is interpersonally exploitative.
7. Lacks empathy, is unwilling to recognize or identify with the needs of others.
8. If often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

Many people with NPD do not have the stereotypical presentation of being overtly arrogant or haughty.  I believe the DSM model has been based on treatment experiences with white American males. I work with a diverse population and I've noticed that some people, especially women from cultures in which deference and politeness are valued, can have NPD that is only revealed through an examination of their mental content, not their social behavior.

No one has ever come to my practice for treatment of their Narcissistic Personality Disorder. As I mentioned in my previous post, personality disorders are created by the use of pathological ego defenses that are unconscious. People with NPD are unaware that they have the disorder. Most people with NPD whom I've seen have come to therapy because of dissatisfaction with careers, depression, addictions, or problems managing anger. I will confess that I do not believe I have ever cured anyone's NPD, nor am I aware of any therapist who has done so. Most clinicians and theorists believe that NPD is barely treatable and probably not cureable. However, people with NPD can be helped to develop insight and better judgment, and their symptoms of depression and anxiety generally improve with therapy.

Psychoanalytic theorists became very interested in NPD between the 1970s and the 1990s, but the disorder has received little attention in recent years, in terms of treatment protocols. Yet some research has shown that NPD is on the increase, and it can be a dangerous disorder when it involves lack of empathy. It cannot be resolved with medication, and I believe there's a possibility anti-depressants may make it worse, because they increase self-esteem without increasing insight,  which could result in a spike in feelings of grandiosity. Perhaps research will eventually suggest mood stabilizers should be used to treat NPD, but these would not cure the underlying disorder.

Two main theorists have written about NPD: Otto Kernberg, who I mentioned in my previous post, and Heinz Kohut, another psychoanalyst. Kernberg describes a developmental process in which unempathic caregivers give a child the message he or she cannot emotionally depend on anyone. The child may be used for the parent(s)' own purposes, for example, as someone to show off.  This interferes with the normal development of the superego. In normal development, the superego includes a component called the ego ideal, which one might describe as the "carrot" whereas the punitive aspects of the superego are the "stick." In normal development, the ego ideal is a psychic structure based on internalizations of persons, systems or values that are admired and desired to be emulated. Without a healthy ego ideal, the child  develops "pathological grandiosity" in which he or she become his or her own ego ideal, in a sense worshiping him/herself. This self-worship in lieu of healthy internalizations often leads to a feeling of being hollow, because humans are social animals who depend not only on others in the external world, but also on our internalized representations of others.  Kohut developed a slightly different theory that holds that although the ego ideal is necessary for ambition, people with NPD are likely to suffer from a disordered sense of self that is due to a lack of "mirroring" in childhood. His branch of psychoanalytic theory is known as "Self Psychology" and clinicians who follow Kohut's theories tend to believe that therapy that validates a patient's accomplishments as well as emotions,  and tolerates a natural idealization of the therapist,  is curative.

I've worked with many patients with narcissistic traits, but probably only a few who have had full-blown NPD. What I have experienced in my treatment of persons with NPD and of people with the traits, is that they often improve a lot in the first six months of therapy. Their depression decreases, and  if they have had problems managing anger, that usually gets better. They often enjoy therapy. But I've also noticed that after a certain point, the therapy stalls. This can be from a number of reasons, including the difficulty in giving up grandiosity and sometimes, the patient's envy of the therapist, which leads him or her to subtly sabotage the therapy. Here are some examples of how therapy can be only partially effective for people with narcissistic problems:

1. A woman came to see me due to problems with depression and some other issues. She started feeling better and resolved some issues after about six months. But, she continued to complain of some symptoms including a feeling of being "hollow." She continued in therapy and I began to notice what seemed like a change: She came to her sessions directly from work, and I saw that sometimes she wore sexually provocative clothing that seemed inappropriate for the workplace. She began to describe herself and her friends using superlatives that most people do not use in ordinary descriptions. She began dating someone who was sociopathic and although she realized there might be something wrong with him, was adamantly convinced that they had a "special" relationship. She was chronically dissatisfied in her career and frequently changed jobs. I eventually realized, as did she, that therapy was beginning to stall. I had begun to feel that it didn't matter what I said and although the patient was continuing to attend therapy, it seemed we were no longer making progress. Eventually we mutually agreed to terminate her therapy. We had resolved her depression, but not her narcissistic traits. (Note: Although the patient had some symptoms that might suggest mania/bipolar disorder, she lacked the classic symptoms of high energy with little sleep, impulsive behavior that is out of character, and pressured speech. Some symptoms of NPD and bipolar disorder overlap).

2. A woman came to see me for career dissatisfaction among other concerns. Although some of her problems cleared up after awhile in therapy, she did not resolve her career dissatisfaction. We discussed various possibilities for modifying her career, but I began to notice that if I suggested an avenue to explore, she gave me a reason why she couldn't do it or wasn't interested in it. No type of work or activity really appeals to people with NPD unless it involves attention from others, or what could be called fame or glory. The normal reasons why people value their work, such as pride in achieving certain skills or helping others, are meaningless to the NPD. Sadly, many jobs and activities don't result in praise and attention, and the NPD is therefore chronically dissatisfied. This chronic dissatisfaction is why NPD is so often implicated in substance abuse and in chronic depression.

3. A man  came to see me because of career dissatisfaction and some interpersonal events. He had had a traumatic break-up and I hoped that he could find a happy relationship that would help him get over the traumatic break-up. But as he described his dating activities, it became quite evident that he had no empathy for the people he dated and was sometimes quite critical of how a person looked, (even though he was willing to have sex with them regardless of whether he found them attractive). It turned out he'd pursued his career because he thought it would give him a sense of importance, but the reality is that few jobs change the world or make one famous, just as few romantic partners are beautiful or dramatically exciting. I couldn't think of any realistic career path that would give this man what he craved, and he seemed to come to the realization eventually that he wasn't  interested in a committed romantic partner--at which point he left therapy.


There may be a treatment program that is effective for NPD, even though it wasn't, at least not overtly, designed to treat NPD at all. The 12-step program was designed to treat addictions, but as I have studied it over the years, it has struck me how much of it might actually be targeted toward the symptoms of NPD:  The 12-step program insists that its members "deal with life on life's terms," and "turn it over" to a "higher power." It has occurred to me that the "higher power," when internalized, could create a healthy ego ideal. The group norms of the 12-step program, such an anonymity, help to stifle grandiosity and instead provide emotional nurturance through group support. Slogans such as "Easy Does It" and "Live and Let Live" may help temper the rage, envy and other problems that plague people with NPD.  Although the 12-step program may not totally "cure" NPD it may control and ameliorate it.

The therapeutic dyad sometimes sets up a power struggle for the person with NPD by making him/her feel vulnerable. Kohut's idea that the therapist can be idealized and that this is curative I find to be somewhat ridiculous--adults don't idealize people the way children do, or if they do, they set themselves up for a quick disappointment. It's well known that people with NPD often idealize, then devalue others.  Only abstractions--such as a "Higher Power"--can be truly idealized and internalized in adulthood.