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 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.
2. 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 partnership--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.
Showing posts with label personality disorders. Show all posts
Showing posts with label personality disorders. Show all posts
Sunday, November 1, 2015
Wednesday, October 14, 2015
Diagnosing and Treating Borderline and Narcissistic Personality Disorders, Part One: Borderline Personality Disorder
Over the past 10 or 20 years there have been increased mentions of Borderline Personality Disorder and Narcissistic Personality Disorder in the media, including newspapers, self-help books and even feature films. These disorders are complex and manifest differently in different individuals. Many times clinicians can't diagnose, or won't diagnose, these
disorders in the first session or the first several sessions, especially
if the person is initially depressed.
How to diagnose personality disorders remains controversial in the mental health field. The Diagnostic and Statistical Manual of Mental Disorders, the main reference book for diagnosis, uses checklists of symptoms. Is a checklist of symptoms really the most accurate way to diagnose a disorder? A checklist does not describe causes or underlying psychological processes.
The current checklist for Borderline Personality Disorder in the DSM-V, is the following ( only 5 of these symptoms need be present to make the diagnosis). One can see that there might be significant overlap with other diagnoses, such as depression and PTSD:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
3. Identity disturbance: markely and persistenly unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentialy self-damaging.
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective (emotional) instability.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Starting in the 1970s, a psychoanalyst and researcher named Otto Kernberg began studying borderline personality disorder, a condition that had begun to be identified after the time of Sigmund Freud. Prior to the development of the term "borderline personality disorder," clinicians sometimes came across patients with what they called "ambulatory schizophrenia" or the "As If" personality. What they were trying to describe was a syndrome in which the person functioned mostly normally, and had no obvious evidence of psychosis, but under psychoanalysis or even just persistent questioning, revealed themselves to have highly distorted thought processes. Kernberg came up with a type of initial evaluation to diagnose this condition. He also developed a theory that remains controversial today. He believes that all personality disorders are subsets of borderline personality disorder, because the disorder isn't really a syndrome at all but a type of personality organization--"Borderline" refers to the border between neurosis and psychosis. "Normal" people have a neurotic level of organization (no one is completely mentally healthy), psychotic people have lost the ability to distinguish reality from fantasy, and borderlines, in the middle, remain in touch with physical reality but distort perceptions based on pathological psychological defenses. These distorted perceptions can lead to problems in interpersonal relationships and other issues. Other personality disorders, such as narcissistic personality disorder, function on the same level, but simply manifest differently due to slightly different personality development.
The subject of psychological defense mechanisms is complex. However, this explanation, taken from Wikipedia, is generally correct:
A defence mechanism...reduces anxiety arising from unacceptable or potentially harmful impulses. Defence mechanisms are unconscious and are not to be confused with conscious coping strategies "
... In psychoanalytic theory, defence mechanisms...are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses
....Healthy persons normally use different defences throughout life. An ego defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected.
Kernberg and others have found that people with borderline personality disorder often extensively use the defenses of idealization, devaluation (often combined in "splitting"), grandiosity, and types of projection. But use of these defenses often are not apparent to the casual observer, and, because defenses are unconscious, the borderline person remains unaware of their own use of these defenses.
Although I believe Kernberg's theories to be mostly correct and especially helpful in terms of formulating a prognosis, like many psychoanalytic theories, it doesn't really address the issue of later environmental factors (Kernberg believes that early environmental factors combined with genetics are at the root of personality disorders). Starting about 20 years ago, theorists began to notice that the typical symptoms of persons with borderline p.d. were quite similar to those of trauma survivors and suggested that some borderlines might actually have PTSD and had been misdiagnosed. But one could say that this is the very reason why Kernberg's perspective is important, because it emphasizes the underlying defenses rather than the overt symptoms.
Earlier this year I went to a talk by Dr. Michael Stone, the forensic psychiatrist, in which he suggested clinicians decide whether the borderlines with whom they were working had primarily a trauma-based condition or primarily a genetic condition. I've begun to believe that there are different types of borderline p.d. Perhaps eventually diagnostic manuals will reflect what clinicians have been seeing for many years.
How is borderline personality disorder treated? Some would answer, not well. The general consensus is that the disorder is resistant to change. However, there are a multitude of treatments that may help. Traditionally the disorder has been treated with intensive psychotherapy to address the pathological defenses. The underlying premise of this treatment is that human personality is malleable, is developed in an early dyadic relationship, and can be altered by the patient/therapist dyadic relationship even in later life. I believe this to be somewhat true. In the 1990s, a psychologist named Marsha Linehan developed a treatment protocol called Dialectical Behavior Therapy to help borderlines learn to cope with their emotions and interpersonal relations. DBT is now used to help people with other disorders as well. I occasionally use DBT techniques, as they help people learn assertiveness as well as distraction techniques, especially "mindfulness," to relieve overwhelming emotions. I have found people with anxiety disorders often benefit from DBT. The DBT program does not really alter the underlying personality structure, however.
I've treated a number of people with borderline personality disorder, and have found them to be quite different from each other. A childhood marked by invalidating remarks by parents is common, but not everyone subjected to such an environment will develop BPD. Psychotherapy that combines validation with confrontation of unhelpful defenses seems to be useful for my personality-disordered patients. In a few cases, I've seen patients with borderline personality disorder benefit from a mood stabilizing medication called Lamictal, which moderates their unstable emotions.
How to diagnose personality disorders remains controversial in the mental health field. The Diagnostic and Statistical Manual of Mental Disorders, the main reference book for diagnosis, uses checklists of symptoms. Is a checklist of symptoms really the most accurate way to diagnose a disorder? A checklist does not describe causes or underlying psychological processes.
The current checklist for Borderline Personality Disorder in the DSM-V, is the following ( only 5 of these symptoms need be present to make the diagnosis). One can see that there might be significant overlap with other diagnoses, such as depression and PTSD:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
3. Identity disturbance: markely and persistenly unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentialy self-damaging.
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective (emotional) instability.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Starting in the 1970s, a psychoanalyst and researcher named Otto Kernberg began studying borderline personality disorder, a condition that had begun to be identified after the time of Sigmund Freud. Prior to the development of the term "borderline personality disorder," clinicians sometimes came across patients with what they called "ambulatory schizophrenia" or the "As If" personality. What they were trying to describe was a syndrome in which the person functioned mostly normally, and had no obvious evidence of psychosis, but under psychoanalysis or even just persistent questioning, revealed themselves to have highly distorted thought processes. Kernberg came up with a type of initial evaluation to diagnose this condition. He also developed a theory that remains controversial today. He believes that all personality disorders are subsets of borderline personality disorder, because the disorder isn't really a syndrome at all but a type of personality organization--"Borderline" refers to the border between neurosis and psychosis. "Normal" people have a neurotic level of organization (no one is completely mentally healthy), psychotic people have lost the ability to distinguish reality from fantasy, and borderlines, in the middle, remain in touch with physical reality but distort perceptions based on pathological psychological defenses. These distorted perceptions can lead to problems in interpersonal relationships and other issues. Other personality disorders, such as narcissistic personality disorder, function on the same level, but simply manifest differently due to slightly different personality development.
The subject of psychological defense mechanisms is complex. However, this explanation, taken from Wikipedia, is generally correct:
A defence mechanism...reduces anxiety arising from unacceptable or potentially harmful impulses. Defence mechanisms are unconscious and are not to be confused with conscious coping strategies "
... In psychoanalytic theory, defence mechanisms...are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses
....Healthy persons normally use different defences throughout life. An ego defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected.
Kernberg and others have found that people with borderline personality disorder often extensively use the defenses of idealization, devaluation (often combined in "splitting"), grandiosity, and types of projection. But use of these defenses often are not apparent to the casual observer, and, because defenses are unconscious, the borderline person remains unaware of their own use of these defenses.
Although I believe Kernberg's theories to be mostly correct and especially helpful in terms of formulating a prognosis, like many psychoanalytic theories, it doesn't really address the issue of later environmental factors (Kernberg believes that early environmental factors combined with genetics are at the root of personality disorders). Starting about 20 years ago, theorists began to notice that the typical symptoms of persons with borderline p.d. were quite similar to those of trauma survivors and suggested that some borderlines might actually have PTSD and had been misdiagnosed. But one could say that this is the very reason why Kernberg's perspective is important, because it emphasizes the underlying defenses rather than the overt symptoms.
Earlier this year I went to a talk by Dr. Michael Stone, the forensic psychiatrist, in which he suggested clinicians decide whether the borderlines with whom they were working had primarily a trauma-based condition or primarily a genetic condition. I've begun to believe that there are different types of borderline p.d. Perhaps eventually diagnostic manuals will reflect what clinicians have been seeing for many years.
How is borderline personality disorder treated? Some would answer, not well. The general consensus is that the disorder is resistant to change. However, there are a multitude of treatments that may help. Traditionally the disorder has been treated with intensive psychotherapy to address the pathological defenses. The underlying premise of this treatment is that human personality is malleable, is developed in an early dyadic relationship, and can be altered by the patient/therapist dyadic relationship even in later life. I believe this to be somewhat true. In the 1990s, a psychologist named Marsha Linehan developed a treatment protocol called Dialectical Behavior Therapy to help borderlines learn to cope with their emotions and interpersonal relations. DBT is now used to help people with other disorders as well. I occasionally use DBT techniques, as they help people learn assertiveness as well as distraction techniques, especially "mindfulness," to relieve overwhelming emotions. I have found people with anxiety disorders often benefit from DBT. The DBT program does not really alter the underlying personality structure, however.
I've treated a number of people with borderline personality disorder, and have found them to be quite different from each other. A childhood marked by invalidating remarks by parents is common, but not everyone subjected to such an environment will develop BPD. Psychotherapy that combines validation with confrontation of unhelpful defenses seems to be useful for my personality-disordered patients. In a few cases, I've seen patients with borderline personality disorder benefit from a mood stabilizing medication called Lamictal, which moderates their unstable emotions.
Sunday, January 5, 2014
An Introduction to Personality Disorders
The term "personality disorder" was developed decades ago to describe patients who had a superficially normal presentation without psychosis but who, under psychoanalysis, were revealed to have deep disturbances in their psychological functioning. Many of these patients had chronic problems in interpersonal relationships or social/occupational functioning. Some had symptoms of "neurosis" such as anxiety or depression, whereas others had none. To this day, personality disorders remain difficult to treat. Yet, a large percentage of any psychotherapist's caseload is composed of persons with such disorders, as they comprise approximately 10-20 percent of the general population.
Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.
The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship. Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.
What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation, distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist). I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a part of themselves that they don't like. Consequently, others may be either idealized or devalued.
There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted.
Traditionally, psychotherapists believed that personality disorders were untreatable. This view has changed over time, but whether the view has changed because my profession has become better at treating personality disorders or the view has changed simply because no one wants to admit that a large percentage of patients are only partially treatable at best is open to question. What I have found in my practice is that most people with personality disorders present with depression or anxiety that can be treated, but that their core personality problems are treatable some, but not all, of the time.
The theories of my profession have held that real psychological treatment occurs in the relationship between the patient and the therapist, and my 20 years of experience has shown me that this is true. The reason that personality disorders are difficult to treat is because the personality disorder has a tendency to destroy the patient-therapist relationship. Persons with personality disorders have a tendency to hide important information from the therapist, because either consciously or unconsciously, they are unable to admit what they believe to be shameful information or feelings. This is because they either have an inflated ("grandiose") sense of self that does not allow weakness, or they have an inordinate fear of judgment that is a product of their projection.
What is a personality disorder? In short, it is a malformation of the ego, the part of the psyche that mediates between pleasure-seeking urges and reality. We all make emotional compromises to deal with the fact that reality doesn't always give us what we want. A person with a personality disorder, either because of genetic tendencies, a history of early childhood trauma or both that have disrupted normal processes of maturation, distorts reality instead of compromising with it (people who are simply neurotic, in contrast, engage in "compromise formations" which often involve symptoms that are easily identifiable to both the patient and the therapist). I have found that many of my patients with personality disorders live in a fantasy world. They are unable to see what people around them are really like because they only see what they have projected onto those people, which may be what they wish others to be like, or, a projection of a part of themselves that they don't like. Consequently, others may be either idealized or devalued.
There are many other aspects of personality disorders-- this is a complex subject that cannot be adequately explained in a blog post. If you suspect that you have a personality disorder, the path to recovery is to be completely honest with your therapist, even if it feels uncomfortable. Ultimately this honesty breaks down the pathological defenses that comprise a personality disorder, leading to the formation of an acceptance of reality, a realistic self-image, and perceptions of others that aren't so distorted.
Subscribe to:
Posts (Atom)