Antisocial and Narcissistic Personality Disorders

Derek Rutter & Amanda NantzCNS 770: Classification of Mental Health Disorders

Fall 2013

Antisocial PDDiagnostic criteria (301.83)

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicted by (AIB) 3 or more of the following:

1. failure to conform to social norms with respect to lawful behaviors, AIB repeatedly performing acts that are grounds for arrest

2. deceitfulness, AIB repeated lying, use of aliases, or conning others for personal profit or pleasure

3. impulsivity or failure to plan ahead

4. irritability and aggressiveness, AIB repeated physical fights or assaults

5. reckless disregard for safety of self or others

6. consistent irresponsibility, AIB repeated failure to sustain consistent work behavior or honor financial obligations

7. lack of remorse, AIB being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Antisocial PDDiagnostic criteria (continued)

B. The individual is at least 18 years of age

C. There is evidence of conduct disorder with onset before age 15 years

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

ASPD diagnostic features● deceit and manipulation ● must be 18 and have shown sx’s of conduct d/o before age 15

○ aggression to people or animals○ destruction of property○ deceitfulness or theft○ serious violation of rules or rights of others

● may repeatedly do things that are grounds for arrest○ destroying property, harassing others, stealing

● may repeatedly lie, use an alias, con others, or malinger● decisions made spur of the moment with consideration for personal or

social consequences● irritable and aggressive (including domestic violence)● high-risk sexual or substance use behavior● consistently and extremely irresponsible (work behavior, for example)● unapologetic for having hurt, mistreated, or stolen from someone

Associated features supporting ASPD dx

● callous, cynical● arrogant● opinionated, cocky● superficial charm● irresponsible and exploitive in sexual relationships● irresponsible as parents● more likely than general population to die prematurely in violent ways

(suicide, accidents, homicide)● dysphoria, depressed mood, anxiety, substance use, gambling● somatic probs● financial difficulties● easily bored - high need for excitement

Prevalence of ASPD● child abuse, neglect, unstable or erratic parenting, or inconsistent

discipline may increase chance CD will evolve into ASPD

● likelihood of developing ASPD in adulthood is increased if individual developed CD before age 10 & accompanying ADHD

● 12 month prevalence = 0.2% - 3.3%

● >70% in males with alcohol use d/o and in SA clinics or prisons

● prevalence higher in low SES

More on ASPD● Development and course

-Sx’s most severe in early adulthood, less evident or remit as the person grows older (particularly by 40s)-Cannot be dx before age 18

● Risk & Prognostic Factors○ Environmental

-grow up in families with unsupportive and defensive communication patterns - no childhood models of empathic tenderness - violence and aggression are the language of choice

○ Genetic & physiological-more common in 1st degree relatives than gen pop (50% attributed to genetics, 31% to unique experiences, 11% to shared experiences)

-In the brain: obritofrontal cortex (impulses and emotional & social decision making) appears underdeveloped. Makes it difficult to recognize social cues and to read emotion underlying verbal messages

Culture and gender related diagnostic issues with ASPD

● Culture-ASPD associated with low SES and urban settings-Dx may be wrongly assigned to individuals who are simply surviving - to

someone looking in from the outside, it appears to be ASPD

● Gender-3% of men diagnosed-fewer than 1% of women-potential for underdiagnosed in women due to focus on aggression

ASPD suicide risk, functional consequences, & comorbidity

Suicide risk-More than 11% of those dx have attempted suicide

-5% complete suicide

Functional consequences-difficulty keeping warm, intimate relationships, tend to change partners frequently

-tend to change jobs frequently, too

Comorbidity-People with ASPD often manage depression and anxiety

-More prone to substance-related d/o’s and violence than those with other PDs

ASPD differential diagnosis

Substance use disorders

-If an adult presents with a substance use d/o, a dx of ASPD is only made if the signs of ASPD were present in childhood and continued into adulthood. Some signs of ASPD (selling drugs, stealing to get drug $) might be a consequence of substance use. If there was substance use and ASPD traits in childhood, both are diagnosed if criteria is met.

Schizophrenia and bipolar disorders

-If qualities of ASPD occur only during course of schizophrenia or bipolar d/o, a person should not be diagnosed with ASPD.

Other personality disorders

-ASPD can look like other PDs. All can be diagnosed. However, there are some key difference between ASPD and other PDs.

-If it looks like narcissistic PD, keep in mind those with NPD often do not have impulsivity, aggression, and deceit assoc. with ASPD.

ASPD differential diagnosis (continued)

Other personality disorders (cont.)

- Those with HPD and BPD can be manipulative to gain nurturance. Those with ASPD can be manipulative to gain profit, power, or material gratification

-With Paranoid PD, a desire for revenge is present rather than a desire for personal gain or to exploit others, which can accompany ASPD

Criminal behavior not assoc. with a PD

-A person can engage in criminal behavior with having ASPD. Traits must be inflexible, maladapative, and cause sig. functional impairment to constitute ASPD.

Tx planning for those with ASPDCounseling approaches

-Therapists should avoid punitive stances - should present as specialists and partners in the process

-Development of trust will be difficult and critical

● Most effective tx: prevention○ early intervention, through family therapy for example, when a child is first dx with ODD or CD

● Mentalization-based therapy○ helps client feel the therapist is trying to understand how their thought processes evolved, why they made

sense for that person, and helps them make different choices b/c they want to rather than b/c they should○ helps clients realize what their thought processes are, gain awareness of their triggers and when they are

at risk for acting out rather than thinking through a situation

● Modified Therapeutic Community (MTC > mental health tx for inmates with SA and ASPD)○ treats co-occurring ASPD and substance abuse○ based on community integration and mutual peer self-help○ have clear expectations, encouragement, and clear consequences

Tx planning for those with ASPD

● Schema therapy - focus on altering maladaptive schemas○ mistrust (fearing others will mistreat them)○ sense of entitlement○ lack of self-control○ believe that they are defective and will be abandoned

● Motivational interviewing○ helpful b/c focus on choice and less of an authoritative stance

● Reality therapy○ open the eyes of those diagnosed to self-destructive nature, see their behavior isn’t helpful, and make a

commitment to change

● Behavior therapy○ improve problem-solving, decision-making, and impulse control skills

Tx planning for those with ASPD

● Early sign of progress is emergence of underlying depression○ to encourage clients’ persistence with tx, therapists may need to increase support and empathy○ if depression or anxiety is alleviated too fast, client’s may lose motivation to change ASPD traits

Medications● no convincing evidence for use of meds● if prescribed, should be Rx with caution b/c of clients’ tendency to misuse drugs and their reliance on external

fixes for their problems rather than internal

Prognosis● low motivation to change, co-occurring depression, drug and alcohol abuse, gambling, violence, and anger makes

prognosis pretty grim● tx seems to be more successful with ppl over age 40 and for those who show some remorse for their actions, have

a hx of some attachments, have not been sadistic or violent, are neither too dumb or too smart, and do not have clinicians who are scared of them, BUT…

● early intervention has been shown to decrease development from CD to ASPD by as much as 40%-70%

Narcissistic PD (NPD)Diagnostic Criteria (301.81) (F60.81)

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 context, as indicated by 5 (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 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 that others are envious of him or her.9. Shows arrogant, haughty behaviors or attitudes.

NPD Diagnostic Features● Routinely overestimate their abilities and

inflate accomplishments● Often appear boastful and pretentious● Assume others attribute the same value to

their efforts● Surprised when others fail to praise them● Devalue the contributions of others● Ruminate about “long overdue” admiration

and privilege● Compare themselves to famous people● Feel that they can only be understood by

similarly “gifted,” “unique,” or “perfect” people

● Believe their needs are special● Self-esteem is almost invariably very fragile● Need constant attention and admiration● Often fishing for compliments

● Expect to be given whatever they want, no matter what

● Form relationships with those whom they believe will advance their needs or desires

● Often usurp special privileges● Assume others are totally concerned about

their welfare● Discuss their own concerns in inappropriate

length or detail● Often impatient or contemptuous with others

who talk about their own needs or concerns● Oblivious to the hurt their words or actions

may cause others● Emotionally cold● Harshly devalue the contributions of others● Commonly patronizing

Associated Features Supporting Diagnosis of NPD

● Vulnerability in self-esteem > sensitive to “injury” from criticism or defeat● May be haunted by criticism > may react with disdain, rage, or defiant counterattack● Social withdrawal or humility may mask grandiosity● Interpersonal impairment < entitlement, need for admiration, disregard for

sensitivities of others ● Often high achieving but performance often susceptible to criticism/defeat● May be unwilling to risk competition due to possible defeat● Sustained feelings of shame, humiliation, or self-criticism > social withdrawal,

depressed mood, dysthymia, or major depressive disorder● Sustained grandiosity > hypomanic mood● NPD associated with anorexia nervosa and substance use disorders● Histrionic, borderline, antisocial, and paranoid PDs may be associated with NPD

Prevalence of NPD● Prevalence estimates: 0% to

6.2% in community samples● NPD found in <1% of the

general population● 2% to 16% of clinical

populations● The prevalence of narcissistic

traits is increasing in the general population.

Culture- and Gender-Related Diagnostic Issues Associated with NPD

● Culture○ Believed to be less prevalent in collectivist societies○ Higher prevalence among Black men and women and among Latina

women○ Higher prevalence among separated, divorced, widowed, and never

married individuals

● Gender○ Of those dx with NPD 50% - 75% are male○ In both men and women, an inverse relationship of NPD to age has

been observed.

Development and Course of NPD

● Two pathways to NPD: parental neglect & parental overvaluation in childhood○ Neglect > narcissism develops as attempt to overcompensate for low

self-worth■ Fantasy prefered to reality

○ Overvaluation > lack of need to work for approval, which leads to inflated sense of self-worth■ Frequently in only children

○ Internalized message: self-importance/superiority, but will be rejected if not exceptional

● Narcissistic traits common in adolescents, but not necessarily indicative of NPD > developmentally appropriate to some extent

● People with NPD may have difficulty adjusting to aging.

Differential Diagnosis of NPD● Differentiating NPD from other personality disorders

■ Grandiosity characteristic■ Need attention to be admiring

○ NPD vs. BPD ■ Relative stability of self-image ■ Relative lack of self-destructiveness, impulsivity, & abandonment concerns

○ NPD vs. HPD■ Excessive pride in achievements & disdain for others’ sensitivities■ Relative lack of emotional display

○ NPD vs. ASPD > both may be tough-minded, glib, superficial, exploitive, & unempathetic■ Relative lack of impulsivity, aggression, & deceit■ Lack hx of conduct disorder and/or criminal activity■ ASD lacks relative need for admiration and envy of others

○ NPD vs. OCD > profess commitment to perfectionism & believe self to be superior to others■ Lack relative self-criticism > likely to believe perfection has been achieved

○ NPD vs. SPD & PPD■ Relative lack of suspiciousness and social withdrawal

Differential Diagnosis of NPD (cont.) & Comorbidity Differential Diagnosis of NPD (continued)

● Many highly successful people display traits of NPD○ Only qualify for NPD when traits are inflexible, maladaptive, & persisting ○ Cause significant functional impairment or subjective distress

● Mania or hypomania○ Grandiosity may emerge, but association with mood change & functional impairments help

distinguish from NPD● Substance use disorders

○ Characteristics of substance use disorders may appear similar to NPD

Comorbidity● Men with NPD > significantly higher rates of ASPD & most substance use disorders● Women with NPD > higher rates of MDD and anxiety disorders● In general > increased rates of NPD among those with substance use, mood, and anxiety disorders● Significant associations of NPD with Bipolar I in both sexes & Bipolar II among women have been

observed. ● NPD is highly comorbid with BPD and SPD in both sexes.● The comorbidity of NPD and HPD & OCPD has been observed among males.

NPD Suicide Risk & Functional Consequences

Suicide risk● Individuals with NPD are typically less likely to attempt suicide than those with other PDs,

although they may experience suicidal ideations.● These individuals tend to be less impulsive regarding suicide than other PDs, but no more or less

impulsive than those not dx with NPD.● There is a greater lethality associated with suicide attempts made by individuals with NPD than

without NPD, but no significant difference when compared to those dx with HPD, ASPD, & BPD.

Functional consequences● Some individuals develop vocational impairment due to their fear of failure and rejection or poor

interpersonal skills and intolerance of others.● Some individuals are highly successful due to their high drive for success, as well as their self-

reliance and sense of self-directedness○ May be indicated by comorbidity of other disorders

Tx planning for those with NPD

Counseling approaches● Literature is lacking on controlled outcome studies of tx of NPD● Psychodynamic approaches have been shown to have some success in treating NPD

○ Psychodynamic approaches less successful for those with impulse control disorders■ These individuals respond better to expressive, cognitive, & supportive forms than analytic

● CBT has been shown to be successful○ Behavioral interventions that do not focus on weakness seem most effective○ The Personality Belief Questionnaire and The Diagnostic Interview for Narcissism can be helpful○ Focus on early maladaptive schemas has also shown to be effective

■ Attention on the “lonely child within” and tolerating pain and isolation rather than resorting to maladaptive coping

● The therapeutic alliance (once again) seems to be particularly important in the tx of NPD.● Tx tends to be long-term, but this is often difficult to accomplish

○ Some advocate for brief therapy that focuses on reality testing and interpersonal relationships.● Group therapy consisting solely of individuals Dx with NPD has been shown to be effective.● Couples therapy has also seen success in treating NPD.

Tx planning for those with NPD (cont.)

Medications● No medication has been shown to be successful in treating NPD● Medication can be used to address symptoms of NPD and underlying D/Os

○ SSRI have been shown to decrease vulnerability to criticism, impulsivity, and anger

Prognosis● NPD is difficult to treat & may require up to 100 sessions● Prognosis is favorable unless individuals have strong features of ASPD or

BPD● Prognosis sometimes improves with age

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