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Running head: NARCISSISTIC PERSONALITY DISORDER

Narcissistic Personality Disorder

Saundra E. Burleson

Wake Forest University

February 14, 2016

NARCISSISTIC PERSONALITY DISORDER

Narcissistic Personality Disorder

Narcissistic Personality Disorder (“NPD”), of which 50%-75% of those diagnosed (according to

DSM-V) are male, is a disorder that is characterized by a pervasive pattern of grandiosity, need for

admiration, and lack of empathy. Typically beginning by early adulthood; this disorder presents the

potential for suffering not only to those diagnosed, but also to those who find themselves in a relationship

with them.

Introduction

In Metamorphoses, a fifteen-book, epic Latin narrative poem by Roman poet Ovid, Narcissus the

hunter, who was known for his beauty, was so vainly in love with himself, that he lost his will to live, and

died by a pool of water, staring at his own reflection. Narcissistic Personality Disorder was first

introduced in the DSM-III in 1980. People with this disorder selfishly disregard the wants and needs of

others and exploit relationships. They are “prone to infidelity and both verbal and physical aggression.”

(Dhawan, Kunik, Oldham, & Coverdale, 2010)

Background Provided By Existing Literature

In a study conducted in 2010 and reviewed in Prevalence and treatment of narcissistic

personality disorder in the community: a systematic review, the authors reported that an average of less

than 10 studies per year were conducted on NPD. This is evidence of the fact that more research is

needed in reference to this disorder. The authors conducted research using a structured or semi-structured

interview and found that of the 49,812 participants, 2,169 met the diagnostic criteria for NPD. This result

of 4.35% falls within the range of 0% to 6.2% in community samples reported in the DSM-V.

There has been some interest in researching the psychological effects that parents with NPD have

on their children. Seth Myers, Psy.D. reports in Psychology Today that children of NPD parents suffer

similar psychological bruises at the hands of their parents. “The child of the narcissist realizes early on

that he exists to provide a reflection for the parent and to serve the parent – not the other way around.”

(Myers, 2014)

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Diagnostic criteria for NPD is listed in DSM-V as follows: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.

(American Psychiatric Association, 2013)

Individuals with this disorder generally have a very fragile self-esteem, although their external

behaviors convey something much different. They may expect to be treated with excessive admiration

and their sense of entitlement, combined with their lack of compassion and empathy for, and their lack of

sensitivity to the wants and needs of other people, sometimes manifests as conscious or unconscious

exploitation of others. Because they often assume that others are totally concerned about their welfare,

people with NPD tend to talk about themselves with excessive, inappropriate detail.

Because of their very fragile self-esteem, people with NPD are very sensitive to criticism and/or

defeat. A simple criticism, that would be acknowledged and let go of by most people, can leave a person

with NPD feeling “humiliated, degraded, hollow, and empty.” (American Psychiatric Association, 2013)

Their reaction to criticism may present as rage, disdain, or a defiant counterattack. These episodes can

often lead to social withdrawal. To protect their grandiosity, a person with NPD might also present an

appearance of humility.

People with NPD are oblivious to how their behaviors affect/impact others. They talk as though

they are speaking to anyone within earshot instead of directly to one person. They are not aware of the

fact that they are alienating others with their boastful and arrogant mannerisms, and “their tendency to

refer to themselves repeatedly reflects their need to be the center of everyone else’s attention.” (Gabbard,

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2009) They come across as insensitive because of their inability to comprehend the experience of others.

They are often perceived as having a sender but no receiver.

Personal and professional relationships are often difficult for people who suffer with NPD

because of their sense of entitlement, disregard for the feelings of others, and excessive need for

admiration. Individuals with NPD may be high achievers because of their high level of ambition; but

they may also lack in performance because of their inability to accept criticism or defeat. According to

the DSM-V, NPD “is also associated with anorexia nervosa and substance use disorders (especially

related to cocaine. Histrionic, borderline, antisocial, and paranoid personality disorders may be

associated with NPD.” (American Psychiatric Association, 2013)

Causes of Narcissistic Personality Disorder

There are various theories about the possible causes of NPD, but further research is needed to

confirm a true root cause of this disorder. The cause of NPD is likely very complex. Most professionals

subscribe to a biopsychosocial model of causes and believe that NPD is caused by a combination of

factors such as individual temperamental patterns and early life experiences such as excessive pampering

or harsh or negative parenting. This would mean that a complex, intertwined nature of a person’s early

developmental, environmental, social, and psychological experiences, combine to cause NPD. There is

also research that suggests that if a person suffers with NPD, they are likely to pass this on to their

children; whether through genetics or modeling of the various NPD traits, is not yet confirmed.

Treatment Options for Narcissistic Personality Disorder

There is no known cure for NPD, but counseling might help the person learn to relate to others in

a more positive and rewarding way. One goal in counseling is to provide the client with deeper insight

into his/her difficulties and attitudes in hope that behaviors will change. Another goal of therapy might

be to help the client develop less inflated self-esteem and more realistic expectations of others. It is

important to note that medication can be used to alleviate distressing symptoms such as the anxiety and

sadness that often co-occur with NPD. Psychotherapy outcome studies on NPD are scarce and experts

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typically recommend the use of methods that have been useful in the treatment of other personality

disorders.

Treatment of NPD typically involves long-term psychotherapy and is possibly combined with

medications that can help with persistently troubling symptoms. It is usually considered a difficult-to-

treat disorder and patients with this disorder rarely seek therapy because of the extreme sensitivity to

criticism and/or need for admiration. More likely, a person with NPD will seek treatment for surface

issues such as anxiety, depression, substance abuse and psychosomatic disorders, without considering

possible links to personality aspects and interpersonal functioning related to NPD. There are useful

treatments for NPD, but individuals “often find it difficult to engage.” (Kramer, Berthoud, Keller, &

Caspar, 2014)

Much of the difficulty in treating NPD also arises from the challenging patterns of transference

and countertransference that develop in the course of treatment. These patterns can also be considered a

priority in treating NPD since those who suffer with NPD have significant difficulty in maintaining

gratifying relationships. Counseling sessions can be considered a place where the “clinician can directly

observe how the patient relates to others outside” (Gabbard, 2009) of therapy. Much of the knowledge

about NPD comes from psychoanalysis and intensive psychoanalytic psychotherapy. “Recent empirical

data has helped illuminate those characterological features that are hallmarks of narcissistic personality

disorder.” (Gabbard, 2009)

Hypervigilant NPD patients are extremely sensitive to how others react to them and tune into

facial expressions and listen intently to others in search of evidence of a critical reaction. They will often

feel slighted by others when there was no intention of criticism whatsoever. Oblivious narcissists will use

their therapist as a sounding board that exists solely to enhance the patient’s self-esteem according to Dr.

Glen O. Gabbard in his article, Transference and Countertransference: Developments in the Treatment of

Narcissistic Personality Disorder. These clients don’t connect with their counselor in the way that most

clients do. They talk at length about themselves without any curiosity about the therapist. To an outside

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observer, this interaction might be characterized by an “apparent absence of transference. The astute

clinician, however, knows that this apparent absence is the transference.” (Gabbard, 2009)

It is important for therapists to remember that those suffering with NPD are plagued by feelings

of inadequacy related to inability to regulate their self-esteem. One common defensive strategy that these

clients use is to devalue others as a way to make themselves feel superior and less inadequate. They

may initially treat their therapist with contempt as a way to level the playing field in a situation where

they are dealing with feelings of inferiority. NPD clients are prone to feelings of shame and humiliation

and may scan the their therapist’s reactions (body language and facial expressions) as a way to avoid

exposing their vulnerability by guarding against the experience of humiliation.

Therapists working with NPD clients should be aware of their own need to be needed because

NPD clients may strive to deprive them of fulfilling this need. They will often talk “at” the therapist

instead of “’to” the therapist and without preparing for these types of interactions, the therapist may begin

to feel ineffectual. Untrained or unprepared therapists may react to this type of behavior by becoming

bored or disengaged. Being aware of “common experiences of transference/counter-transference

developments (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014) alerts the therapist to

potential impasses and resistances in the treatment that must be taken into account.” (Gabbard, 2009)

It is essential in the treatment of NPD that therapists use efficient therapeutic procedures from the

very beginning. Constructive work on the individual’s core issues, including “vulnerable self-image,

difficulties in reflecting on mental states, lack of empathy, problems related to shame as central emotional

state, along with problematic emotion regulation, destructive interpersonal patterns related to grandiosity

and dominance or aggressivity, superficiality, and interpersonal avoidance processes”, (Kramer,

Berthoud, Keller, & Caspar, 2014) is extremely important.

One therapeutic approach that is used for patients with severe personality disorders is

transference-focused psychotherapy (TFP). This manualized evidence-based treatment which integrates

contemporary object relations theory with attachment theory and research, is used to attempt a “gradual

integration of disparate, split-off self and object representations into a more integrated stable concept of

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the self and objects, which in turn fosters reflective capacity in that it provides a more integrated,

consistent working model of self and others against which momentary mental states, including those that

devolve from the grandiose self, may be more systematically reflected upon and their defensive function

understood.” (Diamond & Meehan, 2013) The use of TFP in treating individuals with NPD allows for a

systematic analysis of the grandiose self in hopes of affecting a shift from a “grandiose, dismissive to a

more vulnerable, preoccupied narcissistic presentation.” (Diamond & Meehan, 2013)

Motive-oriented therapeutic relationship (MOTHER) is referred to by several therapy models as a

useful intervention principle for use with NPD. MOTHER is a prescriptive concept based on an

integrative form of case conceptualization and is considered to be particularly relevant to the treatment of

individuals with personality disorders.

“Cognitive-Behavior therapy methods of teaching problem solving and social skills and

modification of underlying dysfunctional schemas on self-worth is recommended.” (Kramer, Berthoud,

Keller, & Caspar, 2014) The psychodynamic therapy approach of interpreting transference and counter-

transference within the therapeutic relationship, particularly components of aggression, hate, and

jealousy; can also be useful in working with individuals with NPD.

Metacognitive Interpersonal therapy targets characteristics of NPD such as an “intellectualizing

narrative style, poor metacognition, maladaptive interpersonal schemas, a restricted set of states of mind,

impaired agency and perfectionism” (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014)

and can therefore be a treatment option. These dysfunctions are targeted with a series of formalized

procedures “aimed at first forming a shared formulation of functioning which patients and therapists can

then use to plan change.” (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014) Continuous

awareness of the therapeutic relationship is necessary to minimize misunderstandings

Important in the treatment of those with NPD is therapeutic alliance building, which should be

the focus from the beginning of treatment. Therapists employing this method of treatment will validate

clients’ subjective experience and monitor their own tendencies toward behaving as an aggressive

authority figure. Therapists working with NPD clients should try not to react to the narcissistic

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tendencies to use them as an audience and should instead invite the client to be “active and reflect jointly

on any problems occurring in the therapy room so as to make meaning out of them and repair alliance

ruptures.” (Dimaggio, Valeri, Salvatore, Popolo, Montano, & Ottavi, 2014)

Due to the long-term difficulties and distress caused by living with NPD, people with this

disorder could be at risk for other emotional and behavioral disorders. Drug/alcohol abuse often co-occur

because they are used as a way to cope with the symptoms of NPD. The outlook for people with NPD

depends greatly on the degree of their commitment to engaging in honestly identifying

behaviors/emotions and more positive ways of relating to others. Individuals who seek help and work

toward change can improve their lives.

Case Conceptualization

Client Demographics

Frank is a Caucasian, 45 year old, divorced male. He comes to therapy dressed as if he is

prepared for a business meeting. He is approximately 5’10 and weighs approximately 195 pounds. Frank

reports that he has “several” master’s degrees but is very vague about where he went to school and what

he studied. He has had difficulty finding a job since becoming unemployed and shares that he was let go

from his most recent job (not his fault of course) as a result of being “misunderstood” by his “idiot”

supervisor who “lacked the capacity to understand depression.” He says he has lost touch with his former

colleagues and friends because they “just don’t understand serious mental illness.”

It is apparent, by Frank’s interpersonal style and narrative, that he wants to be perceived as

successful, wealthy, and educated, although he provides no evidence of these attributes. His vocabulary

and language style contradict his report of “extensive higher education.” He becomes frustrated when

asked for specifics and begins to ask for evidence of the counselor’s education and training. It is

important to note that Frank’s ability to give an accurate and cohesive account of his historical

information may be affected by his personality disorder.

Presenting Problem

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Frank’s physician referred him for counseling, reporting that he was seeking assistance for

depression. Frank shares that his own extensive research led him to believe he is depressed even though

he is not exhibiting typical symptoms. He says he believes that this large stack of research documents

may be helpful for the counselor. Frank’s responses to the counselor’s probing questions about

depression keep going back to a sense that he is not achieving what he would like to achieve and is

having difficulty with people. He reports feeling dissatisfied with life and physically run down. When

the counselor asks Frank questions like: “are you feeling sad” he answers with one-word answers and is

very vague. He makes generalized statements about having a happy family life when he was growing up

and now with his daughter, but provides no evidence of close relationships.

History

Frank takes the lead in conversation and does not allow the counselor to make the introductory

statements for the initial session until he has finished his narrative about how he has seen many

counselors previously and has found them all to be inadequate. Frank says that he has seen “several” but

can’t remember exactly how many counselors, psychologists, psychiatrists, etc. he has seen for

depression. He also cannot remember their names.

Frank has a somewhat forced and authoritative quality to his affect. He is happy to tell his story

when asked open-ended questions, but frequently talks over the counselor when she tries to re-direct the

session or clarify. He is vague with his answers and provides statements such as “just not myself” and

“want more from life. Frank continues on to describe himself as “complicated” and says (while smiling)

that other people have not been “smart enough to figure him out either.” His other answers are

inconsistent. For example, when asked if he has stopped doing things he enjoys, he answers “yes.”

When asked what he has stopped doing, he answers that he is not working anymore. When asked if this

was a source of enjoyment, he answers that it was not a very good place to work because they didn’t

know how to “utilize me to my full potential.”

Frank makes no mention of Narcissistic Personality Disorder. He says his last therapist was very

nice but didn’t have the skills to help him. He says that he was hospitalized twice in the recent past. He

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was hospitalized once for “exhaustion” and once for “stomach problems” and says that the doctors had

difficulty giving him an accurate diagnosis. He has no other significant medical history.

Frank says that he had a very happy childhood; his father was in “business” and a “consultant”

but can’t remember the name of the companies he worked for. Frank’s mother was a “typical stay at

home mom” according to him and mentions briefly that his mother had “spells” when he was young.

When asked to elaborate, he is dismissive and says “Oh it was no big deal, she was extremely intelligent

and must have been sick of staying at home all the time when she could have been a very famous

researcher.” He goes into a long story of how his mother dropped out of graduate school when he was

born and otherwise would have been very influential in the field of psychological research. He said “She

was a very good mom though” and when asked by the counselor how she was “good” and then what he

appreciated about her, he repeated the story of how she “would have been a famous researcher” and how

“intelligent” she was. He provides no details about happy memories and indicates no warmth. He adds

that his father was often away but provided well for the family.

Frank had been working in a management position for five years. He did share that he had

several career shifts in his life. He was married from 23 to 35 and has one adult daughter He has little

contact with his daughter, but says they have a “wonderful” relationship and that his daughter is very

successful. Frank has had several relationships since his divorce, but none have lasted more than two

years. He doesn’t have difficulty meeting women and enjoys the “initial chase” especially if they are

unavailable in some way. He then finds himself disappointed when the relationship starts to settle. He

finds fault with small things and generally realizes that they are not good enough for him.

He talks about being successful and living in a trendy part of town. He drives a foreign car (but

the cheapest version of the “name” brand). Through further investigation you discover that he is renting

the car and lives in a small studio apartment and there is no evidence that Frank is financially secure. He

says he likes to keep busy, likes to study and has several degrees (but is vague about the details). He

reports that he has lots of friends and has a very active social life, but is again very vague about the

details.

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Treatment Plan

To prepare a treatment plan for Frank, I have chosen to use the DO A CLIENT MAP (1996, Seligman) as

shown below:

DO A CLIENT MAP

Diagnosis: According to the DSM-V, the most appropriate diagnosis for Frank, from the information that has been gathered, is Narcissistic Personality Disorder 301.81 (F60.81) which is included under Cluster B Personality Disorders. “Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these disorders often appear dramatic, emotional, or erratic.” (American Psychiatric Association, 2013) Frank suffers with at least five of the diagnostic criteria for NPD listed in the DSM-V. His pervasive pattern of grandiosity, need for admiration, and lack of empathy is present in a variety of contexts.

Objectives: Our objectives will be to help Frank to learn to relate to others in a more positive and rewarding way and to develop sturdier, less inflated self-esteem and more realistic expectations of others. Because Frank is experiencing symptoms of depression, it might be helpful to also talk to him about possibly being on medications that could be used to treat the depression symptoms as we work through his NPD with counseling. Alleviating the anxiety and/or depression that Frank is experiencing may make counseling a little less of a challenge.

Assessment: Because cognitive-behavioral therapy has proven to be useful in the treatment of NPD, we will use a Cognitive-Behavioral Assessment emphasizing cognitions and behaviors. It will focus on questions such as: “What particular maladaptive thoughts or beliefs lead to the client’s specific emotional and behavioral problems? How do problematic emotions and behavior feedback into the maintenance of maladaptive thoughts and beliefs?” (Sperry & Sperry, 2012)

Clinician: The clinician working with Frank should be appropriately educated and trained to work with personality disorders, and preferably specifically with NPD. Counselor should also remain aware of potential for transference/counter-transference.

Location: Although Frank reports symptoms of depression and anxiety, he is not currently nor does he have a history of suicidal or homicidal ideation, and his daily functioning is not significantly impaired. Frank does not need a higher level of therapy than outpatient. Because group counseling initially might make Frank feel that his issues are less important (due to his feeling that his issues are more important than others and because the individual attention is important to him), it would be preferable for him to attend individual weekly outpatient counseling. Possible groups could be discussed in the future. Because therapist/client relationship building is such a critical part of working with NPD clients, individual counseling is also preferred.

Interventions: Cognitive-Behavior Therapy – Use of cognitive restructuring methods and teaching problem-solving and social skills and modifying of underlying dysfunctional schemas of self-worth is recommended.” (Kramer, Berthoud, Keller, & Caspar, 2014) The psychodynamic therapy approach of interpreting transference and counter-transference within the therapeutic relationship, particularly components of aggression, hate, and jealousy will be important in working with Frank.

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Rogerian techniques – Use of genuineness, unconditional positive regard, and empathy to both build rapport with Frank and to model appropriate behaviors may provide space for Frank to express his emotions.

Emphasis – Frank’s motivation is moderate. Although he has shown up for therapy, he has shown up to work on his perceived problem with depression and has not yet realized that NPD is the issue. I will be moderately directive with Frank because of the potential for him to stop coming to therapy if he perceives that he is being talked “down” to. I will be moderately directive rather than non-directive because it may be important for Frank to recognize that I have some expertise in this area rather than validating his statements about counselors being incompetent. Given the present-moment nature of Frank’s concern about “depression” and due to his sensitivity to perceived criticism or judgment, the majority of counseling will be present focused. Because of the history of relationship/career problems, it will be helpful to integrate some exploration of these past concerns, particularly as they relate to present difficulties.

Numbers: Frank will be attending individual counseling as rapport building is such a priority in working with clients with NPD. Working initially in a group or bringing in Frank’s family members or friends might feel too overwhelming for someone who puts up a façade of grandiosity that could be easily broken down if there were people present to contradict what Frank is sharing.

Timing: Because Frank has a history of incomplete therapy and because he has a need for feeling as if his issues are more important that others, it might be helpful to meet twice weekly for the first 6 sessions and then re=evaluate progress and discuss meeting once individual sessions of a combination of cognitive-behavioral and psychodynamic therapy.

Medication: Consider bringing up the topic of medication and referral to psychiatrist with Frank given his symptoms of depression. Validating his “research” and self-diagnosis of depression (since this actually can co-occur with NPD) may work toward positive progress in building the therapeutic alliance.

Adjunct Services: (support in addition to counseling) Eventually, it may be helpful to talk to Frank about participating in activities (volunteering?) that may foster a sense of empathy for others. Of course this would depend greatly on how his therapy is going. Exposing him to activities that highlight the needs of others and supporting him in doing for others simply because it is a good thing to do and not as a method of gaining more admiration might be useful for him. Also, after his initial 12 weeks of therapy, it might be useful to help him get involved in NPD support groups so that he can have exposure to how NPD is actually an illness and how others have found ways to cope with this disorder.

Prognosis: Prognosis is poor at this time as Frank does not yet recognize that NPD is the presenting issue and because of his lack of familial or social support. He has several failed attempts at counseling and NPD is a difficult disorder with no proven cure.

Advocacy, Multicultural, and Legal/Ethical Considerations

It is worth mentioning that in dealing with Narcissistic Personality Disorder, it is important to

seek advocacy for both the counselor and the client. The counselor should consult as much as possible

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with other professionals who are experienced in working with clients with this disorder to avoid

ineffective treatment methods, ethical dilemmas, and to ensure their own self care. Advocacy for the

client, especially due to the nature of the illness regarding fragile self-esteem, could come in the form of

group therapy (preferably after rapport has been built with the client in individual therapy.)

In considering multicultural issues, it should be a priority for the counselor to do extensive

research as well as consult with other professionals to make sure that some of her client’s behaviors and

mannerisms are not related to his culture. In some cultures, men do have what would appear to

Americans an “inflated sense of self-esteem” and in their own country this would be acceptable. This

could prove problematic however, for someone who is from another culture and trying acclimate to

employment and social relationships in America. In this case, it would be important to talk about

education and ways to adapt to the client’s present country of residence in enough ways to make

employment and social relationships less stressful.

Conclusion

Narcissistic Personality Disorder is evidently a difficult disorder to work with and treat. It is

important that more research be conducted on this topic and that counselors obtain appropriate training

and experience in working with those who suffer with this disorder. The effects of NPD on the people

who suffer with this disorder, as well as the people who come in contact with them can be devastating.

Counselors can gain significant amounts of insight and self-awareness from working with clients who

struggle with this disorder, therefore being helpful to not only their clients but to themselves.

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personality disorder in the community: a systematic review. Comprehensive Psychiatry , 51 (4),

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