1. Narcissistic PD

2. a pervasive pattern of: grandiosity need for admiration lack of empathy Click here

3. Narcissistic PD Highly controversial Uncertain validity Literature is theoretical/clinical Not a solid research base

4. Epidemiology less than 1% of general population 2-16% of clinical Huge variation across studies Why differences? How NAR assessed, by whom and when

5. Narcissism as style Narcissism Self-confident, asserting Style Disorder Click here, what do you think?What about this?

6. Narcissistic PD - History Narcissus – mythological figure Fell in love with own reflection Was unable to leave Eventually died

7. NPD in Media often cast as main characters does not see effect on others plot sets to correct this flaw CARS

8. Media Examples The Fisher King (Jeff Bridges) Apocalypse Now (Robert Duvall) Star Trek (Q - TNG) Rain Man (Tom Cruise)

9. Movie Review Review the Movie “Malice” Study Dr. Jed Hill How does he meet the criteria for NPD? Review the Movie “A Few Good Men” Study Colonel Jessup How does he meet the criteria for NPD?

10. History

11. Havelock Ellis (1898) First to invoke the myth clinically Case study of a man Excessive masturbation Individual becomes object of own desire

12. History Freud (1914) Primary narcissism – occurs early Secondary narcissism – occurs later Waelder (1925) Narcissistic personality first described Freud (1931) Narcissistic personality type

13. History Nemiah (1961) narcissistic character disorder *Kernberg (1967) Narcissistic personality structure Primitive defense mechanisms Higher Ego functioning *Kohut (1968) – coined Narcissistic personality disorder

14. NAR PD - History large body of literature on this disorder from a psychodynamic perspective NAR first appeared in the DSM-III Narcissism has different meanings no ICD equivalent for NAR...

15. Essential DSM – 5/9 Criteria Grandiose sense of self Preoccupied with the fantasies Is special, Excessive Admiration Sense of Entitlement, Interpersonally Exploitive Lacks Empathy, Envious Arrogant Part IIPart I Part III

16. In addition to DSM view… Westen and Shedler (1999) Survey of clinicians suggests NAR.. More controlling Power Struggles More Competitive

17. Associated Features Exaggerate abilities Don’t like others to succeed Seeks affirmation of special status Ambitious Leaders, act decisively Persuasive, lack of reciprocity Angry if not reinforced

18. Gender More common in men Not clear why Could reflect diagnostic criteria

19. Differential Diagnosis and Co-morbidity Looks like delusional disorder Grandiose type Dysthymia or Major Depression Bulimia, Substance Abuse (cocaine) Borderline PD No single Axis I disorder is consistent

20. Interview Considerations

21. Verbal, likes attention A rehearsed quality to information Talk at you, not to you Rapport sometimes difficult If challenged or not validated Narcissistic injury or rage

22. Interview Considerations Condescending Blames others for disappointment Hypersensitive to criticism The world revolves around them Aspirations don’t match their discipline

23. Interview Themes very sensitive to injury or self-defeat fragile self-esteem aging is handled poorly shallow lonely person, lacks emotional depth insensitive to others, preoccupied with self tries to impress interviewer pathological rivalry

24. Interview Themes arrogant, attention-seeking trouble taking criticism, feel entitled they do not follow rules trouble getting along with others sarcasm, devaluation respond in defensive ways

25. Other themes Headline Intelligence A learning disability among NPD Assimilate catch phrases but are not well- versed on a topic Incapable of thorough studying in a given area

26. Other themes Narcissistic dialoguing Use communication to regulate self-esteem rather than for true communication In other words, the person is talking to themselves.

27. The NPD Cycle 1. Identify with another Person 2. Exploit Person 3. Person becomes exhausted 4. Person then is devalued 5. Person is rejected 6. Find another Person, cycle starts again

28. Cause

30. Not extensively studied Why? – does not have huge impact on society Lacks a clear genetic link to Axis I Explanations sometimes appear contradictory

31. NAR - Cause giftedness from an early age "god-like" praise from parents Narcissistic extensions of parents Nobel Prize Complex feelings of superiority destined for greatness

32. Cause - Psychosocial Mom Was Good, Dad was Bad strong supportive mother absent or weak father Mom Was Bad, Dad was Bad Children are Narcissistic Extensions

33. Cause – blame the parents Lack of “selfless” modeling Or The Incomplete Lesson Observed “selfless” without reinforcing the responsibility of selflessness in the child Expectation of being served without ever having to serve others.

34. Cause – Blame the mother Mahler; Modell; Kinston During critical periods, the mother was unavailable, unresponsive or insensitive to needs of child

35. NAR – Cause - Kernberg spiteful or indifferent parenting causes oral rage or psychic hunger sets stage for using people and/or consuming things beyond realistic limits severe frustration causes “borderline personality organization” use of splitting, not a well developed superego, poor relationships

37. NAR - Cause Heinz Kohut narcissism is the result of the self being damaged during early psychological development (due to inadequate parenting) Parents do not validate child’s concerns

38. Cause - Cognitive Beck and Freeman (1990) Each PD has unique beliefs “I am special” “I am superior” ”I am above the rules”

39. Cause - Cognitive Young (1994) Cause is early maladaptive schemas Key areas Entitlement Emotional deprivation Defectiveness

40. Cause - Fonagy Narcissism is a disorder of self. How is the self developed? Due to mirroring of the parent of child’s emotions – overtime a stable sense of self and emotions is developed

41. Cause - Fonagy If the parent acknowledges child, but does not properly mirror feedback, the child develops a dual representation of self 1) child’s experience 2) false self as mirrored by parent Child does not have a stable self representation and manifests itself as poor affect regulation

42. Types of NAR PD

43. Types - Gabbard Type I Thick skinned Egotistical, grandiose Arrogant, craves attention Disregards feelings of others Type II Hypervigilant Thin-skinned Self-effacing Diverts attention Highly sensitive

44. Types - Millon Unprincipled – NAR + ANT Amorous – NAR + HIS Compensatory – NAR + AVD Elitist - NAR

45. Unprincipled Antisocial Drug problems, in prison Confidently amoral Deceptive Exploit others

46. Elitist Pure variant Self-assured, arrogant, impressive Amplified superior self-image Fear being ordinary “Phallic” types Flaunt symbols of achievement Compare themselves to others

47. Compensated A paradox… Confident outside, insecure inside Plaques on the wall Sensitive to reactions of others Façade of superiority

48. Amorous Skilled at erotic seduction Skilled at tempting the “needy” Sexual exploitation Body narcissism Physical appearance Clothes

49. Hollywood Multiple Marriages 8 Times Mickey Rooney Elizabeth Taylor Lana Turner 7 Times Larry King Stan Laurel Martha Raye

50. Turkat – Three Types acceptance-oriented impression management narcissists ruthless impression management narcissists self-centered impulsive narcissists

51. Type I - Turkat life is about creating an impression hard to maintain close relationships desires close relationships best prognosis

52. Type II - Turkat ruthless impression management skilled at manipulating others’ impressions of him or her not interested in close relationships

53. Type III - Turkat self-centered impulsive type key difficulty here is the impulsivity of their actions a great deal of overlap with ANT

54. Assessment

55. Broad measures MCMI-III PDQ-R SNAP OMNI PIQ

56. Assessment Specific Narcissistic PD scale Ashby et al. 1979 *Narcissistic Personality Inventory Raskin & Hall, 1979 MMPI based Inventories

57. Diagnostic Interview for Narcissism Gunderson and Ronningham Semistructured interview Assesses 33 narcissism areas Grandiosity – fantasies Interpersonal Relations – attention seeking Reactive – sensitive Mood States – boredom, hallow Moral Adaptation – superficial, corruptible

58. DIN - Gunderson et al. Key features Boastful, pretentious Self-centered, self-referential Belief that others envy them

59. unprincipled amorous elitist compensated

60. NEOAC SZDL AVDHL DEPH HSTH NARHhl ANTLL COMh SZTHLl BDLHll PARhL See commentary below slide to understand letters and numbers

62. Therapy

63. NAR – Reasons for Therapy Turkat troubled by depression they want something

64. Therapy Rapport Strategies Need for clients to be dominant Don’t criticize

65. Therapy Cognitive Therapy Schema issues “I am the only one who is special” Beliefs need to be challenged

66. Therapy Need to learn to empathize To become Rogerian Therapists Self-sacrifice exercises Anonymous giving Charity work

67. Therapy Judeo-Christian Bible has many references to “pride” Difference between: Internal pride Comparison pride “pride comes before a fall”