What are Personality Disorders?



Narcissism to Narcissistic Personality Disorder: An Understanding and a CritiqueWhat are Personality Disorders?Personality is the way of thinking, feeling and behaving that makes a person different from other people. An individual’s personality is influenced by experiences, environment (surroundings, life situations) and inherited characteristics. A person’s personality typically stays the same over time. A personality disorder is a way of thinking, feeling and behaving that deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time.There are 10 specific types of personality disorders. Personality disorders are long-term patterns of behaviour and inner experiences that differs significantly from what is expected. The pattern of experience and behaviour begins by late adolescence or early adulthood and causes distress or problems in functioning. Without treatment, personality disorders can be long-lasting. Personality disorders affect at least two of these areas:Way of thinking about oneself and othersWay of responding emotionallyWay of relating to other peopleWay of controlling one’s behaviourTypes of Personality DisordersAntisocial personality disorder:?a pattern of disregarding or violating the rights of others. A person with antisocial personality disorder may not conform to social norms, may repeatedly lie or deceive others, or may act impulsively.Avoidant personality disorder:?a pattern of extreme shyness, feelings of inadequacy and extreme sensitivity to criticism. People with avoidant personality disorder may be unwilling to get involved with people unless they are certain of being liked, be preoccupied with being criticized or rejected, or may view themselves as not being good enough or socially inept.Borderline personality disorder:?a pattern of instability in personal relationships, intense emotions, poor self-image and impulsivity. A person with borderline personality disorder may go to great lengths to avoid being abandoned, have repeated suicide attempts, display inappropriate intense anger or have ongoing feelings of emptiness.Dependent personality disorder:?a pattern of needing to be taken care of and submissive and clingy behaviour. People with dependent personality disorder may have difficulty making daily decisions without reassurance from others or may feel uncomfortable or helpless when alone because of fear of inability to take care of themselves.Histrionic personality disorder:?a pattern of excessive emotion and attention seeking. People with histrionic personality disorder may be uncomfortable when they are not the center of attention, may use physical appearance to draw attention to themselves or have rapidly shifting or exaggerated emotions.Narcissistic personality disorder:?a pattern of need for admiration and lack of empathy for others. A person with narcissistic personality disorder may have a grandiose sense of self-importance, a sense of entitlement, take advantage of others or lack empathy.Obsessive-compulsive personality disorder:?a pattern of preoccupation with orderliness, perfection and control. A person with obsessive-compulsive personality disorder may be overly focused on details or schedules, may work excessively not allowing time for leisure or friends, or may be inflexible in their morality and values. (This is NOT the same as?obsessive compulsive disorder.)Paranoid personality disorder:?a pattern of being suspicious of others and seeing them as mean or spiteful. People with paranoid personality disorder often assume people will harm or deceive them and don’t confide in others or become close to them.Schizoid personality disorder:?being detached from social relationships and expressing little emotion. A person with schizoid personality disorder typically does not seek close relationships, chooses to be alone and seems to not care about praise or criticism from others.Schizotypal personality disorder:?a pattern of being very uncomfortable in close relationships, having distorted thinking and eccentric behaviour. A person with schizotypal personality disorder may have odd beliefs or odd or peculiar behaviour or speech or may have excessive social anxietyThe diagnosis or even the existence of personality disorders can be seen as a contentious issue. It is vital that we, as psychotherapists, maintain a critique and do not simply pathologise our clients. There are many articles that offer a critique of the concept of Personality Disorder – especially in the light of DSM-V, and how DSM-V reached its conclusions on personality disorders.So concerning are the traditional methods of defining personality disorder that DSM-V itself is now proposing alternative ways of considering defining personality.Here are some key ideas or critiques that may engage your thinking.Axis 1 Disorders and Personality DisordersThere appears to be a lack of confidence in the relationship between Axis 1 Mental Health disorders and Personality Disorder. The Psychiatric community, quite rightly so, is concerned about consistency of diagnosis – and meaningful diagnosis leading to consistent and effective treatment. There appears to be a lack of specificity between Axis 1 disorders and Personality Disorders – and a sense of lack of understanding of mediators and moderators between the two concepts. If these cannot be defined or understood then what is their consistent value?Currently there is no way of defining the severity of the personality disturbance, so this makes diagnosis very subjective and the planning of treatment difficult.Controversy 1. Is Personality better defined by categories or dimensions?The historic way of defining personality by categories of behaviour seems less useful. Problems with this include lots of overlap between personality disorders, with people satisfying more than one category. (Page 416 of supporting article, Paragraph: “Definition and Diagnostic Challenges”. The alternative of a dimensional system views personality as a continuum and, in this system, personality disorder shows the same pattern of distribution as a normal personality.?It also allows severity to be discussed.Controversy 2. Which personality variables should be assessed in the assessment of personality disorder?There continues to be some debate as to which personality variables should be assessed to make a diagnosis of personality disorder in the normal/abnormal personality continuum. It would seem to be appropriate in this approach to choose those personality variables more likely to be personal and concerned with functioning, in order to assist in understanding the patient's disabilities and obtain strong clues about them. The difficulties encountered in the diagnosis and study of personality disorder include inconsistencies in assessment across both instruments and raters. The cross-instrument reliability between self-report and interview assessments in personality disorders is remarkably poor.26 traits or 18 factors when attempting to define personality.Controversy 3. Is diagnosis of personality disorder stable?Though the definitive feature of personality disorder in the DSM classification is that it is 'pervasive', it now looks as through this definition is incorrect. There is abundant evidence that personality traits are unstable,?and there is also evidence for greater stability of social dysfunction in long-term studies.Controversy 4. Can personality disorder be graded by severity?It has become increasingly clear that some form of severity assessment is necessary to decide on the priorities to use for the management of personality disorder. The notion of severe personality disorder is central to much of the work in the area of forensic psychiatry. What is clear from empirical research studies is that those with more severe personality disorder do not have stronger manifestations of one single disorder as often postulated,46?but instead their personality disturbance extends across all domains of personality.46-48?Although severity is not normally taken into account when classifying mental illness, it is important in personality disorders, as normal personality and personality disorder are both on the same continuum. Unfortunately, there is no measure of severity for personality disorder in the DSM or ICD classification, and the absence of these measures is of significant concern. Indeed, treatment is justified when it is likely to ameliorate distressing or disabling syndromes, even when the patients fail to meet the full diagnostic criteria of psychiatric disorders and, consequently, the measure of severity is highly relevant to the planning and provision of treatment. A reliable way of assessing personality disorder is to use 3 levels of severity (Table 4). By using this measure of severity, it is possible to use the cluster system to get a measure of severity and this measure is also relevant in assessing those with the most severe personality disorders in forensic psychiatry.Table 4Assessment of severity in personality disorder HYPERLINK "" \t "tileshopwindow" The above extracts are from “The Mind in Action - 1947” by Eric Berne – and again from “A Layman’s Guide to Psychiatry and Psychoanalysis” – 1969 first in UKNarcissism can be described as the libidinal investment in the Self. Normal narcissism is necessary to regulate self esteem and to pursue interests and ambitions. It is reality based; encompass is self satisfaction experienced as self esteem, confidence, and a general sense of well being and includes appropriate concern for others. Narcissism moves to the pathological when it becomes self centred , self involved, lacking in empathy .The Spectrum of Entitlement v Narcissism v Narcissistic Personality DisorderNarcissistic Personality Disorder (NPD) is a complex and challenging construct for both clinicians and researchers. It is widely misunderstood and it is relatively rare.One of the first issues is disentangling the construct of ENTITLEMENT which is a component of but not the whole of Narcissism. Entitlement is a trait, NPD refers to a clinical disorderENTITLEMENTNARCISSISTIC PERSONALITY DISORDERA traitClinical DisorderA single trait is not a disorderCore Content ComponentsBehavioural ExpressionsLead to socioeconomic dysfunctionEntitlement – a traitNarcissism – a constructNPD – a personality disorder.All traits are on a spectrum of severity from mild to extreme – which relates to the degree of adaptive and maladaptive influence and impact.Entitlement is when one has a global sense of being more deserving of personally favorable outcomes over others.Having expectations of special treatment without the need or desire to reciprocateThe belief that one is deserving of special treatment and exemptions from typical social consequences and expectations.It is often accompanied by the following components.The need to possess power over othersThe exploitation of othersLess forgivingMore likely to demand or exact revengeMore likely to abuse others when in a supervisory role.ExhibitionismConduct issuesTwo types of entitlement have been identified:Excessive and Exploitative entitlement (maladaptive)PsychopathyNeuroticismPoor Work EthicLow Self-esteemImpaired Social EmpathyLow agreeablenessLow conscientiousnessLow moralityLow altruismLow co-operation and Low SympathyAdaptive and positive Entitlement.Good self-esteemWell—beingExtraversionFriendlinessAsking for what one needs and wants.Assert self to have standards met.The History of Narcissism The term narcissism is based on the Greek mythological figure Narcissus, who after rejecting the advances of the nymph echo, was punished to fall in love with himself in a pool of water. As Narcissus pined away gazing at his own reflection he changed into a flower that bears his name the Narcissus .In 1914 Freud conceptualised the expression of narcissism as the repression of any information or emotion that lessens the individual sense of self .Horney advanced the conceptualisation of narcissism and defined it as self inflation and love and admiration for the value of self that has no equal. Horney’s view converged with Freud's approach in that narcissism stems from loveless caregivers and he postulated that if parents did not love children for their real selves they would compensate by creating inflated versions of themselves to seek admiration and attention.Horney 1939The outward display of self-love is illusoryNarcissism is derived from an inability to honestly love oneself or anyone else.Freud 1957Narcissists are unable to love others because they love themselves too muchWhat are the types and components of Narcissism?SymptomsSigns and symptoms of narcissistic personality disorder and the severity of symptoms vary. People with the disorder can:Have an exaggerated sense of self-importanceHave a sense of entitlement and require constant, excessive admirationExpect to be recognized as superior even without achievements that warrant itExaggerate achievements and talentsBe preoccupied with fantasies about success, power, brilliance, beauty or the perfect mateBelieve they are superior and can only associate with equally special peopleMonopolize conversations and belittle or look down on people they perceive as inferiorExpect special favors and unquestioning compliance with their expectationsTake advantage of others to get what they wantHave an inability or unwillingness to recognize the needs and feelings of othersBe envious of others and believe others envy themBehave in an arrogant or haughty manner, coming across as conceited, boastful and pretentiousInsist on having the best of everything — for instance, the best car or officeAt the same time, people with narcissistic personality disorder have trouble handling anything they perceive as criticism, and they can:Become impatient or angry when they don't receive special treatmentHave significant interpersonal problems and easily feel slightedReact with rage or contempt and try to belittle the other person to make themselves appear superiorHave difficulty regulating emotions and behaviorExperience major problems dealing with stress and adapting to changeFeel depressed and moody because they fall short of perfectionHave secret feelings of insecurity, shame, vulnerability and humiliationThe Grandiose or Exhibitionistic Narcissist.Grandiosity. A fa?ade of self-assurance, self-confidence and self-preoccupation who constantly pursues admiration. Strives for money, power and fame they show great senses of entitlement, grows enraged when criticised and lacks empathy and concern for others in spite of pursuing them to obtain their admiration and approval.Grandiose false self – inflated.Closet Narcissism.They may appear humble, anxious, inhibited or shy.Their focus is the omnipotent other rather than themselves.The other is idealized and the patient’s grandiosity is gratified.The patient basks in the glow of the object.They may experience envy and self-esteem impairment, and depression.Deflated false self - TABLE 1.?DSM-5 Criteria for Narcissistic Personality DisorderaA 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 contexts, as indicated by five (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 expectation 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 and attitudes.TABLE 2.?Proposed Criteria for Narcissistic Personality Disorder in the Alternative DSM-5 Model for Personality DisordersaModerate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:?1.?Identity:?Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.?2.?Self-direction:?Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.?3.?Empathy:?Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.?4.?Intimacy:?Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.Both of the following pathological personality traits:?1.?Grandiosity?(an aspect of?Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.?2.?Attention seeking?(an aspect of?Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.Childhood Origins of NarcissismKernberg19751986Parental rejection, devaluation and an emotionally invalidating environment. This combined with parental inconsistencies or self-absorbed parenting – interacting with the child only to meet the parents’ needs. The child withdraws and develops a pathological self-grandiosity.The child initially interacts with the world in an authentic fashion.The child realises its needs are not going to be met.In response to this realisation, the child creates a fantasized environment of self and others.The child’s retreat into this fantasy world exacerbates the extent to which they perceive the outside world as a harsh and dangerous place.Solace is found in further distortion of self and other.The fantasized world becomes an integral part of the core content of the self.At the surface this is expressed by narcissistic beliefs, behaviours and patterns.This expression is the splitting of the self that provides the foundation for the key aspects of the NPD spectrum.Later evidenced by subjective feelings of emptiness, a continuous desire for admiration and thrills and shame.Kohut1966Proposes the child creates two systems of narcissistic perfection. To compensate for maternal deficiencies. The child creates an idealized parental imago which protects by bestowing an external object with unlimited power, strength and goodness. Necessarily the real object fails, revealing the world as uncertain, frightening and painful.Es Work by MastersonNarcissism can be described as the libidinal investment in the self.The Masterson Approach recognising the underlying intrapsychic structure of the patient, enables the therapist to understand and determine the ways in which the patient perceives and relates to the world.This structure becomes pathological when it is fixed and chronic. Repeats itself over and over, independent of the external environment. It is based on fantasy, and defends against affect, rather than dealing with reality. It has its strengths and weaknesses, which serve both adaptive and maladaptive purposes. Originally it was the child’s response to developmental issues and getting needs met. This defense served a purpose. But they became fixed and rigid.In NPD, the intrapsychic structure of the patient provides a sense of specialness and uniqueness by either identification with, or idealising of the object in order to ward off underlying feelings of humiliation, shame and fragmentation.Masterson speculates that Narcissism develops early than Borderline disturbance – and that it takes place at the developmental stage of Separation-Individuation (Mahler) rather than later in rapprochement.This is the time when the child starts to crawl and walk, returning to the carer for emotional refuelling. The toddler has a love affair with the world. The main point at this stage is the child’s great narcissistic investment in their own functioning, the body, and the objects and objectives of the child’s expanding reality. They are impervious to most bumps and falls.Masterson describes three emerging themes: Exhibitionistic Parents. The parents using the child as an extension of their own grandiosity. Expectations are projected onto the child, who feels loved, adored, admired and loved in a way through this projection. The carer is always there to promote the child and the real self goes underground. The child’s grandiose self is being mirrored and stays out. Any appearance of the real self is met with scorn and humiliation and derision and shame. In response the idealized child will bring out parts of the self that connect with the carer, developing a fused, grandiose omnipotent unit. The child feels loved but was used.Closet. Here the child comes up against subtle scorn, derision and humiliation for expressing their real self. Attacked, devalued and disparaged. Excessive modesty is employed. The child idealizes the parent and effaces the self. This person is more prone to narcissistic vulnerability and injury and is more aware of the impaired self.Devaluing. Derision moves to intimidation, violence, violation, abuse a consistent threat against expressing real or grandiose needs. Devaluing of others is the defense here.The Masterson internal intrapsychic structure of the patient – diagram above:Fused relations unitsOutward, defensive unit is that of a grandiose self-object, which is superior and elite, and an affect of being perfect, special or unique.The omnipotent object is perfect and powerful and necessary for idealization and mirroringGrandiose ExhibitionThey exhibit their specialness and expect perfect mirroring back.Being unique, great, wonderful, special, promising, adored , perfect and entitled.Hidden beneath is the Aggressive Fused Part UnitAn object that is harsh, punitive and attackingA self-representation that is humiliated, shamed and empty.The abandonment depression experienced as shame, humiliation, narcissistic injuryThe affects of the abandonment depression are so devastating, they are immediately defended against by externalizing the depression and projecting its object representation as causing the depression. The problem becomes “out there”They keep equilibrium by avoiding, denying or devaluing.Treatment Considerations from MastersonTracking the triad:Self-activation leading to Painful affect leading to Defensive processes.The mirroring interpretation of narcissistic vulnerability:PAIN - Identify and acknowledge the painful affect the patients self is feeling. This is the mirror that demonstrates to the patient that you understand and empathise with what they are expressing and it makes it possible for you then to add SELF - Emphasise the impact on the patient self in such a way as to indicate your understanding of the patients experience .DEFENSE - Identify and address the defence or resistance which can then be tide to the first part by observing how it protects defends calms and soothes the patient from the experience of the painful affect full stop it is important to point out the function of the defence with great care In order to avoid precipitating a narcissistic injury. Keep in mind that the patience action arose from a need to maintain their self esteem and sense of self cohesion ................
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