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narcissistic personality disorder
Definition
An individual with narcissistic personality disorder exhibits extreme self-importance, inability to empathize with others and heightened sensitivity to criticism. Self-involvement and lack of empathy characterize this personality disorder.
People with narcissistic personality disorder are frequently perfectionists and need to be the center of attention, receiving affection and admiration, and controlling the situation. To get the attention he craves, he may try to create crises that return the focus to him. Like patients with antisocial personality disorder, this person places entitlement issues at the fore. He feels that the world owes him, regardless of whether he makes a contribution.
Alcohol and other drugs (AOD) can induce states that mimic a personality disorder, but if an AOD-using person with a personality disorder abstains, only the symptoms of the personality disorder will still be evident. AOD use may trigger or aggravate a personality disorder. The course and severity of personality disorders can also be made worse if other psychiatric problems, such as mood, anxiety and psychotic disorders are present.
A patient with a personality disorder frequently uses AODs to relieve her symptoms: to raise self-esteem, decrease feelings of guilt and amplify feelings of diminished individuality.
Narcissistic personality disorder often leads to use of drugs, particularly stimulants. As a disinhibitor, alcohol may help lower anxiety and alleviate depression. A shy person with narcissistic personality disorder may depend on marijuana to relieve her social anxiety, while others use steroids to boost confidence in physical perfection. Without AODs, a person with narcissistic personality disorder may believe that others are overly critical or do not adequately appreciate her good qualities. In a crisis, she may become severely depressed.
Symptoms
* Overreacts to criticism, becoming angry or humiliated * Uses others to reach goals * Exaggerates own importance * Entertains unrealistic fantasies about achievements, power, beauty, intelligence or romance * Has unreasonable expectation of favorable treatment * Needs constant attention and positive reinforcement from others * Is easily jealous
Causes
The exact cause is not known. Although onset of the disorder is usually early adulthood, it is likely to be in response to childhood experiences. A psychological evaluation may be performed.
Treatment
Psychotherapy may be useful in getting the individual with narcissistic personality disorder to relate to others in a less maladaptive manner. The following guidelines may help therapists working with these patients, especially those who are also AOD-dependant.
Engagement
Therapists can actually use the narcissistic features of their patients to engage and assess them. To avoid angering the patient, it's important to work with, rather than belittle, the narcissistic ego. A therapist should, for example, address a patient's heightened self-importance and desire for control by saying such things as "Because you are obviously such an intelligent and sensitive person, I'm sure that, working together, we can get you past your current difficulties."
Narcissistic personality traits can also be used to provide motivation for therapy. The patient may be induced to change negative behaviors: a better appearance, improved career prospects, or romantic and sexual conquests can been viewed as a reward for recovery.
Therapists will need to address thinking errors—which may reflect inflated self-esteem ("I'm the star of the office") or hypersensitivity ("My coworkers are trying to get me fired")—that interfere with the patient's ability to work.
While empathizing with the patient, the therapist should offer reality testing. If a patient complains that, "things are really going wrong" or "everyone is against me," the therapist might sympathize, but tactfully point out the reality of the situation and how it could be improved by behavior changes the patient could make.
Crisis stabilization
In a crisis situation, the therapist should assess the patient's defenses, and to put them to therapeutic use. For example, when a patient blames his wife for "calling the police on me," the therapist can mention that the best way to avoid being arrested is to stop getting drunk and hitting her.
Patients with narcissistic personality disorder are often perfectionists. For them, the best way to approach their problems is from a "no-fault" disease perspective. This removes blame from the patient and allows her to perceive her illness as a biochemical disorder, reducing the sense of failure that can make treatment more difficult.
A patient with narcissistic personality disorder tends to become depressed when his feelings are badly hurt, when his defenses have let him down and when he believes his world is collapsing. When wounded, he is at the greatest risk of acting out, either against himself or others. A patient experiencing a narcissistic rage may become homicidal, particularly if he has a need to seek revenge. Because of the intensity of the narcissist's emotions, the counselor needs to deal very carefully with this anger and avoid a power struggle.
Patients believed to be suicidal should be asked to sign a safety contract. To stabilize the patient, a brief, goal-oriented hospitalization may be necessary.
Because HIV-positive patients with narcissistic personality disorder are likely to view themselves as expert lovers, therapists should establish contracts with them to practice safe sex. Otherwise, the wide-ranging sexual encounters that often accompany the narcissistic ego, puts them at high risk for sexually transmitted diseases.
Longer-Term Care Individual Counseling
Ongoing therapy is needed to manage not only the self-aggrandizement, hypersensitivity, and need for control and attention found in narcissistic patients, but also their anger and depression. Individual and group treatments for patients with antisocial personality disorder, including 12-step programs, are often helpful for patients with narcissistic personality disorder. In fact, therapists may want to approach an individual with narcissistic personality disorder as a hypersensitive version of an antisocial personality disorder patient.
Group Therapy
Group therapy may be helpful for patients with narcissistic personality disorder, but the therapist should, tactfully but firmly, place limits on their speaking time so that they cannot control the discussion or focus all the attention on themselves. Explaining that members of the group need to share the time, therapists may want to make a contract with patients with narcissistic personality disorder before each session to encourage pro-social behaviors. Some of these behaviors include:
* Limiting speaking time * Not interrupting other speakers * Respecting the feelings of others * Responding to other group members * Listening objectively to responses and feedback from others
It is important to continue to use the patient's behavior traits rather than to attack the narcissistic ego. It's best to be empathic while confronting the narcissist: "I can see that you are hurt to hear that not everyone in the group believes you."
Continuum of Care
For patients with narcissistic personality disorder, the least restrictive treatment environment is preferable. It permits patients to feel that they are in control. These patients are normally moved quickly from inpatient to outpatient levels of care. If they do not like the treatment, they will stop participating. Thus, it is critical not to over-pathologize the patient's disorder with constant criticism. However, acute hospitalization for psychiatric emergencies (such as homicidal or suicidal plans) may be necessary.
Narcissistic patients generally enjoy the attention they receive through involvement in outpatient treatment. Long-term outpatient involvement is critical to maintain a narcissistic patient's pro-social behavior and sobriety. Therapists who strive to build narcissistic patients' strengths and who pay close attention to them in therapy will find them active participants in the recovery process. In addition to their personality disorder and AOD use disorder, some patients may engage in compulsive sexual or spending behaviors that should be addressed therapeutically.
