Dimensional Conceptualization and Diagnosis of NPD

Similar documents
Understanding Narcissistic Personality: A Brief Introduction NEA-BPD Call-In January 13, 2109

Personality Disorders Explained

Cluster A personality disorders- are characterized by odd, eccentric thinking or behavior.

Managing Personality Disorders in Primary Care

Personality Disorders. Mark Kimsey, M.D. March 8, 2014

Slide 1. Slide 2. Slide 3 Similar observations in all subsets of the disorder. Personality Disorders. General Symptoms. Chapter 9

Personality Disorders

Personality disorders. Eccentric (Cluster A) Dramatic (Cluster B) Anxious(Cluster C)

sample SWAP-200 Clinical Interpretive Report by Jonathan Shedler, PhD Client/Patient: Age: 38 Jane S Race/Ethnicity: Clinical treatment, outpatient

Intersect between self-esteem and emotion regulation in narcissistic personality disorder - implications for alliance building and treatment

Exam 2 Problem Items

Use this list of Emotional Energy Trigger Values to see how the emotions you are feeling affect you physically and behaviorally.

Mental Health Nursing: Self- Concept Disorders. By Mary B. Knutson, RN, MS, FCP

Personality and its disorders

EMOTIONAL INTELLIGENCE TEST-R

Personality Disorders

100% Effective Natural Hormone Treatment Menopause, Andropause And Other Hormone Imbalances Impair Healthy Healing In People Over The Age Of 30!

Reference document. Difficult personalities

COURSES ARTICLE - THERAPYTOOLS.US

Department of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT

Functional Analytic Psychotherapy Basic Principles. Clinically Relevant Behavior (CRB)

Mental Health and Stress

Personality Disorders

Look to see if they can focus on compassionate attention, compassionate thinking and compassionate behaviour. This is how the person brings their

Silent ACEs: The Epidemic of Attachment and Developmental Trauma

Chapter 3 Self-Esteem and Mental Health

Copyright Stan Tatkin, PsyD all rights reserved 1

Advocacy in Difficult Situations. AFSCME Local 88 Steward Training October 19, 2011

Can my personality be a disorder?!

Personality Disorders

Multidimensional Perfectionism Scale. Interpretive Report. Paul L. Hewitt, Ph.D. & Gordon L. Flett, Ph.D.

PERFECTIONISM Inwardly-Focused Outwardly-Focused

Misdemeanors A to Z. Working with Challenging Clients SPD Annual Conference Attorney Liesl Nelson Hudson Trial Office

CCM Conflict Coaching -- Workplace. Coaching High Conflict Parties -Dealing with Defensiveness -Coaching the HCE Conflict Coaching Matters LLC

Other Disorders Myers for AP Module 69

INDIVIDUALS ARE COPING ALL THE TIME.

Dealing with Difficult People Personality Disordered Psychopaths. Anna Salter

Narcissistic Personality Disorder: A Current Review

Psychological Disorders. Schizophrenia Spectrum & Other Psychotic Disorders. Schizophrenia. Neurodevelopmental Disorders 4/12/2018

Maintaining Relationships with Difficult People

Development. summary. Sam Sample. Emotional Intelligence Profile. Wednesday 5 April 2017 General Working Population (sample size 1634) Sam Sample

The Attentional and Interpersonal Style (TAIS) Inventory: Measuring the Building Blocks of Performance

9/28/2018. How Boosting Emotional Intelligence Improves Your Leadership Ability

ANGER MANAGEMENT CHECKLIST. by Frank D. Young Ph.D., R. Psych.1[1]

BORDERLINE PERSONALITY DISORDER: A LITTLE COMPASSION CAN GO A LONG WAY

Psychiatric Diagnoses In Developmentally Disabled Persons

What is schizoid personality disorder? Why is the salience or ability to focus and connect potential punishments important in training sociopathics?

The mosaic of life. Integrating attachment- and trauma theory in the treatment of challenging behavior in elderly with dementia.

TTI Success Insights Emotional Quotient Version

Personality disorders. Personality disorder defined: Characteristic areas of impairment: The contributions of Theodore Millon Ph.D.

Can my personality be a disorder?!

Traits: Prominent enduring aspects and qualities of a person.

Chapter 2 Lecture. Health: The Basics Tenth Edition. Promoting and Preserving Your Psychological Health

Debra Dupree, MA, MFT Advanced Practitioner in Workplace Mediation Certified Conflict Coach THE EMOTIONALLY INTENSE EMPLOYEE

Emotional Development

Outline. Emotion. Emotions According to Darwin. Emotions: Information Processing 10/8/2012

Can my personality be a disorder?!

Self-confidence can increase or decrease according to the context (situation, time, people) we are in.

Dealing with Difficult People Personality Disordered Psychopaths. Anna Salter

Glossary of Terms for HONORS GROUP. Segment #1: Term Definition Notes Psychological health depends on being able to

BroadcastMed Bipolar, Borderline, Both? Diagnostic/Formulation Issues in Mood and Personality Disorders

Behavioral EQ MULTI-RATER PROFILE. Prepared for: By: Session: 22 Jul Madeline Bertrand. Sample Organization

Personality Disorder in Primary Care. Dr Graham Ingram Consultant Psychiatrist

The Healing Power of Emotion

Overview of Sullivan's theory

Obsessive Compulsive and Related Disorders

Mental Health and Stress Management

Helping Your Asperger s Adult-Child to Eliminate Thinking Errors

COMMUNICATION- FOCUSED THERAPY (CFT) FOR OCD

THE INTEGRITY PROFILING SYSTEM

Emotional Quotient. Andrew Doe. Test Job Acme Acme Test Slogan Acme Company N. Pacesetter Way

PowerPoint Lecture Outlines prepared by Dr. Lana Zinger, QCC CUNY Psychosocial Health: Being Mentally, Emotionally, Socially, and Spiritually Well

3/9/2017. A module within the 8 hour Responding to Crisis Course. Our purpose

Emotional Intelligence

Hostility Management in the Workplace and Beyond

Overview of cognitive work in CBT

SAMPLE. Behavioral EQ SELF-PERCEPTION PROFILE. Prepared for: By: Session: 23 Jul Lars Dupont. Sample Organization

Strategies for Dealing with Challenging Interpersonal Interactions in a Mental Health Setting

Neff, K. D., & Lamb, L. M. (2009). Self-Compassion. In S. Lopez (Ed.), The. Encyclopedia of Positive Psychology (pp ). Blackwell Publishing.

Enhancing Support for Special Populations through Understanding Neurodiversity

Nineteen Relational Brain-Skills That Must Be Learned

Mental Illness and Disorders Notes

Communication Tools. Paul Deslauriers

Compassion Resilience

Resilience in the RTW Context

References. Note: Image credits are in the slide notes

Benchmarks 4th Grade. Greet others and make introductions. Communicate information effectively about a given topic

Violence and Mental Illness Resources Wednesday, August 16, :30 PM 5:00 PM

COUPLE COUNSELING ASSESSMENT

Emotional Quotient. Megan Nice. Owner Sample Co Your Address Here Your Phone Number Here Your Address Here

Can my personality be a disorder?!

Personality Disorders. Personality Disorders. Definition of personality. Trait theory of Personality. Trait theory of Personality

Psychological needs. Motivation & Emotion. Psychological needs & implicit motives. Reading: Reeve (2015) Ch 6

Contents. Chapter. A Closer Look at You. Section 17.1 Your Personality Section 17.2 Develop a Positive Attitude. Chapter 17 A Closer Look at You

Emotional-Social Intelligence Index

Jonathan Haverkampf SELF-CONFIDENCE SELF-CONFIDENCE. Christian Jonathan Haverkampf, M.D.

EMOTIONAL INTELLIGENCE QUESTIONNAIRE

Groups and Group Dynamics. Steve Buller

Leadership Beyond Reason

INTERPERSONAL RELATIONSHIPS (IR)

Transcription:

Dimensional Conceptualization and Diagnosis of NPD APA Atlanta 2016 Elsa Ronningstam, Ph.D

. No Conflicts of Interest

Objectives 1) outline the DSM-5 Section III hybrid dimensional and trait focused diagnosis for narcissistic personality disorder; 2) identify the range of narcissistic personality functioning with fluctuating self-esteem and co-occurrence of both self-enhancing grandiosity and self-depleting vulnerability; 3) discuss empathic capability and compromised functioning

Case Vignette A young man, Bob 21 years old, dropped out of college and was hospitalized with a range of problems: At the initial evaluation the clinician noticed general anxiety, obsessive compulsive preoccupation, racing thoughts, social anxiety, avoidance, and suicidality. Family members and friends portrayed Bob as inconsiderate, demanding and demeaning with threatening and verbally aggressive behavior, and involved in poly substance abuse. Bob described himself as struggling with internal agony caused by his inconsistent cognitive intellectual functioning, and feeling overwhelmed by insecurity and internal self-criticism. He often felt frustrated with other people; he found them stupid, unpredictable and difficult to understand. In addition, he had been isolating and engaged in internet sex-dating where he felt safer and more in control compared to if he tried to meet somebody at bars and parties.

Case vignette continue.. Bob also described the week before being hospitalized; On Friday he met with his professor and began outlining a project for a paper. He thought the meeting went well as he perceived that his ideas were well understood and appreciated by his professor, and he left feeling motivated and competent. On Sunday he spoke in front of 10.000 people at a big sports event at his college. Apparently he did a good job, both according to his own assessment and based on the others enthusiastic feedback. With a smile he admitted that he felt he could become a future president of the US. On Tuesday he found himself unable to speak in front of his class of 8 peer students. It was his turn to present the outline of his project, and just before the class began he experienced sudden anxiety with difficulties holding on to logical thinking and reasoning. When he was about to begin he experienced a total cognitive blockage and had to leave the room. A day later he saw no future for himself and struggled with excruciating self- reproach and intense suicidal ideations and impulses. He anticipated critical and stupid comments from his peers and feared the anticipation of exposing himself to something he could not control. Most of all, he felt unable to rely upon his own competence and dreaded a sudden loss his ability to think and speak.

Case vignette continue. Bob was highly intelligent, with an IQ in the range between 140 and 150. Some even considered him to be a genius, although he himself did not believe that, but he appreciated the admiration and acknowledgement. He was a competitive swimmer and leader of his swim team, and had encountered no problems with either swimming or team leadership. He had overall done well in college, especially on exams, and received high grades despite some inconsistencies. His professional aspirations and plan was to become a lawyer like his grand-father. He met 8 out of the 9 DSM IV criteria for NPD (not #6, interpersonal exploitive) according to the Diagnostic Interview for DSM IV Personality Disorders, DIPD-IV, (Zanarini et al 1996).

Case vignette end. After having presented this rather diverse set of experiences Bob said to the therapist: I cannot trust my faculties, I do not know from one day to another whether I can rely on my thinking and reasoning, access my knowledge, communicate and perform. I struggle inside myself with dreadful self-scolding, constantly comparing and criticizing myself. I am a perfectionist, and I know that I can be very good, even exceptional. I have been considered a genius, but it does not hold up. I can t tolerate closer contact with people. I get so angry and frustrated at them. I can see that I may be unfair, at times, but I just can t stand it. It works much better when I am in charge or if there is a distance to other people, like if I have a large audience. I feel extremely afraid of the future and ashamed of having to be in treatment. Some days I really doubt that anything can change or that I can get help, other days I can feel more optimistic

NPD in DSM 5 Section II - the Trait Model 1 Grandiose sense of self-importance 2 Fantasies of unlimited success, power, etc. 3 Believes being special and unique 4 Requires excessive admiration 5 Sense of entitlement 6 Interpersonally exploitive 7 Lack of empathy 8 Envious of others 9 Arrogant, haughty behavior or attitude

Shortcomings in trait focused NPD diagnosis Insufficient conceptualizations of NPD/narcissism not including: nature of narcissism: from normal and healthy to pathological and malignant phenotypes of pathological narcissism: grandiose and vulnerable expressions of pathological narcissism: overt/external/interpersonal and covert/internal/subjective self-regulatory fluctuations in identity and self-esteem, emotions, empathy and interpersonal relations

Major dimensions in pathological narcissism and NPD Healthy narcissism pathological narcissism High level of function low level of function disabled, antisocial/psychopath Functional stability functional fluctuations Enhanced /grandiose devalued /vulnerable co-existing with both overt and covert expressions Confident/assertive insecure/ inadequate difference between external presentation and internal experiences Pincus, Lukowitsky 2010; Russ, Shedler, Bradley, Westen. 2008; Horowitz 2009; Vater, Ritter, Strunz, Ronningstam, Renneberg, Röpke, 2014; Pincus Cain, Wright 2014

NPD in DSM 5, Section III The alternative Hybrid Model - Dimensions #1 A. Moderate to greater impairment in personality functioning manifest 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 may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem. 2. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations. American Psychiatric Association 2013, pp 669-670

NPD in DSM 5, Section III The alternative Hybrid Model - Dimensions #2 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. American Psychiatric Association 2013, pp 669-670

NPD in DSM 5, Section III The alternative Hybrid Model - Traits B. 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; condescending toward others. 2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking. American Psychiatric Association 2013, pp 669-670

Advantages with DSM 5 Section III for NPD #1 Incorporates conceptualizations and research on narcissism and self-esteem regulation, perfectionism, empathic functioning and emotion regulation Captures a broader range of narcissistic personality functioning, including the fluctuations and variability and its phenotypic and clinical presentation Applies a language that is more diagnostically meaningful and informative, and less one-sided, judgmental and derogatory

Advantages with DSM 5 Section III for NPD #2 Self-direction => self-agency, competence, decision making, sense of control (internal, external) Interpersonal relationships => influenced by selfregulatory patterns, emotions, empathic capability and self-esteem/self-enhancement Empathy => a capability with impairment and fluctuations ( NOT a lack of empathy)

Diagnostic benefits Dimensional self-regulatory conceptualization of pathological narcissism can help to: 1) identify the patient s fluctuating self-esteem and the co-occurrence of both self-enhancing grandiosity and self-depleting vulnerability 2) differentiate temporary fluctuating or externally provoked features and patterns from enduring indications of pathological narcissism 3) recognize narcissistic individuals internal suffering related to insecurity, self-criticism, anxiety, shame, and fear and differentiate from external often domineering or provocative surface presentation

Self-esteem regulation in NPD: DSM 5 section III #1 Identity: excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in selfesteem.

Self-esteem regulation in NPD: DSM 5 section III #2 Self-direction: goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement

Self-esteem regulation in NPD: DSM 5 section III #3 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.

Sum up: NPD and self-esteem in DSM 5 Self-esteem regulation include both enhancement and depreciation (grandiosity and inferiority) and fluctuations in between other-oriented/gain and approval self-focused /standards and assessment affected by emotion regulation Self-esteem traits self-centeredness, self-enhancement (grandiosity, uniqueness etc) entitlement, admiration seeking, condescending

Empathy A trait or dimension in NPD in DSM-IV-TR and DSM 5, Section II Lack of empathy ********************************* in DSM 5, Alternative Section III 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. American Psychiatric Association 2013

Conclusions from empirical studies on empathic functioning in NPD Evidence for compromised empathic functioning, but not an inability or its absence, in people with pathological narcissism and NPD. Research suggests: a) neural deficiency in emotional empathy, b) motivational and self-regulatory based fluctuations (engagement/disengagement) in cognitive empathic functioning c) tendency to overestimate own emotional empathic capability. d) difficulties accessing own and others emotions and simulating others affective states e) shift from inter to intra-subjective relationship and increased focus on self Ritter Dziobek, Preissler et al, 2011 ; Fan, Wonneberg, Enzi, et al., 2011.

Compromised empathic functioning in narcissistic personality disorder, NPD Can be caused by absence of motivation or by deficits in cognitive functioning or emotion regulation The person can be able to see and understand others reactions but be unable or unwilling (either or both) to respond The perception of others feeling states can evoke overwhelming powerlessness, disgust, shame or loss of internal control that trigger strong aggressive reactions or emotional or physical withdrawal. Other s empathy towards self can be experienced as a dangerous intrusion The narcissistic patient may or may not be aware of such a deficit Ronningstam 2009; Tangney 1995; Glasser 1992 ; Baskin-Somers, Krusemark, Ronningstam, 2014

Video Recording

Clinical observations of empathy in patients with NPD oscillation between susceptible awareness with sometimes intense negative reactivity (pain, intolerance, irritability), which can co-exist with obliviousness or ignorance. notable interpersonal fluctuations altering between self-motivated and skillful self-promoting engagement, aggressive rejections, and emotional coldness or dismissive avoidance. surprising capability and accuracy in reported self-awareness, as well as in their more distant perceptions and descriptions of own and others emotional states and reactions. Both motivational fluctuations (engagement/disengagement) as well as interactions and fluctuations between competence and deficits in empathic processing are actively influencing the patients interactions. Baskin-Somers, Krusemark, Ronningstam, 2014; Ronningstam 2009

Factors impacting on empathic capability and functional pattern a) high degree of self-centeredness and focus on self-enhancing and self-serving interpersonal strivings. b) emotion dysregulation, i.e. insensitivity or impaired ability to appraise certain emotions in others, such as despair, sadness, grief, joy, happiness; or difficulties in tolerating, modulating and processing certain own emotions triggered by the perception of others experiences or emotions, such as strong negative feelings of contempt, shame, rage or envy. c) self-esteem dysregulation where the perception of others experiences evoke self- promoting or self-enhancing strivings, or alternatively, feelings of inferiority, or powerlessness; d) superego dysregulation with compromised ability for care and concern, exploitative efforts, disregard for the possessions and well-being of other people, or deceitfulness.

Compromised empathic functioning in patients with NPD #1 Can cause: recurrent interpersonal failures or conflicts; fluctuating or consistently low self-esteem; underlying insecurity The narcissistic individual, ready to blame others, may or may not be aware of such deficits. Ronningstam, 2009

Compromised empathic functioning in patients with NPD #2 Empathic impairment can: threaten or even cause a loss of the individual s sense of internal control. The perception of others feeling states can evoke overwhelming powerlessness, disgust, shame or loss of internal control that trigger strong aggressive reactions or emotional or physical withdrawal. be expressed in a tendency to selflessly merge and tune in to the other to perfect an empathic effort. Ronningstam 2009

Stability and fluctuations in NPD. Factors contributing to stability in NPD Theory of mind Cognitive empathic ability Dismissive and avoidant attachment Interpersonally critical, devaluing, contemptuous attitude Motivational need for admiration /personal gain Factors contributing to fluctuations in NPD Emotion dysregulation Compromised emotional empathic capability (identifying, tolerating, verbalizing, communicating feelings) Anxious /preoccupied attachment Motivational oscillations Diamond, Meehan 2013; Baskin-Sommers, Krusemark, Ronningstam 2014;

Stable narcissistic self-esteem dys-regulation Competence and strategies to enhance or sustain self-esteem and protect fragility include: skillful vocational, interpersonal and/or social engagement to ensure self-sufficiency and control, gains, attention, approval, or success. Underlying fragility when unfolded can lead to increased pathological narcissism, functional collapse, depression or suicide

Fluctuating narcissistic self-esteem dys-regulaiton Competence and sustaining/enhancing strategies less consistent and alternating with more or less intense experiences of fragility/ reactivity and insecurity emotional dysregulation interpersonal/social dysfunction compromised sense of agency and skillfulness

A Regulatory Model for Narcissistic Personality Functioning Ego-ideals/ perfectionism Self-criticism Internal control selfregulation Self esteem Sense of agency Life competence and affiliation Work, creativity, relationships, social and moral adjustment Emotion regulation Empathic ability

Stability and fluctuations in NPD Conclusions Co-existence of vulnerability and grandiosity in NPD can explain paradoxical instability of narcissistic behavior patterns Due to meta-cognitive deficits and low self-regulatory abilities, people with NPD are unable to resolve the contraction between grandiose ideal self-presentations and underlying vulnerability. Underlying (not necessarily conscious) insecurity guides the perception of social cues and, in response, triggers self-serving internal and interpersonal strategies. For example, when grandiose ideals are threatened by negative social feedback, people with NPD engage in defensive behavior strategies in order to defend the vulnerable self. Vater, Ritter, Strunz, Ronningstam, Renneberg, Roepke 2014

A dimensional approach to identifying NPD Treatment implications Attend to: the individual range of narcissistic self-esteem regulation including areas or moments of healthy, enhanced, vulnerable, brittle as well as (when applicable) malignant/psychopathic and destructive functioning the organizing and protective role of pathological narcissistic functioning i.e., self-enhancement, excessive perfectionism, aggressive reactivity, variable emphatic engagement, etc specific contexts and experiences that cause regulatory fluctuations, vulnerability and threats to self-esteem or sudden loss of agency

Sum up Patients with NPD can be consistently high functioning, vocationally successful, and/or socially adjusted and connected. develop relationships and life contexts that support sense of agency and capability, and protect their underlying vulnerability. experience changes in life or face actual circumstances that may lead to a sudden unfolding fragility with immediate or gradual impairment and aggravation of pathological narcissistic patterns and features. present with fluctuating personality functioning ranging from self-enhancement and assertiveness to inferiority and insecurity and with more or less severely disabling narcissistic character patterns and long-term impairments. Functional fluctuations can be dependent on interpersonal, as well as social, vocational, or general life contexts. underlying narcissistic trauma; malignant, psychopathic, or antisocial traits; comorbid mental disorders (mood disorder, substance use disorder, PTSD Phenotypic presentation range from : charming and friendly, competent and assertive; shy and timid, intrusive and controlling; domineering and competitive, aggressive and manipulative.

END