Introduction This research paper is on Narcissistic Personality Disorder. Three journal articles were utilized in the research process. The first article is titled Subtypes, Dimensions, Levels, and Mental States in Narcissism and Narcissistic Personality Disorder. It was written by Kenneth N. Levy of Pennsylvania State University and published in 2012. The main points discussed in this article are surrounding the various concepts of NPD existing in dimensions and with overt and covert sublevels. The author used research to point out how the DSM-IV fails to capture that grandiose presentations and covert vulnerable presentations actually represent the two sides of a single spectrum. I chose this article as it gave a deeper perspective than the more ridged clinical picture offered in the DSM-IV. The second article is titled Categorical and Dimensional Models of Pathological Narcissism: The Case of Mr. Jameson. It was written by Christopher R. D. Roberts and Steven K. Huprich of Eastern Michigan University and published in 2012. The main points discussed in this article are how the current categorical construct of NPD ignores the complexities of the underlying vulnerabilities of the disorder. It also discusses how assessing grandiosity and vulnerability as dimensional, interactive components provides a greater working utility. The authors accomplish this through offering examples of various supporting research in addition to a detailed case study of a patient who presented as fragile, shy, and sensitive, yet had vivid fantasies about his superiority. The authors highlighted how anxiety, shame, and submissiveness can co-occur with grandiosity and maintain the classic NPD characteristics of self-esteem dysregulation. I chose this article to gain deeper insight into how grandiosity would subconsciously present within the covert vulnerable presentation. The third article is titled Mirror, Mirror on the Wall: Reflecting on Narcissism. It was written by Donna S. Bender of University of Arizona and was published in 2012. The main points discussed in this article are surrounding the conceptualization and treatment of NPD. The author achieves this by exploring research surrounding various treatment methods, and offering a breakdown of techniques and suggestions used in a presented case study. I choose this article as it provided insight into how NPD is best treated.

Background: Narcissistic Personality Disorder Narcissistic Personality Disorder (NPD), also known as pathological narcissism, is a personality disorder best conceptualized as a dysregulation of self-esteem. Narcissistic traits can begin as healthy, normal parts of human development. Narcissistic behaviors are commonly seen in children and teenagers and do not indicate a future pathology. Healthy narcissism compels one to achieve their highest goals and have a balanced self-esteem. It also has a protective element in that it grants one the ability to interpret a criticism as a passing event to be ignored or one to learn from. Narcissistic Personality Disorder, however, decodes the same comment as an attack on the sense of self (Roberts and Huprich, 2012). NPD is essentially characterized by pervasive patterns of grandiosity, increased need for admiration, and a lack of empathy for others beginning in early adulthood and presenting in various context. NPD is prevalent in 2-16% of the clinical population and less than 1% of the general population with three-quarters of them being men. There is a growing sense that pathological narcissism is on the rise and is more prevalent among younger adults (Bender, 2012). According to the DSM-IV-TR there are nine criterion and five or more must be present to receive this diagnosis. NPD can be broken down in two subtypes: overt type and covert type where the basic elements are present, although they may present differently. Many current clinical writers argue that rather than viewing NPD through the lens of sublevels it would prove increasingly beneficial to view them as two dimensions that interact together to comprise a single pathology (Bender, 2012). The recommendation is to assess both dimensions along with the existence of any healthy narcissistic attributes to gain the greatest clinical utility and most comprehensive understanding of a patient’s individual pattern (Bender, 2012). Individuals with NPD may exaggerate their achievements while overestimating their abilities. The overt type often appear arrogant, pretentious, and boastful where in contrast the covert type presents as inhibited and outwardly modest expressing their grandiosity through an over identification with suffering. The covert thought is that no one suffers as much as they do and they should be held in the highest regards for their ability to with stand great amounts of pain. Individuals with both types of NPD are extremely self-absorbed with unrealistic grandiose expectations of themselves (Levy, 2012). Due to a grandiose sense of self-importance they tend to assume others hold the same perspective of them and view them as superior. When the opposite is found these individuals tend to be surprised at the absence of adoration or feel that the lack is due to envy. Accompanying this inflated sense of self is a devaluation of the successes or contributions of others. There is often times a preoccupation with fantasies of unlimited power, success, beauty, brilliance, or ideal love. Individuals with NPD often compare themselves to famous celebrities and other high achievers. They may spend time reflecting over accomplishments where praise is overdue or privileges should have been granted. These individuals believe they are unique and superior and therefore can only be understood by others of the same accord. They tend to be very selective with whom they associate or institutions they are affiliated with. Their self-esteem is heightened as they reflect over the idealized value they place on an associate or institution, however, in the event of a disappointment they will protect themselves by devaluing the credits of the aforementioned. Discrediting of the success of others can also be attributed to an underlying jealousy towards those receiving praise as they arrogantly believe they were better suited for the acknowledgement. Due to the inability to regulate their self-esteem these individuals invariably have very fragile self-esteems resulting in a hypersensitivity to the evaluations of others. This vulnerability in self-esteem increases the risk of “injury” from criticisms or perceived defeats. Outward reactions to inflicted “injuries” may range from frustration, rage, and defiant counterattacks to cold indifference, embitterment, and disdain. All the while these reactions appear to be used to mask haunting feelings of humiliation and pessimism that can lead to social withdrawal and depression. There is a feeling of deep shame from the perception that they have fundamentally fallen short of some internal idea when they are faced with any form of criticism (Bender, 2012). This almost inability to cope with defeat may lead to them avoiding taking on competitive encounters that risk exposing their vulnerability. In the covert type this can present as an assiduous avoidance of the spotlight, while in both types in can present as a decrease in vocational functioning. Many clinical writers believe that these individuals suffer with violently oscillating mental states that swing from heights of grandiosity to depths of despair and self-incrimination (Levy, 2012). This oscillating theory may account for one of the frequently associated co-morbid diagnosis of Anorexia Nervosa, Cocaine Abuse, or Major Depressive Disorder. To counter these negative emotions these individuals require excessive admiration and often times are preoccupied with how they are favorably regarded by others as there is a need of constant feedback from outside elements to determine their worth. They can be quite charming in the pursuit of admiration which can lead to a favorable first impressions, however a strong sense of entitlement evident in unreasonable expectations often results in difficulty maintaining healthy long term relationships. This sense of entitlement leaves them feeling like their priorities are of the highest importance and that others should always and willingly defer to them. Any form of hesitance from others is met with irritation or anger as there is a thought that they are entitled to whatever they want or need regardless of the effect on others. They often display patronizing attitudes and snobbish behaviors. This lack of sensitivity towards other people’s feelings can lead to the exploitation of others with relationships being formed only at the appeal that it will enhance their self-esteem or advance their goals. They tend to have little regard for the feelings of others as well as possessing a general lack of empathy. They are often impatient and contemptuous when others present their needs and will defer the attention back to their own desires. When the needs or feelings of others are recognized by them it is usually viewed as a weakness and may even be pointed out in a hurtful comment. People with close interactions with these individuals are usually left feeling unappreciated, used, and exploited due to the emotional coldness and lack of reciprocal relational investment.
Causes of the Disorder Traditional psychodynamic theorist propose NPD is the result of cold, rejecting parents and the disorder is derived from unhealthy coping skills formed to defend against feelings of rejection, and unworthiness (Comer, 2013). Object relations theorists view grandiose self-image as a way of convincing one that close personal relationships are not needed as one is self-sufficient. “Kernberg (1984) identified the roots of pathological narcissism as an attempt to survive with parents who were rejecting and devaluing, or who used the child to satisfy their own needs” (Bender, 2012). Research has supported this perspective by finding that people who are abused, or lose their parents through adoption, divorce, or death are at a particularly high risk for developing NPD (Comer, 2013). In contrast cognitive- behavioral theorist propose NPD may develop when people are treated too positively in their early developmental stages by overly doting parents (Comer, 2013). In this theory certain individuals may acquire a superiority complex second to receiving repeated praise for minor accomplishments or in spite of lack of accomplishments. Sociocultural theorist see a link between NPD and “eras of narcissism” in society resulting from a break down in family values and social expectations (Comer, 2012). The current rising trend of NPD among young adults could be contributed to the culture of narcissism that is being developed in the United States today as evidenced by the preoccupation with self that is evident in the popularity of Facebook, Instagram, and reality TV.
Treatments of the disorder Narcissistic Personality Disorder (NPD) is the most challenging disorder to treat. This is in part to the basic patterns of the disorder such as an inability to acknowledge weakness, an extreme sensitivity to slight leading to increased difficulty receiving feedback, and a poor appreciation for the effects their behaviors have on others. These basic patterns can lead to power struggles between the client and the therapist creating significant challenges in establishing good working alliances. Another barrier to a cohesive team approach to treatment is the presence of sadomasochistic traits related to narcissistic disturbance (Bender, 2012). People with narcissistic difficulties display a compensatory pattern of sadomasochistic relationships. They attempt to manage their own vulnerabilities by either masochistically submitting or sadistically exerting power over others, or often times both. This inevitably comes into play in the patient-therapist relationship and leaves the therapist unable to effectively utilize various therapeutic interventions (Bender, 2012). Once in treatment these individuals may try to manipulate their therapist and develop a love-hate relationship with them (Comer, 2013). Therapist have to pay attention and prepare for instances of negative transference. Yet another barrier to treatment is the ever present destructive presence of perfectionism. Debilitating perfectionism is one of the core pathological aspects of narcissism (Bender, 2012). These perfectionist demands are put upon themselves as an attempt to regulate their self-esteem, however this typically results in ongoing extreme self-criticism and disappointment from not reaching an unrealistically high standard. This serves to feed a perpetual cycle of magnified expectations quickly followed by debilitating defeat. This pattern gets in the way of therapeutic growth as once these individuals are able to except the need for treatment and become engaged, they set high expectations that they will be able to heal themselves in an unrealistic time frame only to feel like a failure when they have not met this perceived goal. The repeatedly occurring instances of vacillation between idealizations and devaluations can leave a therapist feeling confused and deskilled. “Therapist have to be on guard not to over interpret these behaviors or respond defensively, aggressively, or collude with the pathology through passivity” (Levy, 2012). Avoiding these counterproductive reactions or therapist burn out can be facilitated by the therapist maintaining a personal reflective stance as well as engaging in structured supervision. Patients with NPD typically show significant impediments to beginning treatment and/or fully engaging in treatment. Typically patients who seek treatment usually do so because of a related disorder, most commonly depression or anxiety, however it is imperative that a thorough assessment of symptoms is taken to distinguish NPD. Unfortunately when a person with NPD is presenting with multiple symptoms coupled with the aforementioned barriers they are treated with medications or symptom-focused therapies that do not address the underlying pathology. This presents a strong challenge and a need for address as the literature that exists clearly shows that NPD increases the likelihood of treatment dropout and slow symptom change (Levy, 2012). Critics to the DSM-IV believe that the ridged clinical picture of NPD adds to this occurrence as it only includes criteria that asses for grandiosity, entitlement, exploitation, and arrogance omitting aspects of vulnerability (Roberts and Huprich, 2012). By understanding these behaviors serve as defense mechanisms against the vulnerability that is felt then NPD may be more easily identified. In addition to therapist having a more dimensional perspective for assessment and treatment sharing diagnostic impressions with the patient may help facilitate a stronger collaborative effort and commitment to treatment goals on behalf of the patient. If the patient thinks they only have a depressive disorder, yet the therapist is assessing a personality disorder and not sharing then it perpetuates the barriers to treatment. “Having a diagnostic understanding of their problems allows patients to better understand the rational for the treatment approach and facilitates reflection on their symptomatology and the therapeutic process” (Levy, 2012). Psychotherapy appears to be the most widely used therapeutic technique to treat NPD with psychotherapist working to help patients to address insecurities and unhealthy defenses. Cognitive-behavioral therapist tend to utilize metacognitive interpersonal therapies (MIT) to facilitate improvements in adaptive behavior and mental and emotional functioning (Bender, 2012). This is achieved by redirecting the patient’s focus onto the opinions of others increasing their ability to empathize while teaching them to interpret criticism more rationally and changing their all or nothing thought pattern ( Comer, 2013). Unfortunately, none of these approaches have proven clear consistent success in treatment.

Reflections I chose to research narcissistic personality disorder (NPD) to gain personal insight. During my own treatment in therapy I was introduced to NPD while working through some challenges in my relationship with my mother. I grew up in a very emotionally unstable family unit due to my mother’s apparent challenges with suffering from NPD. I always knew there was something wrong with our interactions and the way she would emotionally swing from haughtiness to crippling lows, however I personally thought she was “just crazy and hormonal.” I experienced a lot of personal pain from not having a healthy relationship with my mom and harbored much bitterness towards her perceived selfishness. In fact I began this research project searching more for entertaining confirmation of my beliefs. When I first heard of NPD it sounded like an excuse for bad behavior. My thoughts were that therapist were just enabling abusive and manipulative behaviors. What I’ve learned has left me far more humble and understanding of my mom’s inner battles. Reflecting over the pathology of NPD as well as my mother’s history I better understand how she would develop this disorder. My mother abruptly lost her own mother at the impressionable age of fifteen and then was quickly rejected by her stepmother. She then entered into various emotionally, verbally, and physically abusive relationships beginning in her early adolescence and into her adult life. My mother sought to protect herself from the vulnerability that caused her pain in the classic NPD style, all the while being the barrier to her own healing by not being able to address the underlying causes of her originating pain. This research has served to change my perspective of NPD and provide me with an educated understanding of how destructive this pathology can be to the effected person and their relationships. My mother would always take credit for any accomplishment of my brother and me, yet she would quickly blame our failures on our own stupidity and failure to adhere to her instructions. I have a strong memory of being twelve years old and telling my mother that I had been a victim of sexual abuse at seven, but had been too afraid to tell her. I have carried the pain of rejection that my mother did not advocate on my behalf, yet instead opted to hide the “embarrassing secret” because I was too stupid to tell her when it happened. Where I have been struggling with painful rejection, this research has made me reflect on what in her pathology may have contributed to her reaction. Having to publically admit to something so hurtful and shameful happening to her child would leave my mother vulnerable to questions of her ability to protect and care for her children. It would have brought up the common question that is asked whenever a child is harmed “where was the mom?” Her pathology may have disrupted her thinking thus blocking her from seeing that she was not to blame any more than I was, but instead left her feeling like the ultimate parental failure. This false revelation would be something she would not have been able to face due to her hypercritical self-evaluation process. I often wondered why my mother would begin treatment for her frequent bouts of depression, but would never continue to completion. I better understand that depression is what brought her in, yet the NPD was not addressed due to her challenge of being unable to accept the therapist feedback. This created a barrier for treatment in my mother as she believed the therapist were inadequate in their skills, yet she knew she couldn’t conquer her issues alone. The usual result of the short lived treatment plan would be for mom to try another antidepressant which never seemed to have any lasting effect. This research has assisted me in understanding that what I was viewing were the barriers to care that NPD patients and their therapist are challenged with facing. My mother is not a terrible person, yet she appears to be suffering with a fragile self-esteem and a disorder that magnifies this. I appreciate the research that I have done and the effect it has had on my own personal healing.