NPD and ASPD

What are the DSM traits of NPD?

Grandiose sense of self

Need for admiration

Arrogance

Entitlement

Fantasies of success, power etc.

Envious of others

Feeling special

Lack of empathy

Exploitative

What are the prevalences of NPD?

Between 0-6.2%)

Forensic studies: higher prevalence (around 27.7%)

Higher prevalence of diagnosis in men (50-75%) -- Overdiagnosis

What traits do people with grandiose narcissism have?

* Dominance


* Self-assurance
* Immodesty
* Exhibitionism (centre of attention)
* Aggression

This is the NPD as seen in the DSM

What traits do people with vulnerable narcissism have?

* Introversion


* Negative emotions
* Interpersonal coldness
* Hostility
* Need for recognition (positive reinforcement)
* Entitlement
* Egocentricity

More similar to BPD(?), less diagnosed because these traits are not in the DSM

What factors are in the dimensional approach to NPD and what aspects are in these factors?

**Identity**

* Uses others for self-definition and self-esteem
* Exaggerated self-appraisal
* Emotion regulation fluctuates with self-esteem

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**Self-direction**

* Goal setting based on gaining approval
* High/low personal standards
* Unaware of own motivation

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**Empathy**

Attentive to reactions of others to self

Over or underestimating own effect on others

Impaired ability to recognise/identify

**Intimacy**

* Superficial relationships


* Restrained mutuality (little genuine interest)

What 2 pathways to achieve goals to narcissistic people have?

Admiration pathway:

* Strive to be admired, unique
* Charming
* Grandiose fantasies
* Uses social skills to build up a persona



Rivalry pathway

* Will build ego based on tearing other people down

DSM-Criteria for Antisocial Personality Disorder

A. A pervasive pattern of disregard for and violation of rights of others

* Repeated illegal shit
* Repeated lying or conning
* Impulsivity, failure to plan ahead
* Irritability or anger outbursts
* Reckless, disregard for safety of self or others
* Irresponsibility
* Lack of remorse



C. There is evidence of conduct disorder before age 15

What’s the prevalence of antisocial personality disorder?

0.2-3.3%

Forensic studies: higher prevalence (30%)

Higher diagnosis of men than in women

Factors of psychopathy

Affective: Lack of guilt

Callous

No remorse, responsibility

Superficial charm, manipulative behaviour

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Lifestyle

Poor behavioural control,

criminality

High need for stimulation, no long term realistic goals, parasitic lifestyle,

impulsivity,

irresponsibility

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Other

• Promiscuous

• Short-term relationships A lot of overlap with ASPD

What do you often need when diagnosing ASPD?

Often need for secondary source of information

• Criminal investigation/records

• Family or other sources

What are factors in the dimensional model of ASPD?

**Identity**

 

Egocentric

Self-esteem derived from personal gain, power, or pleasure

 

**Self-direction**

Based on personal gratification

Absence of prosocial internal standards

 

**Empathy**

No concern for others

No remorse

 

**Intimacy**

Incapacity for mutually intimate relationships

Exploitation is used to relate to others

Use of dominance of intimidation

When will people with ASPD go to therapy?

Will only go to therapy if forced or in a forensic setting

When voluntarily, will come in for a different problem (burnout or whatever), don't see a problem with their personality

Why is it hard to make a diagnosis of ASPD?

Charming/manipulative: can manipulate you

Might appear normal -- have been socialised to manage their emotions

Externalizing blame: their problems are never their own fault

What can happen when you’re trying to treat someone with NPD?

Egocentricity can be subtle --> hard to tell

Emphasizing own suffering

Gaslighting

Why should you be careful in diagnosing ASPD?

• It's a spectrum

• Might be a mask for anxiety

• ASPD diagnoses might be damaging

• Situational things that could similar to ASPD

• Cultural and generational differences

• Gender x culture differences (men expected to be more narcissistic/ antisocial)

**Consequences of these PDS**

* Involvement in criminal justice system
* Poor interpersonal relations
* Negative consequences for others - in close relationships or work settings (can lead you to be successful -- might do really well)
* Poor personal outcomes

How to treat ASPD?

Tailor it to the needs of the person: Teach them to function on a basic level

Treatments for BPD are often used

Good signs:

* Taking responsibility
* Varied emotional responses/high emotionality

Focus on harm reduction (especially for psychopathy) \n \n However, there are limits

How might (counter) transference be experienced in people with NPD?

Client

• Might try to use admiration/rivalry

• Does not listen, only talks

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Therapist

• Might get bored

• Might get competitive, frustrated

How might (counter) transference be experienced in people with vulnerable narcissism?

Client

• Seems anxious, but constantly looks for confirmation

• Is sentitive to what therapist says

You

• Might become overly invested/empathetic

• Might become irritated

How might (counter) transference be experienced in people with ASPD?

• Client:

Depends on level of emotionality

You • Hopeless • Irritated/frustrated

How might (counter) transference be experienced in people with primary psychopathy?

Client: Manipulative/conning

You • Might think there is less of a problem • Frustration when therapy does not seem to improve • Overly invested

What is the prevalence of drug abuse in ASPD?

42-95%

What are common comorbidities with ASPD?

Depression, anxiety, ADHD, sexual deviancy and pathological gambling

What specific genetic factor is present in the development of ASPD?

Low MAO-A gene activity, which codes for a neurotransmitter building enzyme

What guidelines should there be before starting treatment with someone with ASPD?

Legal advantage must be ruled out

Consultant who focuses on (counter)transference

Therapist needs to feel safe

No excessive expectations

No being coerced into misconduct

Monitoring of countertransference

Denial and minimization of the antisocial behaviour needs to be confronted

Therapist has to help connect action with internal states (

Awareness of potential comorbidities

Capacity for mentalizing should be developed

No remaining neutral

Therapist cannot force collaboration

Unacceptability of lying needs to be recognised

Why does NPD have some traits that are hard to define on a checklist?

Everyone has some degree of narcissism

Cultural factors play a huge role in what is healthy self-esteem and what is narcissism

Fluctuating self-esteem in adolescence - can NPD be diagnosed in all age groups?

Lack of research on NPD

High functioning/exhibitionist narcissism

Outgoing and energetic, very charming (related to grandiose narcissism

Comorbidities in NPD?

MDD, BP1, anxiety, SUD (highest). HPD, ASPD, BPD. Comorbid ASPD has the worst prognosis

Biological aspects of NPD

Left anterior insula and fronto-limbic areas have lower grey matter

Anterior insula and anterior cortex dysfunction could lead to focus on internal processes and lack of empathy

Larger cortisol output following social stressors

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Twin studies: medium-high heritability

Significant father-daughter correlations (X chromosomes)

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Environmental aspects of NPD

Permissive parenting, increased use of social media, parental coldness

Theories of NPD

Psychoanalysis: NPD is a concern of wishing to be seen by others

Heinz Kohut: Parental coldness or overindulgence leads to narcissistic traits

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Otto Kerberg’s model: Grandiose: secure/dismissive attachment

Vulnerable: fearful/disorganized attachment styles

Transference in people with NPD

Grandiose: Ignore therapist, arrogant and self-centered, doesn’t care what the therapist is saying

Vulnerable: Full of shame and self-loathing, try to “size up” therapist’s words and behaviours

In what way is idealization and devaluation used in patients with NPD?

Increasing self-esteem by either creating a connection to an admired object or putting down the other

Countertransference in NPD

Grandiose: Boredom, tiredness (therapists feel like they’re not actually part of the conversation)

Vulnerable: Overinvestment, identification with patient’s suffering

Both: Try to control treatment → Therapist thinks that no progress is being made

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Feelings of being criticised, angry, overwhelmed, helpless, in the therapist

What “tension” exists in identity?

The tension between the desire to be seen as individual, but also fit in

How are concepts like self-concept, self-confidence, etc constructed?

By how others observe us and what inferences they make about our behaviour

What happens if there is too much “sameness” or “difference” in a group?

Sameness: Nazis

Difference: Incoherence, social isolation, competition and loneliness