NARCISSISTIC PERSONALITY DISORDER
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Table of Contents
TOC \o "1-3" \h \z \u Discussion: PAGEREF _Toc18921832 \h 3
Personality Disorder By Applying The Major Theories Of Personality PAGEREF _Toc18921833 \h 3
Discuss the problems and impact on normal and abnormal development as it relates to personality theories. PAGEREF _Toc18921834 \h 5
Literature Review PAGEREF _Toc18921835 \h 6
Treatment PAGEREF _Toc18921836 \h 8
Discussion:
Personality Disorder By Applying The Major Theories Of Personality
Kernberg exposes his latest contributions about narcissism. It offers a very detailed description of the clinic of this pathology, giving a lot of value to the differential diagnosis. He presents the approaches of several authors, including Kohut, Rosenfeld and himself. Kernberg exposes what happens in the sessions with narcissistic patients describing not only the relationship in its most common form but also exposes the greatest difficulties that a therapist encounters (Kernberg, 2018). For this, it offers us ways of “doing therapy” as well as an exhaustive explanation of the value of the transfer relationship. All this work is framed in the dynamic approach and since the last contributions of psychoanalytic psychotherapies. This work adds to many others that they illustrate the controversial issue of the effectiveness of dynamic counseling therapies, making it clear that research must continue as well as the analysis of clinical work. Kernberg encourages health professionals to find better ways of doing therapy.
Kernberg gives a review of the definition of narcissism from the psychoanalytic theory of meta-psychology. This defines it as the libidinal investiture of the self. Narcissistic libido is the libido invested in the self, referring to libido as one of the two motivational forces of personality organization, the other being aggression (Kernberg, 2016).
Currently this duality is being questioned even from psychoanalytical approaches. A conception of the psyche that emphasizes the weight of affectivity and gratification is gaining strength (Coleman, et.al. 2017). That is, the self is understood as a substructure of the ego system that reflects the integration of all self-images or self-representations that develop throughout all the individual's interactions with others. Objective libido is the investiture of libido in such objects and their psychic representations. Narcissistic libido, according to the Kernbergs recent proposals, is the investiture of libido in the self as a substructure of the Self.
And how is it understood from a clinical conception? Caligor states that narcissism is related to the abnormal regulation of self-esteem or self-consideration. This will depend on the experiences that the human being has with others, whether frustrating or gratifying, as well as on the personal evaluation that he carries out of the achievements or failures that he experiences throughout his life. Likewise, the distance between personal aspirations and real failures and achievements will influence. Caligor states that it is very complex to make this assessment and diagnosis, to understand the abnormal regulation between self-esteem, prevailing moods, the degree of integration or dissociation of representations and the vicissitudes of internalized object relations (Caligor, et.al. 2018).
The regulation of self-esteem depends among other factors on the role that the superego plays, the way in which it exerts power over the self. A demanding superego with unconscious demands of perfectionism and children's prohibitions will favor low self-esteem. Low self-esteem is also due to the lack of satisfaction of both libidinal and aggressive needs. The regulation of self-esteem will also depend on the internalization of libidinal invested objects that are in the form of libidinal object representations reinforcing the libidinal investiture in the self. They are the representations of those who love, for whom one feels loved, thus reinforcing self-esteem. In the same way, conflicting relationships weaken the libido invested in others and in the corresponding representations as well as in the libido of the self, thus weakening self-esteem (Watson, et.al. 1984).
Discuss the problems and impact on normal and abnormal development as it relates to personality theories.
The Kernberg considers it useful to expose a classification proposed in 1984 according to which narcissism divided into three categories: normal adult narcissism, normal childhood narcissism and pathological narcissism. Normal adult narcissism is characterized by stable self-esteem resulting from a normal structure of normally integrated or "total" internalized object representations, an integrated superego, and the satisfaction of needs within a context of stable object relations as well as a system of appropriate values.
It is important to consider the fixation or regression in children's narcissistic goals (children's mechanisms of self-esteem regulation) since it is a characteristic of every character pathology. The normal childhood narcissism is self - regulation by an adequate satisfaction of needs at the age it implies a value system demands and normal childhood prohibitions. Within the pathological narcissism the slightest is the one that is explained due to the regression to children's regulations of self-esteem implying a regression to this level of normal childhood narcissism. In this type of pathology, the regulation of self-esteem depends in excess of the expression of child satisfaction or of the defenses against him that are routinely discarded in adulthood (Dowgwillo, Dawood, & Pincus, 2016).
A second less frequent but more serious type of pathological narcissism is the one Freud described to illustrate the narcissistic choice of object. Here the patient's self is identified with an object, at the same time that the representation of the patient's infant self is projected on said object, thus creating a libidinal relationship in which the functions of the self and the object have been exchanged, a relationship that is found, for example, between some homosexual people since they love someone as they would like to be loved.
The most serious type of narcissistic pathology is the narcissistic personality disorder itself, one of the most challenging pictures of psychiatry. This disorder is the focus of the topic in this chapter. It is a specific type of character pathology whose main feature is a great self. In this simple introduction about narcissism we can appreciate the importance of the object relations approach to the Kernberg.This approach is not only useful for understanding the disorder but for treatment.
Literature Review
The three contemporary psychoanalytic approaches advocate psychoanalysis as the appropriate treatment of narcissistic patients: Kohut and self-psychology, the Kleinian approach of Rosenfelds point of view of the psychoanalytic theory of object relations. It should be noted that Kohut exposes limits to treatment with narcissistic patients. However, Rosenfeld and Kernberg have expanded the spectrum of narcissistic cases to include those with borderline features. Rosenfeld maintains psychoanalysis for these patients but Kernberg (1984) proposes that patients with limited functioning have contraindications in psychoanalysis and need to be treated with exploratory or expressive psychotherapy and if psychoanalytic psychotherapy is contraindicated Kernberg then proposes supportive psychotherapy as a treatment for choice (Kernberg, 2018).
Rosenfeld proposes a technique that coincides with Klein's work: the classic analysis is modified with narcissistic patients when they require a systematic exploration of their primitive defense mechanisms in the transfer. Rosenfeld emphasizes the importance of interpreting the transfer either positive or negative and only modify his technique with narcissistic patients who have borderline personality traits. It is about carefully exploring the situation that causes paranoid and psychotic regressions in order to contain and elaborate them (Kernberg, 2018)..
Kohut let the narcissistic idealization of the patient towards the therapist be unleashed without making premature interpretations. This approach allows the deployment of a type of transfer called “mirror reflection”. The patient relives traumatic experiences with the containment and support of the therapist, so the patient lives this transference relationship whose idealized object is the therapist, he will internalize this representation through the process he called “transmutative internalization” of the idealized object. The psychoanalyst has to be very empathetic, focusing on understanding the narcissistic needs and frustrations of the patient. It should not focus so much on the conflicts resulting from the failure to meet those needs but on themselves. Kohut insists on a change of attitude and not on the change of technique: it is about being much more empathetic in contrast to the idea of objective neutrality as psychoanalysis itself marks, and focusing on the weaknesses of the present self and not on past structural impulses and conflicts that no longer exist.
For Kernberg, the most important thing is to work on the great self that exists in the patient-analyst transfer relationship. The performance of the great self occurs in therapy when the patient feels without affective abilities to respond to the analyst. The patient treats the analyst as a special person projecting in him a personality with a lot of self-esteem, with feelings of superiority. This triggers an attitude of superiority in the patient that continues to project in the analyst, generating a climate with the apparent feeling that there is only one and the same person. According to the Kernberg, this is the relationship that must be worked on in therapy. Between the two they will work this link building a healthier and more primitive type of relationship. Here the expression of omnipotence, the reactions of rage, the scorn towards the analyst, the negative reactions of the therapist as a result of the patient’s sensation when seeing that the analyst is helpful is interpreted. The defense mechanisms against the desire for omnipotent control, projective identifications, primitive idealizations and undervaluation, are constant in the transfer relationship and require a long and systematic work.
After the seemingly simple activation of narcissistic rage are unconscious primitive emotions associated with past object relationships, pathological relationships, representations of the split self and unedited oedipal and pre-oedipal conflicts. These conflicts may gradually arise as the great pathological self-remits during the exhaustive analysis. A transfer of paranoid character appears with the emergence of primitive transfers that express paranoid distrust, direct aggression in the transfer, and, finally, the performance of real and ideal internalized object relationships, of real or ideal representations of oneself. In the final stage of the resolution of the great self, the treatment situation usually resembles that of the psychoanalysis of neurotic patients in which the patient can already establish a real dependence on the analyst,
The detailed aspects of the psychoanalytic technique within any of these competing formulas are beyond the objectives of Kernberg's present work. It does specify that so far there are no controlled studies comparing the different treatment methods. Discussions regarding their respective merits and problems are based exclusively on the clinical experience of psychoanalysts specialized in this field.
However, the subtle and convincing description of the transfer in Klein's works comes to convey the feeling of high efficiency. Despite this, the discussion of the long-term efficacy of treatment remains open.
Treatment
Usually the characteristics of a poor prognosis are seen from the beginning of the evaluation but we are all also accustomed to the fact that despite carrying out a thorough evaluation, data of interest may appear in the middle of the treatment altering our initial diagnosis and hypothesis as prognosis. There are manifestations that from the beginning will show insurmountable obstacles to carry out the treatment (Ronningstam, 2016).
One type of difficult situation is that which occurs when the patient has been attending therapy for many years. Patients who have collaborated little in the treatments received, this entails the dependence of family members or people who receive them, provided they have economic possibilities, or if not, they end up depending on social services. This chronic dependence usually means a secondary gain for the patient, which is one of the main causes of treatment failure (Schmidt, 2019).
In case of the United States in which patients are large consumers of these services, however they do not receive the necessary help from them. The reason is that these patients come to treatment consciously or unconsciously, not because they are interested in improving but because they want demonstrate the inability of services to provide an improvement in their health. They usually choose to be in some type of treatment in order to obtain a supportive housing, a supplementary insurance. or social security disability. Michael Stone, a member of the Cornell Personality Disorders Institute, concludes that if a patient is able to earn at least 1.5 times the sum of money he is receiving from social services, he may be motivated to work again. Otherwise, the secondary benefit of their illness, the care and support received from public services will be a greater benefit for them and therefore their modus vivendi. (Stone, 1990).
The fact that work from mental health fails for the patient, together with his ideas of greatness, unleashes the following belief in the society that surrounds them: they are people who hide a genius inside, do not let themselves be handled or helped by others, they are great unrecognized talents: the unknown painter, the disabled writer, the rebel musician. Normally these patients are willing to be in treatment whenever it is financed by a third party. They leave when the payment cannot be made by a third party and although they have certain income to pay it, they do not want to finance it (Scalabrini, et.al. 2018).
In these cases, a more educational court treatment is better. According to Kernberg, in the therapeutic work with these cases it should be clarified that the secondary benefit of third-party support, whether from family members or social services, will disappear. The importance of being the ones to finance the treatment must also be clarified. Depending on the cases, a period of 3-6 months is proposed for the patient to achieve this goal and to commit to it otherwise the treatment would be interrupted (Clarkin, & Kernberg, 2015). From this first moment the unconscious reactions of the patient are triggered that result in the rejection of being responsible for their improvement. Resentment responses are revealed against the therapist seen as threatening to the patient. The patient projects these representations in the therapist as well as in himself as it comes to be seen as the impediment to begin to improve, to respect himself and to begin to have a successful professional life. From this beginning in which the framing is marked, the initial transference responses must be analyzed since they have content of interest for the analysis.
Another type of difficult situation described by Kernberg is that which occurs in patients with great arrogance. The syndrome of arrogance arises from the patient observes the inability of health professionals to provide support and stability. From this the patient obtains a secondary benefit. Patients become experts in their disease. They research on the internet the past and the curriculum of the professionals, study the merits and failures, and are considered as those that offer the professional a chance that he will achieve professional success if they help them. However, they do not fail to obtain a benefit if the therapy does not work. They will feel victors because they could not be helped by the therapist.
They are people who also have problems in their relationships, have episodes of acute depression and anxiety symptoms when they are threatened by problems. The symptoms of depression respond positively to the pharmacological treatment together with the therapy. However, they will not recognize the value of the therapy and will only give value to the effect of the medications. Medication without therapy will no longer help.
References
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Caligor, E., Kernberg, O. F., Clarkin, J. F., & Yeomans, F. E. (2018). Psychodynamic therapy for personality pathology: treating self and interpersonal functioning. American Psychiatric Pub.
Clarkin, J. F., & Kernberg, O. F. (2015). Transference-focused psychotherapy for borderline personality disorder: a clinical guide. American Psychiatric Pub.
Dowgwillo, E. A., Dawood, S., & Pincus, A. L. (2016). The dark side of narcissism.
Kernberg, O. F. (2018). Treatment of Severe Personality Disorders: Resolution of Aggression and Recovery of Eroticism. American Psychiatric Pub.
Kernberg, O. F. (2016). What is personality?. Journal of Personality Disorders, 30(2), 145-156.
Scalabrini, A., Mucci, C., & Northoff, G. (2018). Personality and Personality Disorders. In Neuropsychodynamic Psychiatry (pp. 377-411). Springer, Cham.
Schmidt, A. (2019). Comparison of Kernberg’s and Kohut’s Theory of Narcissistic Personality Disorder. Turk Psikiyatri Dergisi, 30(2).
Ronningstam, E. (2016). Pathological narcissism and narcissistic personality disorder: Recent research and clinical implications. Current Behavioral Neuroscience Reports, 3(1), 34-42.
Watson, P. J., Grisham, S. O., Trotter, M. V., & Biderman, M. D. (1984). Narcissism and empathy: Validity evidence for the Narcissistic Personality Inventory. Journal of personality assessment, 48(3), 301-305.
