Transcript Narcissistic Personality Disorder

Ibtihal M.A.Ibrahim
The word "personality" originates
from the Latin persona, which
means mask.
It is the distinctive and
characteristic pattern of thought,
emotion, and behavior that define
an individual's personal style of
interacting with the physical and
social environments.
Ibtihal M.A.Ibrahim
Human behavior is
determined by
forces beyond our
control
unconscious status
of our motivations
and thus he
deprived us from
rationality.
Psychoanalytic
Portrait of
human nature:
sexual and
aggressive
nature of those
motivations
human nature is
basically evil.
Ibtihal M.A.Ibrahim
People are not
inherently good or evil
but are readily
modified by events
and situations in their
enviroment
Behaviorist
approach to
personality is
determinism
Behaviorist
Portrait of
human nature
The human
personality is
highly
modifiable
We are shaped
primarily by
forces beyond
our control.
Ibtihal M.A.Ibrahim
individual has an innate
tendency to move towards
growth, maturity and
positive change
basic force motivating the
human organism is the
actualizing tendency
Humanistic
Portrait of
human nature
people are responsible for
their lives and actions and
have the freedom and will to
change their attitudes and
behavior.
people are essentially good.
Personality is learned
through obstacles we face
and overcome.
Ibtihal M.A.Ibrahim
behavior
is egosyntonic
rigidly
pervasive
• lead to
unhappiness and
impairment.
deviate
from
cultural
standard
s
• onset in adolescence or
early adulthood.
• stable through time
Enduring
subjective
experiences
and
behavior
Ibtihal M.A.Ibrahim
enduring
pattern
of
• Cognition
• Affectivity.
• interpersonal
functioning
• impulse control
inflexible and
pervasive
Clinical
significant
distress or
impairme
nt
• Social
• Other important
areas of
functioning.
• onset can be traced
back at least to
stable and
adolescence or
of long
duration
early adulthood.
Ibtihal M.A.Ibrahim
ICD 10
• No clusters.
DSM IV
• Personality disorders are grouped into 3
clusters.
• Cluster A:
• Paranoid.
• Schizoid.
• Dissocial.
• Emotionally unstable
•
Impulsive.
•
Borderline.
• Histerionic.
• Anxious ( avoidant).
• Dependent.
• Anankastic (obsessive compulsive).
• Paranoid.
• Schizoid.
• Schizotypal.
• Cluster B:
• Antisocial.
• Borderline.
• Histerionic.
• Narcissistic.
• Cluster C:
• Avoidant.
• Dependent
• Obsessive Compulsive.
Ibtihal M.A.Ibrahim
Paranoid
odd,
aloof
features
Cluster A
personality
Disorder
Schizotypal
Schizoid
Ibtihal M.A.Ibrahim
0.5-2.5% of
general
population
♂>♀
Epidemiology
higher in minority
groups, immigrants
and deaf people
Ibtihal M.A.Ibrahim
S
four (or more
U
Spouse
fidelity
suspected
Unforgiving
S
Suspicious of
others
P
T
Threats
perceived
in benign
events
A pervasive
distrust and
suspiciousness
Perceives
attacks
"Enemy
or friend
C
Confiding in
others is
feared
E
Paranoid
Personality
Disorder
Ibtihal M.A.Ibrahim
7.5% of
general
population
Epidemiology
may be
♂:♀→2:1
Ibtihal M.A.Ibrahim
D
I
four
(or
more)
Indifferent
to criticism
and praise
S
Sexual
experience
s of little
interest
T
Detached
(or
flattened)
affect
T
A pervasive
pattern of
detachment
from social
relationships
Tasks
(activities)
done
solitarily
Takes
pleasure in
few
activities.
Absence
of close
friends
A
Neither
desires nor
enjoys
close
relations
N
Schizoid
Personality
Disorder
Ibtihal M.A.Ibrahim
3% of the
general
population
Epidemiology
Higher incidence
among relatives
with
schizophrenia
Ibtihal M.A.Ibrahim
M
R
E
Experience
s unusual
perceptions
P
Paranoid
ideation
E
Eccentric
behavior
or
appearan
ce
C
Magical
thinking or
odd beliefs
Rule out
psychotic
disorders and
pervasive
development
al disorder
A pervasive
pattern of
cognitive or
perceptual
distortions and
eccentricities of
behavior
Constrict
ed (or
inappropri
ate)
affect
U
Unusual
(odd)
thinking
and
speech
five
(or
more)
A
Anxiety in
social
situations
Ideas of
reference
Lacks close
friends
L
I
Schizotypal
Personality
Disorder
Ibtihal M.A.Ibrahim
dramatic impulsive
and erratic features
Antisocial
Borderline
Cluster B
personality
Disorders
Histrionic
Narcissistic
Ibtihal M.A.Ibrahim
3% in men &
1% in
women
A familial
pattern is
present
75% in
prison
populations
Epidemiology
More
common in
poor urban
areas
Ibtihal M.A.Ibrahim
cannot
follow
law
O
three
(or
more
obligations
ignored
R
remorsel
essness
R
C
T
pervasive
pattern of
disregard for
and violation
of the rights
of others
reckless
ness
temper
under
hande
dness
P
planning
deficit
Antisocial
Personality
Disorder
U
Ibtihal M.A.Ibrahim
1-2% of the
population
♂:♀→1:2
Epidemiology
Ibtihal M.A.Ibrahim
P
five
(or
more
Paranoid
ideas
R
Relationship
instability
A
Emptiness
pervasive
pattern of
instability
Angry outbursts,
affective
instability,
abandonment
fears
S
Suicidal
behavior
I
Ibtihal M.A.Ibrahim
E
Impulsive
behavior,
identity
disturbance
Borderline
Personality
Disorder
2-3% of
general
population
♀>♂.
Epidemiology
Ibtihal M.A.Ibrahim
R
five
or
more
A
P
relationships,
considered
more
intimate than
they are
attention,
must be at
center of
provocative
(or
seductive)
behavior
E
exaggerated
emotions –
theatrical
pervasive
pattern of
excessive
emotionality
and attention
seeking
influenced
easily
I
S
speech
(style) wants to
impress,
lacks detail
M
make-up physical
appearance
used to draw
attention to
self
emotional
liability,
shallowne
ss
E
Histrionic
Personality
Disorder
Ibtihal M.A.Ibrahim
Children of such
Narcissistic
Personality Disorder
parents have higher
risk for developing
the disorder
themselves
<1% in
general
population
Epidemiology
Ibtihal M.A.Ibrahim
G
five
or
more
R
Requires
attention
A
Arrogant
N
E
Grandiose
Need to
be special
A
pervasive
pattern of
grandiosity
Dreams of
success
and power
D
Envious
Interperson
ally
exploitative
Sense of
entitleme
nt
Others
(unable to
recognize
feelings/need
s of
I
S
O
Narcissistic
Personality
Disorder
Ibtihal M.A.Ibrahim
Dependent
anxious and
fearful features
Cluster C
Personality
Disorder
Obsessive
compulsive
Avoidant
Ibtihal M.A.Ibrahim
1-10% of
general
population
Epidemiology
Infants with timid
temperament may
be more
susceptible to the
disorder
Ibtihal M.A.Ibrahim
A
four
or
more
Avoids
occupationa
l activities
V
Views self as
socially inept
O
Occupied
with being
criticized or
rejected
I
R
Restrains
from intimate
relationships
pervasive
pattern of social
inhibition and
hypersensitivity
to negative
evaluation
Inhibited in
new
interpersonal
situations
Denies to get
involved with
people
Embarrassed
by engaging
in new
activities
D
E
Avoidant
Personality
Disorder
Ibtihal M.A.Ibrahim
♀>♂
2-5% of all
personality
disorders
Persons with
chronic physical
illness in childhood
may be most
susceptible to the
disorder
Epidemiology
Ibtihal M.A.Ibrahim
E
five
or
more
P
excessive
need to
obtain
nurturance
and support
from others
preoccupie
d with fears
of being left
to take care
E
D
exaggerated
fears of being
unable to care
for himself or
herself
N
difficulty
making
everyday
decisions
“take care
of me” is
his or her
motto
pervasive and
excessive
need to be
taken care of
needs
others to
assume
responsibili
ty for his or
her life
difficulty
expressing
disagreeme
nt with
others
T
noticeable
difficulties in
initiating
projects or
doing things on
his or her own
end of a
close
relationship
is the
beginning of
another
relationship
D
N
E
Dependent
Personality
Disorder
Ibtihal M.A.Ibrahim
Diagnosed
most often
in oldest
children
♂>♀
Epidemiology
Ibtihal M.A.Ibrahim
C
Four
or
more
R
S
Cannot
discard
worthless
objects
Rule
obsessed
I
Stubborn
Reluctant
to
delegate
to others
pervasive
pattern of
preoccupation
with
orderliness,
perfectionism
Inflexible
Excludes
leisure due
to devotion
to work
Perfectionistic
Miserly
R
P
E
Obsessive
Compulsive
Personality
Disorder
M
Ibtihal M.A.Ibrahim
• pervasive
pattern of
passive
resistance to
demands
• pervasive
pattern of
depressive
cognitions and
behaviors
• presence of
features of more
than one specific
Personality
Disorder
Passive
Aggressive
Personality
Disorder
Depressive
Personality
Disorder
mixed
personality
Ibtihal M.A.Ibrahim
Deficit
Model:
Conflict Model:
Conflict between
unconscious
interacting
forces.
Weakened,
absent or
distorted
intrapsychic
structures
Dynamics related
to object
relations:
Traumatic selfobject
internalizations
from childhood
constitute a
blueprint for later
patterns of relating
to others.
Ibtihal M.A.Ibrahim
object
relations
model
dangerous
&unpleasant &
hostile thoughts and
feelings related to
bad object are split
off "schizoid
component"
Paranoidschizoid
position
+ve & -ve qualities of
self & object are not
integrated into whole
self & object
representations
They are then
projected and
attributed to others →
paranoid component
The patient becomes
frozen at this position
living the role of a victim
versus external
aggression or persecution
. he lives in a state of
anxiety.
Ibtihal M.A.Ibrahim
The core pathological
process is splitting or
fragmentation of self
into different self
representations
Marked
contrdictions in
personality
Overtly
Covertly
detached,
cold,
indifferent,
prefers
isolation to
relatedness
senstive,
vigilant,
creative,
emotional
need for
relatedness
This splitting of the self results in:
Identity
diffusion
They are not
sure who they
are. They lack
sense of
unique & table
identity.
They feel that
their real self
is inaccessible.
Fragile self
esteem
They view
themselve as
exteremly weak,
vulnerable & lack a
sense of worth &
competence.
This reflects an
internal lack of
good or sufficient
self object
representation
Apparant non
relatedness to
others
Deficit model:
They have deficit in
their ability to
relate
They froze
developmentally at
an early stage of
relatedness
Conflict
model:
There is a conflict
between the need or
wish to relate to
others and the fear
that this need will
harm others and
derive them away or
that others will
engulf them
Ibtihal M.A.Ibrahim
From
Schizoid
form a continuum
from those who are
much like schizoid
to those closer to
schizophrenia.
Schizotypal
Schizophrenia
Ibtihal M.A.Ibrahim
Borderline
Personality
Disorder
The borderline
personality
organisation:
Ego
psychologicalobject relations
model
(kerenberg)
Role of
pathological
splitting:
Developmental
dynamics:
The borderline
core
personality:
Ibtihal M.A.Ibrahim
From the dynamic
prespective there
are two levels of
antisocial
personality
disorder
A primitive or lower
level disorder
(psychpathy) →pure
form with full criteria.
a higher level disorder (white
collar criminals)→ a relatively
attenuated form in which the
patient's conscience does not
operate in certain circumscribed
areas.
A narcissistic component allows
them to be successful.
Ibtihal M.A.Ibrahim
Dynamic
interpretation of this
disorder is based on:
Ego psychological
model
It reflects an
impairment of
superego formation
Object relations
model
It is a primitive variant
of narcissistic
personality disorder
(Kerenberg)
Biological Factors
Aetiological
factors
Enviromental
(psychological)
factors:
Ibtihal M.A.Ibrahim
Selfpsychological
model
Narcissistic personality disorders is related to failure to satisfy self object needs (i.e.
esteem needs)→ mirroring, idealizing, twinship needs
As a result of this deficit , narcissistic patients become developmentally arrested at such
stage.
They continue to require these needs from external figures to be able to
maintain their self esteem & cohesion.
so others are not regarded as separate persons but as sources for gratificatifying their self
esteem.
Aggression in narcissistic patients is not primary but secondary to self-esteem
injuries.
Ibtihal M.A.Ibrahim
Ego
psychologic
al –object
relations
model
narcissistic patients develop a defensive structure in the form of "integrated but pathological grandiose self".
This pathological grandiose self is formed by fusing the real self with ideal self and ideal object images or
representations.
The integrative effects of the pathological grandiose self structures differentiates them from
borderline patients.
Relatively higher ego functioning
Less ego weakness e.g. less problems with
impulse control and anxiety tolerance.
The chronic intense envy that characerizes them is related to underlying excessive aggression.
It is a primary aggression caused by constittional or enviromental factors or both.
Ibtihal M.A.Ibrahim
Subtypes:
Lower level
(hystrionic) subtype:
symptoms are florid
or exaggerated.
Higher level
(hysterical) subtype:
Symptoms are
moderate or
attenuated
Ibtihal M.A.Ibrahim
Psychodynamics of
histrionic personality
disorder
Fixation at early
developmental
stage
Lower level
(histerionic)
subtype:
Higher
level
(hysterica
l) subtype
Origin of
dramatization or
exaggerated
theatrical
behavior
Role of
incest or
childhood
seduction
Cognitive style
and defense
mechanisms
Cognitive
style
Defensive
style and
emotional
ity
Ibtihal M.A.Ibrahim
Avoidant personality
disorder
Psychodynamic meaning of avoidant anxiety:
Shame→ is the central affective experience in such patients.
Shame is based on an assessment of the self as inadequate →abnormal low self
esteem.
Ego-psychological perspective:
Shame is closely related to the ego ideal aspect of the superego.
The ego ideal in these patients is hypertrophied, highly demanding and overcritical
(due to internalization of parental figures with such pathogenic qualities)
Object relations model:
These patients are characterized by internalization of representations of
significant objects that used to shame, ridicule, humiliate and embarrass the
patient.
Self-psychological model:
Negative self evaluation and abnormal self esteem are related to deficit or
failure of gratification of self object needs (mirroring, idealizing and twinship
needs).
Ibtihal M.A.Ibrahim
Parental reinforcement of dependency:
Parental reinforcement of dependency throughout all phases of development.
Studies reveal that families of these patients are low in independence and high in control.
Attachment theory:
Insecure attachment is the core of Dependent personality disorder.
Their parents communicate one way or another to their children that independence is
dangerous.
They may reward them for being close and loyal and reject them for any move towards
independence.
Defensive function:
Dependent behavior is viewed as a defensive measure to avoid reactivation
of past traumatic experiences.
Dependency & aggression:
Dependency often masks underlying aggression.
The target of dependency clinging may actually experience the patient’s
demands as hostile and tormenting.
Ibtihal M.A.Ibrahim
Classical psychoanalytic views:
It is related to fixation at anal psychosexual stage of development.
.
Hypertrophied superego & quest for perfection:
Harsh and demanding parental figures are internalized as a superego demanding for perfection.
Patients become driven by a secret belief →”if only they can become perfect and flawless”
But this goal is never reached and they rarely seem satisfied which explain the link between obsessive
compulsive character and depression.
Self-esteem problems:
Self doubt is a common trait of obsessive compulsive patients.
Reports indicate that as children, they did not feel sufficiently loved or valued by their parents (esteem
needs were not gratified).
Management of dependency and anger:
These patients have difficulties with strong unfulfilled dependency needs and a reservoir of intense
anger directed at parents for not being more emotionally available.
These feelings are consciously unaccepted so they use reaction formation and isolation of affect to
defend against their emergence.
Difficulties with intimate relationship:
Intimacy presents a risk because they fear their dependency
wishes and angry resentment will get out of control
Ibtihal M.A.Ibrahim
Psychotherapy
Two types
type R
type S
Pharmacotherapy
Ibtihal M.A.Ibrahim
Paranoid
PD
• supportive therapy
• Group and family therapy, not surprisingly, is not of much use
Schizoid PD
• individual psychotherapy
• Cognitive behavior therapy
• Group therapy
Schizotypal
PD
• Psychodynamically oriented therapies
• Cognitive-behavioral therapy
• Interpersonal therapy
• Group therapy, Marital and family therapy
Ibtihal M.A.Ibrahim
Borderline
PD
Antisocial
PD
Histrionic
PD
Narcissistic
PD
•Cognitive-behavioral therapy (CBT),
•Dialectical behavior therapy,
•Psychodynamic therapy,
•Family therapy,
•Support groups,
•Self help groups
•Behaviour therapy.
•Cognitive approaches
• Psychodynamic therapy
• Cognitive-behavioral therapy
• Group therapy
• Family therapy
•Cognitive-Behavioral Therapies
•Dynamic Psychotherapy
Ibtihal M.A.Ibrahim
Avoidant PD
• Psychodynamically oriented therapies
• Cognitive-behavioral therapy
• Interpersonal therapy
• Group therapy, Marital and family therapy
• Psychodynamically oriented therapies
• Cognitive-behavioral therapy
• Interpersonal therapy
Dependent PD
• Group therapy, Marital and family therapy
Obsessive
compulsive PD
• insight-oriented psychodynamic
• cognitive behavioral therapy
• group therapy
Ibtihal M.A.Ibrahim
Selective Serotonin
Reuptake Inhibitors
Atypical
Antipsychotics
Anticonvulsants/
Antiepileptics
Benzodiazepines
• Depressive syndromes
• Obsessive-compulsive syndromes
• Anxiety
• Being tense, loss of impulse control, aggressiveness
• Psychotic symptoms
• Loss of impulse control, aggressiveness
• Loss of impulse control, aggressiveness
• Labile mood
• Acute arousal states
• Acute anxiety states
Ibtihal M.A.Ibrahim