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Narcissistic Personality Disorder: Assessment, Diagnosis, and Treatment

Diagnosis, Assessment and Treatment

According to the Diagnostic and Statistical Manual of Mental Disorders; DSM-V; (American Psychiatric Association, 2013), for an individual to meet the criteria for Narcissistic Personality Disorder, the individual must exhibit 5 out of 9 items listed under the criterion. The duration begins in the teens or early twenties and endures. The symptoms include: a grandiose sense of self, a preoccupation with success and attractiveness, a sense of feeling special and that only others who are special can relate to them, a hunger and thirst for admiration, a strong sense of entitlement, a lack of empathy, a sense of being envious towards others and an attribution that others are envious of them, and arrogance are among the symptoms. It is also important to consider the differential diagnosis in order to avoid a misdiagnosis. For example, NPD can be comorbid with substance abuse disorder. Further, bipolar disorder and other personality disorders can be taken into consideration.

With regard to diagnosing personality disorders, Crowe, Carter, Campbell, and Miller (2016) pointed out that personality disorders are frequently overlooked as well as overdiagnosed. The researchers explained the importance of verifying the duration of the symptoms to make sure they have present since early adulthood with the exception of antisocial personality disorder. The process of interviewing informants such as family can also yield valuable and valid data for diagnosis.

Crowe, Carter, Campbell, and Miller (2016) pointed out a particular measure of narcissistic grandiosity known as The Narcissistic Grandiosity Scale. The scale consists of what the researchers termed as an adjective rating that includes 16 items such as perfect, heroic, superior and so forth. Each item is rated on a 1 to 7 scale. The researchers explained one of the strengths of the measure pertains to its attempt to identify a homogeneous trait related with narcissism. The researchers noted using homogeneous scales in studying the complexity of NPD, for example carries an advantage in that it can help figure out the aspects of the disorder that are related to key criteria.

The participants in the study were recruited through Amazon's Mechanical Turk. The data were collected within three separate samples comprised of females, Caucasians, and Asians ranging in ages from 31. 6 years to 29.7 years. The combined sample consisted of 870 participants 57% female and 71% White, and 21% Asian of ages 31.5 years. The goal of the study was to offer a formal assessment of the validity and reliability of scores using the Narcissistic Grandiosity Scale (NGS) which the researchers held provided measures they considered promising. The results indicated the NGS served to be a consistent measure.

In other research, Trull (2014) explained that in considering the diagnosis, causes and treatment of NPD, it is critical to investigate the possible sociocultural influences that might impact the prevalence of NPD. Some researchers argue that prevalence of NPD might be related to cultural influences and that traditional psychotherapy modalities might actually either support of worsen the NPD symptoms in the individuals diagnosed with it.

With regard to treatment, Stern, Diamond, and Yeomans (2017) pointed out that Transference Focused Psychotherapy provides psychodynamic psychotherapy twice a week and was developed to explore the patient's defense mechanisms that serve to support the patient's, "split sense of self" (p. 383) with the goal in mind to gain a better understanding about the needs of the defensive processes, and of supporting the patient in being able to tolerate a more adaptive view of self and others. There are pre-treatment stages in the therapy that include an evaluation to ascertain the NPD symptoms that are present.

There is also an assessment undertaken to determine the quality of the patient's values as related to whether there exists a capacity for guilt or not, the presence of aggression or anti-social tendencies and so forth. These features help to ascertain the level of severity concerning the patient's pathology. The researchers asserted after the evaluation is completed and the diagnosis is shared with the patient, a discussion is launched regarding the conditions in which the treatment will be delivered to the patient for optimum success. The researchers admitted that the discussion may appear to carry controversy. However, the researchers explained that individuals with NPD appreciate being given a clinical framework from which to work and better understand what appears to the patients to be a an enormously complex disorder.

Further, Stern, Diamond, and Yeoman (2017) asserted that TFP work poses a threat to patients with NPD in that patients can potentially be triggered negatively by the interpretations the therapist provides. Hence, the patient may begin to exhibit shame and rage. Most of the time, the patient experiences the therapist's interpretations as a reflection that that the therapist appears to be resisting a tolerance for the patient's distressing internal states. As such, the researchers pointed out that therapists have acknowledged the importance of modifying analytic technique in order to meet the needs of their patients with NPD.

TFP in the beginning stage, establishes a treatment focus and framework, as the researchers termed it that serves to help facilitate a process of exploration whereby the, "representation of self and other" (p. 394) mold the patient's experiences. Therefore, exploring the patient's experiences in depth can be used as an effective tool in therapy. As time goes on, the patient can begin to better tolerate negative experiences that he or she had once projected.

Pincus, Dowgwillo, and Greenberg (2016) contended NPD appeared to be a diagnosis subject to change as a result of diverse points of view regarding the nature of its diagnostic features and the way NPD presents clinically. The researchers asserted clinicians and researchers have acknowledged that the DSM-5 criteria for NPD is defined in a narrow manner and do not address in enough depth the dimensions of personality impairment related to pathological narcissism. However, the impairments lend themselves to be summarized a manifestation of, "two broad phenotypic expressions," (p. 166). The researchers noted these phenotypic expressions are known as narcissistic grandiosity and narcissistic vulnerability. To further illuminate the concept, the researchers contended grandiosity reflects self-enhancement realized through maladaptive behavior towards others, a sense of entitlement, a self-image that reflects grandiosity, and attributions that are self-serving in nature.

The researchers pointed out that vulnerability is a reflection of emotional dysregulation as a reaction to expectations that have not been met and the failure of the self-enhancement that follows.

In another study, Kealy, Goodman, Rasmussen, Weiderman, and Ogrodniczuk (2017) contended their study provided a basis for treatment regarding pathological narcissism. The researchers clarified there exists a paucity of empirical research associated with treatment of NPD. The researchers reported psychodynamic approaches have included self-psychology which was developed to help restore the patient's fragile sense of self through the use of empathy in therapy. The researchers noted that what they termed, "empathetic attunement" (p. 36) represented an experience that in the patient's early development that may have been disrupted but is believed to occur once the patient internalizes greater capacities. In other words, the approach expands the patient's capacity to experience empathy but only through the participation in therapy and use of empathetic attunement.

On the other hand, Baskin-Sommers, Krusemark, and Roningstan (2014) argued that research efforts that used self-report and interview measures were not successful in identifying a lack of empathy as a feature in patients with NPD. The researchers contended that research indicates that several other factors such as self-centeredness, low self-esteem, emotional intolerance and so forth might co-occur with NPD and impact the patient's empathic capacity and functional pattern.

Further, the researchers explained that their study was the first to investigate systematically the treatment of NPD using the points of view of psychotherapists in the community who used diverse approaches. With regard to their method, the researchers recruited psychotherapists in private practice using e-mail and listserv for outreach to large scale organizations. Sixty nine psychotherapists demonstrated an interest in participating and requested materials. Out of the 69, 49% completed the study providing a sample of 34 psychotherapists. The researchers explained the size of the sample represented consistency with Q-methodology. The materials consisted of clinical case vignettes that were developed by the researchers and equaled six vignettes. The vignettes represented patients presenting with narcissistic grandiosity and narcissistic vulnerability as well as panic disorders without pathological narcissism. Both a male and female version of the vignette were developed. In addition, a 100 item instrument created to facilitate a description of the psychotherapy process was used and referred to as the The Psychotherapy Process Q-set.

Psychological Research and Neuroscience

Abram and DeYoung (2017) contended personality neuroscience uses techniques drawn from personality psychology and neuroscience in order to explain the neural foundation associated with individual differences within "cognition, emotion, motivation, and behavior" (p. 2). The researchers noted these domains are frequently measured through self-report questionnaires but in order to obtain greater validity, gathering further data from peer informants is critical. It is also possible to assess for personality traits through behavioral and cognitive tasks or decision tasks can be used.

With regard to neuroimaging, the researchers pointed out that the MRI represents the most used method for the purpose of conducting examinations of personality, the researchers asserted the MRI is considered non-invasive and can produce three-dimensional brain images. An important consideration in personality neuroscience pertains to the ability of imaging technology to identify regions of the brain that are of interest. For example, investigations using neuroimagery became initiated twenty years ago in the exploration of Borderline Personality Disorder (BPD) that used tomography to explore the entirety of the brain. The researchers explained that personality neuroscience is useful in expanding our understanding about the neural mechanisms that support trait dimensions representing a range of adaptive and maladaptive trait dimensions. This knowledge is important as exploring traits is key in the diagnosis of personality disorders.

Kinley and Reyno (2016) explained that several therapies focus on the treatment of maladaptive emotions and the process of regulation that includes cognitive behavioral therapy, (CBT) dialectical behavior therapy (DBT), mindfulness as well as psychodynamic approaches. Neuroimaging findings associated with studies have shown for example, that mindfulness training and DBT result in lowering hyper-responsivity in the amygdala and that CBT as well as psychodynamic treatment result in a modification in neural circuits responsible for the regulation of maladaptive emotions and fear. These treatments would be beneficial for individuals with NPD as they often have problems regulating difficult emotions. The researchers contended that with the advancement of neuroimaging research pertaining to mental illness and psychotherapy, it is possible to create a tentative hypothesis pertaining to neural correlations related to presentation of symptoms, outcomes to treatment, as well as mechanisms of change.

Ethical and Cultural Issues

The American Psychological Association clarifies the importance of psychologists practicing beneficence and nonmaleficence in order to support avoiding harm and promoting the best interests of the patient in working toward the good of all patients. The issue of boundary violations therefore is critical to explore and as a relevant side note, researchers have investigated narcissistic traits among therapists and the impact on psychotherapy.

Luchner, Mirasalimi, Moser, and Jones (2008) clarified that the challenge regarding the difficulty in preventing boundary crossing between the therapist and the patient may arise when the therapist exhibits covert narcissistic traits and tendencies. The researchers noted this area has not been widely investigated in the literature but is worth exploring.

The researchers explained that the act of offering psychotherapeutic services appears to have a connection with how covert narcissism is described. It has been described as, "the importance of attunement and one-sided nature of therapeutic work" (p. 3). The researchers asserted that attunement and having the patient's needs at the forefront are skills that contribute to building a strong therapeutic alliance. The need the therapist has to be selfless and focus on the patients are all realized in the practice of psychotherapy. The researchers suggested that psychotherapy may be counterproductive in nature. As the working alliance is key in the therapeutic relationship as are focusing on upholding emotional safety and trust. Hence, it is critical for therapists to examine their own possible narcissistic traits to ensure the health of the therapeutic relationship and that harm does not result.

Crisp (2018) pointed out patients with psychotic experiences and psychopathology have reported their therapeutic and healing process became enriched in the presence of a therapist who demonstrated genuineness and also who also provided hope. In addition, when the therapist demonstrated an accepting attitude toward the patient's symptoms rather than asserting the importance of the removal of the symptoms and also upheld the patient's autonomy, the process of recovery improved. The researchers pointed to the work of Bessel Van der Kolk who had argued that a person-centered approach in which unconditional positive regard is upheld and in which patients' feel validated by their therapist results in more positive outcomes. The American Psychological Association ethical guidelines emphasize the principle regarding that psychologists aspire to respect the dignity and worth of all patients. Therefore, it is important to practice a person-centered approach with patients exhibiting psychopathology despite any resistance they may demonstrate during the treatment process. For example, Nicolo, Carcione, Semarari, and DiMaggio (2007) pointed out the therapeutic alliance with patients with personality disorders can be fraught with problems as the patients can exhibit weakness in being able to admit they have problems of a psychological nature, as well as exploring the root cause of their difficult emotions, and interpreting another's intentions towards them.

The exercise would demonstrate competent metacognition. However, these skills are absent in patients with personality disorders. Therefore, the researchers noted working to strengthen the patient's metacognition would serve as an important goal of therapy and represent an ethical therapeutic approach.

With regard to cultural considerations, Graham, Sorensen, and Hayes-Skelton (2013) asserted the United States has become more and more diverse with individuals of color comprising 36.2 % of the population. Further, 3.4 % of the adult population in the United States identify as lesbian, gay, bi-sexual or transgender. These statistics point to the importance of addressing the mental health concerns a diverse and marginalized population. The researchers contended clinicians who demonstrate cultural competence discover they are able to realize increased positive outcomes with their patients. As such, some of the treatments for Narcissistic Personality Disorder such as cognitive behavioral therapy (CBT) that has been discussed in an earlier section of the paper, can be tailored to better serve diverse populations with the disorder. Therefore, the researchers contended emphasizing cultural competence with the use of CBT while addressing multicultural principles as outlined by the American Psychological Association ethical guidelines can result in the best outcomes. One of the guidelines emphasizes that psychologists aspire to promote culturally adaptive interventions and advocacy within and across systems as they relate to prevention, early intervention and recovery. The researchers noted that CBT has been an effective approach in the treatment of many disorders among the White population. However, some general studies that have been undertaken have ignored taking culturally diverse and marginalized groups into account. For example, in a metaanalysis conducted by Stewart and Chambers (2009) as the researchers explained, 57 effectiveness about CBT treatment for adults with anxiety disorders and found CBT to be effective. In only 20% of the studies did diverse groups make up the sample. In addition, few studies have investigated CBT as an effective treatment among marginalized groups. A study of exposure based CBT among Latino and European American youth with anxiety disorders, found that both groups had experienced positive outcomes.

The researchers asserted that the literature on multicultural competence emphasizes the importance of tailoring treatment with the purpose in mind of producing the best outcomes for diverse populations. Further, it is critical in the interest of ethical practice, for clinicians to appreciate the importance of gaining a deeper understanding of their patient's culture and lived experience especially in light of strengthening the therapeutic alliance.

The researchers highlighted the work of Hays (2008) ADDRESSING framework to focus on how clinicians can begin to build the therapeutic alliance with diverse patients by discussing their own identities and exploring with the patient any concerns about potential cultural differences or similarities. The ADDRESSING framework is a useful tool in exploring an individual's cultural influences. For example, in using the framework, the therapist would explore the patient's age and generational influences, any developmental disabilities, religious and spiritual influences, ethnic and racial identity, socioeconomic status, sexual orientation, indigenous heritage, National origin, and gender.


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