7 Phases of Narcissistic Abuse

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Genetic Factors In Personality Disorders

Although there were no antisocial patients in this cohort, other lines of research (Cadoret, Yates, Troughton, Woodworth, & Stewart, 1995 Cloninger, Sigvardsson, Bohman, & von Knorring, 1982) have suggested heritable factors in that disorder. Notably, in two disorders (the borderline and narcissistic categories) that have aroused the interests of psychoanalysts and have not traditionally been considered to be heritable, genetic factors accounted for about two-thirds of the variance.

Social Factors In Personality Disorders

A parallel conjecture could be made concerning narcissistic personality disorder (Paris, 2003). Although we have no good community studies of the prevalence of narcissistic personality disorder, some clinicians (e.g., Kohut, 1977) have thought that more cases are presenting for treatment. If this is so, we might hypothesize that heritable narcissistic traits are normally channeled into fruitful ambition by strong family and social structures but that under conditions of rapid social change, the same traits can become dysfunctional.

Etiology Of Identity Diffusion

The lack of integration of the concept of self and of significant others also interferes with the internalization of the early layers of internalized value systems, leading particularly to an exaggerated quality of the idealization of positive values and the ego ideal, and to a persecutory quality of the internalized, prohibitive aspects of the primitive superego. These developments lead, in turn, to a predominance of splitting mechanisms at the level of internalized value systems or superego functions, with excessive projection of internalized prohibitions, while the excessive, idealized demand for perfection further interferes with the integration of a normal superego. Under these conditions, antisocial behavior may emerge as an important aspect of severe personality disorders, particularly in the syndrome of malignant narcissism, and in the most severe type of personality disorder, namely, the antisocial personality proper, which evinces most severe identity diffusion as well...

The Clinical Assessment Of Identity

The nature of adolescent school failure also includes a broad spectrum of diagnostic possibilities and does not reflect directly the syndrome of identity diffusion depressive reactions, attention-deficit-hyperactivity disorder, physical, sexual or emotional abuse, significant inhibitions of many origins, the characteristic pattern of narcissistic personalities of being the best student in some courses and the worst in others, and generalized breakdown in the functioning at school as a reflection of identity diffusion have to be differentiated from each other. The capacity to fall in love and to maintain a stable love relation, in general, is related to normal identity, but some adolescents may be delayed in their capacity to establish sexual intimacy out of inhibition, and the absence of that capacity is not necessarily diagnostic. Sexual promiscuity, on the other hand, may or may not reflect identity diffusion in adolescence. Significant changes in mood and emotional lability are...

The Treatment Of Identity Diffusion

The tactical principles of the treatment include rules and procedures that apply in each session, the consideration of particular priorities of interventions, and management of complications in the treatment. These tactics involve, first of all, special modes of contract setting geared to protecting, at all times, the patient's life, the lives of others, the continuity of the treatment, and, above all, the maintenance of the treatment frame. This frame usually is severely tested by regressive transference developments. In addition, tactics involve a series of priorities of interventions in the light of frequent complications in the treatment, including severe suicidal behavior, threats to the continuity of the treatment, severe acting out in and outside the sessions, patients' mendacity, blocking of treatment development by severe narcissistic resistances, and defensive trivialization of the content of the hours.

The Therapeutic Relationship

The therapeutic style should be markedly different with a dependent patient versus a patient with clear narcissistic or paranoid features (Velzen & Emmelkamp, 1996). When working with a dependent phobic patient at the start of treatment, it may be advisable to enquire by telephone how the homework assignments are coming along. With a narcissistic patient, however, the therapist would be advised to refrain from this as it may reinforce the narcissistic tendency to demand excessive attention. The same applies for the paranoid patient as this patient may interpret the therapist's good intentions as doubts as to whether he or she is completing the homework assignments. Note that later in therapy one should fade out the telephone inquiries with the dependent patient as well, as these calls may end up reinforcing the undesired dependent behaviours.

Toward A New Classification Of Personality Disorders

Cloninger (2000) proposed that the defining features of personality disorder (Step 1) be based on low levels of the character dimensions of the Temperament and Character Inventory (TCI Cloninger, Przybeck, Svrakic, & Wetzel, 1994). Low levels of Self-directedness are reflected in irresponsibility, purposelessness, helplessness, poor self-acceptance, and impulsivity. Low levels of Cooperativeness are reflected in intolerance, narcissism, hostility, revengefulness, and opportunism. Low levels of Affective Stability are reflected in anx-iousness, irritability, envy, hatefulness, and bitterness. Low levels of Self-transcendence are reflected in an unstable self-image, an erratic worldview, magical thinking, emptiness, and aesthetic insensitivity. Individual differences in personality disorder phenomenology (Step 2) are then based on variation in combinations and levels of the TCI temperament dimensions of Harm Avoidance, Novelty Seeking, and Reward Dependence.

Psychoanalytic Perspectives On Psychopathology

1A review of the psychodynamics of individual PDs is beyond the scope of this chapter. Indeed, numerous volumes have been written on this topic, with narcissistic, borderline, antisocial, and histrionic PDs receiving the greatest attention from theorists. Rather than evaluating the psychoanalytic model of each DSM-IV-TR PD, I evaluate the heuristic value of the psychoanalytic perspective in toto, with brief discussion of the psychodynamics of select PD syndromes. 2 Characteristic forms of neurotic psychopathology include phobias and mild depression representative psychoses include schizophrenia and dissociative disorders. Personality disorders in the psychoanalytic model (e.g., borderline, narcissistic) are discussed in the following sections. In the following sections I discuss the role of ego strength, defense style, and object relations in the etiology and dynamics of PDs. Although these variables are discussed in separate sections for the sake of clarity, PD dynamics typically...

Marshall L Silverstein

During the past 30 years, the fields of personality disorders and psychoanalytic self psychology have developed important reformulations of personality. The contemporary period of conceptualizing personality disorders began by operationalizing diagnostic criteria and assigning these disturbances to their own axis of classification in the multiaxial structure that originated with the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III American Psychiatric Association, 1980). Thus, continually refining criteria and differentiating personality disorders from syndromal disorders securely established a basis for investigating the clinical psychopathology of the personality disorders. This approach continued the neo-Kraepelinian tradition that substantially influenced contemporary American concepts of schizophrenia and affective disorders. It set the pace for the empirical studies that were to follow, emphasizing matters of diagnostic overlap or comorbidity,...

Limitations In The Way Prototype Categorization Is Operationalized In Dsmiv

The DSM-IV algorithms for diagnosing PDs, which involve counting the number of criteria met and applying diagnostic thresholds, represent one possible way of operationalizing prototype classification (which we hereafter refer to as the count cutoff method of diagnosis). This was a substantial advance over prior approaches that implicitly or explicitly assumed a classical (defining features) model of categorization. The count cutoff method of diagnosis, however, actually represents a mixed model of classification, in two senses. First, perhaps the most central feature of a prototype approach to classification is the recognition that for many categorization tasks, dichotomous classification (i.e., a case is either a member of a category or it is not) is inappropriate because the construct is a fuzzy set. (The same is true for dichotomous, present absent diagnostic criteria.) Yet the DSM retains a categorical diagnostic system that requires clinicians and researchers to assume just the...

Dynamic Psychotherapy

The authors describe STDP, based on the work of Davanloo, as more active and confrontational than BAP. The study included patients who met DSM-III criteria for compulsive, avoidant, dependent, or histrionic personality disorder, or more than one of these. The authors found no difference between therapies but patients in both groups were significantly improved compared with the waiting list condition on their primary complaint (Battle et al., 1966), the SCL-90 (Derogatis & Cleary, 1977) and the Social Adjustment Scale (Weissman & Bothwell, 1976). The original study by this group excluded patients with borderline and narcissistic features but a later study by the same group (Winston et al., 1994) incorporated some patients with Cluster B disorders and obtained similar results.

The value of the publicprivate distinction

A mistrust of the private sphere and what it represents runs through Sennett's work. He sees the concern of the Western state with individualism as a near-narcissistic obsession with the self, a condition that leads to the imposition of individual values on all aspects of life, public and private. This, he argues, results in the public sphere being regarded as an inferior state because it cannot provide the individual with self-affirming

The Construct Of Psychopathy

Personality attributes as the defining characteristic. Millon and Davis (1996) noted the variety of concepts proposed in the clinical literature, such as instinct-ridden characters, manipulative personalities, or malignant narcissism, but the most influential concept has been that of Cleckley (1941 1982). Cleckley rejected detailed classifications of personality disorders, including Schneider's, seeing most categories as neurotic or psychotic disorders, but he proposed a distinct clinical entity, which he considered to be a disorder of personality. working-class criminality. F2 also related more strongly than F1 to DSM-III antisocial personality disorder, whereas F2, but not F1, correlated with narcissistic disorder. Self-report personality measures generally correlate only weakly with the PCL-R, but scales of narcissism, Machiavellianism, and lack of empathy correlate significantly with F1, while impulsivity and sensation seeking correlate with F2 (Hare, 1991). A second example of...

Psychopathy As Personality Disorder

Cleckley's acceptance of DSM-II antisocial personality and his concept of a distinct clinical entity encouraged the assumption that psychopathy is currently represented in DSM-IV, albeit inadequately, by the APD category. PCL-R criteria were, in fact, considered as a replacement for APD in DSM-IV (Hare, Hart, & Harpur, 1991). However, psychopathic traits appear in other personality disorders, notably narcissistic (grandiosity, lack of empathy) and histrionic (superficial charm, insincerity, shallow affect, egocen-tricity). DSM-IV adds that narcissistic disorder shares with APD the traits of tough-mindedness and exploitativeness, while impulsivity, excitement seeking, recklessness, and manipulativeness are common to both histrionic disorder and APD. Apart from criteria of seeking admiration or attention, histrionic and narcissistic disorders are distinguished from APD by usually lacking a history of conduct disorder or criminality. Given that criminal behavior was not intrinsic to...

Psychopathy As Human Variation

The focus on diagnosing this entity also creates a dichotomous way of thinking that exaggerates the differences between psychopaths and other offenders while minimizing similarities (Toch, 1998 Wulach, 1983). This is also seen in speculations about successful psychopaths in the community. If this means that some successful people have traits associated with Cleckley's psychopathy, it would hardly be surprising and is entirely consistent with a dimensional view of psychopathy. For example, narcissistic traits of grandiosity, lack of empathy, and exploitativeness are not uncommon among corporate leaders, and such traits may be valued by organizations, even though not by their employees (Hogan, Raskin, & Fazzini, 1990 see also Levenson, 1992). Often, however, successful psychopaths implies subclinical psychopaths getting away with undetected crimes, reflecting a dichoto-mous view of psychopathy as a dangerous diagnostic entity. Patterns of both normal and dysfunctional adaptation are...

Psychological Theories

What is notable about BPD is the conflict between the two polarities of each dimension, which emerges as a near-constant state of ambivalence and tension. This is not true of all people with personality disorders. The person with dependent personality disorder can feel comfortable in an environment in which he or she is consistently nurtured and supported similarly, the individual with narcissistic personality disorder can feel comfortable if interacting with one or more admirers, but not so for the borderline. A persistently nurturing other person tends to elicit fears of engulfment however, anything less than complete devotion at every moment elicits abandonment terror. Similarly, the person with BPD tends to alternate between passively hoping for attention and affection from others and actively seeking to have his or her emotional needs met. Millon describes this polarity conflict as signifying . the intense ambivalence and inconsistency that characterizes the borderline, their...

Long TermCare Facilities

The negative perception that society, and older adults in particular, have of nursing homes is due in part to the desire of older adults to remain with their families in familiar surroundings rather than being placed in an unfamiliar environment to be tended by strangers and await death. Accounts of unsanitary and unsafe conditions and inadequate treatment of patients by nursing home staff during the 1970s and 1980s prompted a number of investigations of the entire nursing home industry. One result of these investigations and the attendant publicity was passage of the Nursing Home Reform Act of 1987, containing a set of regulations that apply to all nursing home facilities. This legislation resulted in the gradual phasing out of the distinction between nursing homes and intermediate care facilities, and, more importantly, to a greater respect for patients' rights. Nursing home patients are now more likely to be treated as individuals who merit respect and should be permitted and...

Instruments For Assessing Normal Styles And Dimensions

Narcissistic, confident, asserting, ambitious Typically bold and self-assured, these individuals think highly of themselves and expect others to cater to their wishes and demands. They can be charming and manipulative, and others may see them as lacking empathy. The PD counterpart is narcissistic.

Issues In Translation Of Personality Scales

Paranoid), eight basic personality patterns (schizoid, avoidant, dependent, histrionic, narcissistic, antisocial, compulsive, and passive-aggressive), and two correctional scales of denial versus complaint. The instrument identifies or calculates whether a patient is or is not a member of a diagnostic entity. Each scale is composed of a number of items. The raw score is transformed into base rate scores, and a conversion is determined by known prevalence data and by using cutting lines designed to maximize correct classification. The MCMI-I uses an item overlap keying for theoretical, practical, and empirical reasons. Because it is based on Millon's theory on psychopathology, you might expect that the avoidant and the dependent personalities share some common basic features, a finding gauged by empirical covariations. By using item overlap, the number of items in the 20-scale inventory could be kept to a minimum.

Self Psychologically Influenced Framework For Personality Disorders

Crucial imperative in the histrionic, dependent, and antisocial personality disorders if a compensatory structure can be acquired. The prototypic disorder of the self, narcissistic personality disorder, can represent any of these three mechanisms, and admixtures also are not uncommon. Fragmentation phenomena take the form of intense tension states that are not readily dispelled but are instead experienced as overwhelming. States of fragmentation such as these leave patients feeling adrift or unanchored, resembling phenomena that Kohut (1971) first called disintegration products, such as outbursts of helpless anger (narcissistic rage). Fragmentation results from experiences with caregivers who could not provide the selfobject experiences of mirroring or idealization to bolster the self when normal developmental yearnings had not yet solidified to form a reliable psychological structure. It predisposes children to feel an overriding sense of lacking something vital, which is the quality...

Integrating Psychodynamic Personality Disorder Processes

Although every PD can be described in terms of ego strength, defenses, and introjects, it is the complex interplay among these variables that determines the underlying dynamics and surface manifestations of each syndrome. Brief reviews of borderline, dependent, and narcissistic PDs illustrate the interactions among these variables. Narcissistic Narcissistic Two contrasting psychodynamic models of narcissistic personality disorder (NPD) have emerged in recent years. Kohut (1971, 1977) argued that NPD results from a fundamental flaw in the development of the self that stems from inadequate parental empathy and ineffective parental mirroring early in life. As a result, the individual never fully differentiates from the primary caregiver, and subsequent relationships are characterized by boundary confusion and merging of self and other (Auerbach, 1993). Other theorists argue that NPD reflects defenses used to manage an overwhelming sense of failure that stems from the parents' inability...

Natural History And Longterm Outcome In Personality Disorder

Stone (2001) reviews the available data on the natural history and long-term outcome of personality disorders, noting that individuals within the 'antisocial realm' historically constituted a diverse group incorporating those meeting criteria for DSM antisocial personality disorder psychopaths, as defined by Hare et al. (1990) and individuals with sadistic personality disorder (Appendix, DSM-III). The Hare Psychopathy Checklist-Revised (PCL-R) (Hare et al., 1990) allows for the differentiation of psychopaths from individuals who are antisocial without scoring high on psychopathy. Recent studies suggest that the prognosis is considerably better for those in the latter group than it is for the former, who score high on the extreme narcissistic traits subsumed in Hare's Factor-I. While Dinwiddie & Daw (1998) found that antisocial personality disorder was largely stable over an eight-year follow-up, other studies have shown a tendency for criminality to decrease over time (Arboleda-Florez...

Recent Advances In Self Psychology

This section incorporates the expanded view of a psychology of the self, a broader perspective extending beyond Kohut's (1966, 1971) initial description of the narcissistic personality and behavior disorders. This is a development in self psychology that may not be familiar to those primarily acquainted with self psychology's attempt to understand a previously un-treatable group of narcissistic disorders. Thus, the self psychological formulations I discuss emphasize the self rather than drive states or ego functions as the central agent of mental life. I begin with a discussion of three recent advances in self psychology, which is followed by outlining a self psychological framework for conceptualizing personality disorders. Treatment of the vertical split requires attention to the walled-off affects of the split-off segment of the self. Although it may be advantageous to consider the vertical split as a type of personality disorder, its relationship with antisocial personality...

Modes of Adaptation The Passive Active Polarity

At the ecologically accommodating end of the passive-active continuum are personality adaptations that exhibit an excess of passivity. Several personality patterns demonstrate this passive style, although their passivity derives from and is expressed in appreciably different ways. (See Table 11.1 for all personality patterns explicated in this section.) Accommodating (e.g., dependent Millon, 1996, pp. 330-331) personalities, because of deficits in confidence, initiative, and autonomous skills, display a tendency to wait passively for others to provide nurturance, offer protection, and assume leadership. Passivity among conscientious (e.g., obsessive-compulsive Millon, 1996, p. 513) personalities stems from their aversion to acting independently because of intrapsychic resolutions they have made to quell troubling thoughts and emotions generated by their self-other ambivalence. Ambitious (e.g., narcissistic Millon, 1996, pp. 403-404) personalities presumptuously assume that they are...

Aaron L Pincus

Personality disorders continue to be perplexing clinical phenomena to define, classify, diagnose, and effectively treat. Although conceptions of abnormal personalities have existed since the earliest clinical nosologies of the twentieth century (Abraham, 1921 1927 Krae-pelin, 1907 Reich, 1933 1949 Schneider, 1923 1950), the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III American Psychiatric Association, 1980) was a landmark event for the clinical science of personality disorder. DSM-III provided a separate diagnostic axis (Axis II) on which personality disorders were to be evaluated and also introduced the contemporary categories of avoidant, borderline, dependent, and narcissistic personality disorder to the official nomenclature. From 1980 through the end of the century, DSM-III Axis II and its subsequent revisions (DSM-III-R, APA, 1987 DSM-IV, APA, 1994 DSM-IV-TR, APA, 2000) stimulated an enormous increase in psychological...

Traits and Types

Though they represent smaller dimensions of personality than types, traits may still be quite broad. For example, traits such as authoritarianism, humanitarianism, narcissism, and Machiavellianism (power-striving) may be so dominant or pervasive in a person's life that they are expressed in almost all of his or her activities.

Case Study

Y is a 30-year-old, African American female with a college education who had been in psychotherapy for three months at the time the treating clinician described her. The clinician gave her an Axis I diagnoses of dysthymic disorder and eating disorder NOS and a GAF score of 50, indicating moderate impairment. As part of the assessment, the clinician completed a randomly ordered checklist of all of the symptoms comprising Axis II. When we applied DSM-IV diagnostic algorithms, the patient met criteria for borderline, histrionic, and dependent PDs. We also asked the clinician to rate this patient on each of the empirical prototypes of the Cluster B PDs using the rating system described earlier. The clinician rated the patient as meeting criteria for borderline PD (a rating of 5) and having significant features of histrionic PD (a rating of 3). She gave the patient ratings of 2 and 1, respectively, for narcissistic and antisocial PD. On a questionnaire that addresses developmental and...

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