Cluster B: Narcissistic Personality Disorder

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29 March, 2000

Cluster B: NARCISSISTIC PERSONALITY DISORDER (NPD)

Mental Health Issues Treatment Issues NPD & Addiction:
Dual Diagnosis Treatment Issues

Essential Feature: A pattern of pervasive grandiosity, need for admiration, and lack of empathy (DSM-IV™, 1994).
Self Image: Inflated self-image, special, unique; extraordinary and deserving of elevated status; expects to be acknowledged as superior without commensurate achievements (Beck, DSM IV™, Millon).
View of Others: Assume to be consumed with NPDs' welfare (Benjamin). NPDs are envious of and rageful toward others (Oldham).
Relationships: Assume others will submerge their needs in favor of the NPDs' comfort and welfare (Millon). NPDs are vulnerable to the most negligible slights; they are exploitative in relationships (Benjamin).
Authority Issues: NPDs often are authority figures. Flout conventional rules; see self as above or outside of conventional restraints (Millon).
Behavior: "His Majesty, the Baby;" if successful, may be admired; may be tolerated if gifted; seen as arrogant, impatient, abrasive, abrupt and hypersensitive (Benjamin, Beck, Oldham).
Affective Issues: Rage when confidence is shaken; vulnerable to shame and humiliation; intense envy; lacking in empathy (Millon).
Defensive Structure: Preoccupied with fantasies about self; idealization of the self; devaluation of others; little genuine self-esteem; expansive and inclined to exaggerate; inflexible, self-important, and entitled (Millon, McWilliams, Oldham, Sperry).
The NPD Coming Into Treatment: NPDs are more likely to enter treatment through the criminal justice system than self-referral. They are astonished at the consequences of their behavior. Depression may also bring NPDs into treatment (Beck). However, narcissistic depression is colored with narcissistic outrage and humiliation (Masterson).
Medication Issues: NPDs are vulnerable to severe depression and rage. Anti-depressant medication may be needed if the seemingly invulnerable NPD armor made of grandiosity, arrogance, and self-centeredness is penetrated (Masterson). SSRIs have been used to reduce target symptoms of interpersonal reactivity (Sperry, 1995).
Treatment Provider Guidelines: The treatment provider must have a nonjudgmental, realistic attitude toward his or her own human imperfection and frailty (McWilliams). The need for tact and caution has to do with the tenuous quality of the relationship with clients with NPD. These individuals will flee any situation in which they experience their self-esteem as diminished (McWilliams).
Countertransference Issues: NPDs chronically devalue those around them and demonstrate little empathy or need for basic interpersonal reciprocity. Service providers can "run out of steam" in such one-sided interaction. Supervision and peer support become important to assist the service providers in avoiding having their own narcissistic issues triggered.
Treatment Techniques: Individuals with NPD have dysfunctional beliefs about the self, the world, and the future. Cognitive therapy tailors treatment of NPD to three basic components: grandiosity, hypersensitivity to criticism, and empathic deficits. Interpersonal therapy addresses changing the patterns of entitlement, grandiosity, and envy of the success of others (Sperry).
Treatment Goals: NPDs often come into treatment to have their narcissistic wounds soothed rather than seeking change (Sperry & Carlson). Treatment must include confrontation regarding aspects of reality which NPDs deny, devalue or avoid (Masterson). Treatment should aim at the most adaptive expression of their confident personality style.
Incidence of Co-Occurring SA Disorders: Cluster B represents the highest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, 1990).
For NPDs, immediate relief from personal discomfort and a sense of self-importance and power can be achieved with the use of drugs and alcohol. Substance abuse can also develop as part of the overall narcissistic pattern of self-involvement and indulgence (Beck).
NPDs are vulnerable to substance abuse because many drugs support an inflated sense of self or interrupt feelings of low self-esteem. NPDs will use drugs to enhance feelings of vigor, power, or euphoria (Richards).
NPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders. Cocaine, as a high-status drug, is particularly attractive to the narcissist (Beck).
Dual Diagnosis Treatment: Since reality is not a serious check on how NPDs view themselves, negative consequences can accumulate to a substantial degree without challenging the NPDs' denial system. NPDs are prone to hidden addictions if drug abuse is inconsistent with their self-image (Richards).
NPDs will likely "feel sorry" for other people who cannot handle alcohol or other drugs. Their expectations of special protection from consequences may allow them to experiment without particular anxiety. They often believe they have a special power of will and the strength to control the substances they use. They are very vulnerable to relapse; they do not believe it could happen to them.
Confrontation usual to substance abuse treatment is useful to break through the powerful defenses used to protect the narcissistic uniqueness. However, be aware that support will be needed if defenses do break down. Abstinence as a prerequisite of treatment is useful. Consequences do apply and need to be enforced. Use should be confronted and may result in termination from treatment once that has been made a clearly stated consequence.

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Cluster B: NARCISSISTIC PERSONALITY DISORDER (NPD)
Mental Health Issues	Treatment Issues	NPD & Addiction: Dual Diagnosis Treatment Issues
Essential Feature: A pattern of pervasive grandiosity, need for admiration, and lack of empathy (DSM-IV™, 1994). Self Image: Inflated self-image, special, unique; extraordinary and deserving of elevated status; expects to be acknowledged as superior without commensurate achievements (Beck, DSM IV™, Millon). View of Others: Assume to be consumed with NPDs' welfare (Benjamin). NPDs are envious of and rageful toward others (Oldham). Relationships: Assume others will submerge their needs in favor of the NPDs' comfort and welfare (Millon). NPDs are vulnerable to the most negligible slights; they are exploitative in relationships (Benjamin). Authority Issues: NPDs often are authority figures. Flout conventional rules; see self as above or outside of conventional restraints (Millon). Behavior: "His Majesty, the Baby;" if successful, may be admired; may be tolerated if gifted; seen as arrogant, impatient, abrasive, abrupt and hypersensitive (Benjamin, Beck, Oldham). Affective Issues: Rage when confidence is shaken; vulnerable to shame and humiliation; intense envy; lacking in empathy (Millon). Defensive Structure: Preoccupied with fantasies about self; idealization of the self; devaluation of others; little genuine self-esteem; expansive and inclined to exaggerate; inflexible, self-important, and entitled (Millon, McWilliams, Oldham, Sperry).	The NPD Coming Into Treatment: NPDs are more likely to enter treatment through the criminal justice system than self-referral. They are astonished at the consequences of their behavior. Depression may also bring NPDs into treatment (Beck). However, narcissistic depression is colored with narcissistic outrage and humiliation (Masterson). Medication Issues: NPDs are vulnerable to severe depression and rage. Anti-depressant medication may be needed if the seemingly invulnerable NPD armor made of grandiosity, arrogance, and self-centeredness is penetrated (Masterson). SSRIs have been used to reduce target symptoms of interpersonal reactivity (Sperry, 1995). Treatment Provider Guidelines: The treatment provider must have a nonjudgmental, realistic attitude toward his or her own human imperfection and frailty (McWilliams). The need for tact and caution has to do with the tenuous quality of the relationship with clients with NPD. These individuals will flee any situation in which they experience their self-esteem as diminished (McWilliams). Countertransference Issues: NPDs chronically devalue those around them and demonstrate little empathy or need for basic interpersonal reciprocity. Service providers can "run out of steam" in such one-sided interaction. Supervision and peer support become important to assist the service providers in avoiding having their own narcissistic issues triggered. Treatment Techniques: Individuals with NPD have dysfunctional beliefs about the self, the world, and the future. Cognitive therapy tailors treatment of NPD to three basic components: grandiosity, hypersensitivity to criticism, and empathic deficits. Interpersonal therapy addresses changing the patterns of entitlement, grandiosity, and envy of the success of others (Sperry). Treatment Goals: NPDs often come into treatment to have their narcissistic wounds soothed rather than seeking change (Sperry & Carlson). Treatment must include confrontation regarding aspects of reality which NPDs deny, devalue or avoid (Masterson). Treatment should aim at the most adaptive expression of their confident personality style.	Incidence of Co-Occurring SA Disorders: Cluster B represents the highest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, 1990). For NPDs, immediate relief from personal discomfort and a sense of self-importance and power can be achieved with the use of drugs and alcohol. Substance abuse can also develop as part of the overall narcissistic pattern of self-involvement and indulgence (Beck). NPDs are vulnerable to substance abuse because many drugs support an inflated sense of self or interrupt feelings of low self-esteem. NPDs will use drugs to enhance feelings of vigor, power, or euphoria (Richards). NPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders. Cocaine, as a high-status drug, is particularly attractive to the narcissist (Beck). Dual Diagnosis Treatment: Since reality is not a serious check on how NPDs view themselves, negative consequences can accumulate to a substantial degree without challenging the NPDs' denial system. NPDs are prone to hidden addictions if drug abuse is inconsistent with their self-image (Richards). NPDs will likely "feel sorry" for other people who cannot handle alcohol or other drugs. Their expectations of special protection from consequences may allow them to experiment without particular anxiety. They often believe they have a special power of will and the strength to control the substances they use. They are very vulnerable to relapse; they do not believe it could happen to them. Confrontation usual to substance abuse treatment is useful to break through the powerful defenses used to protect the narcissistic uniqueness. However, be aware that support will be needed if defenses do break down. Abstinence as a prerequisite of treatment is useful. Consequences do apply and need to be enforced. Use should be confronted and may result in termination from treatment once that has been made a clearly stated consequence.