Narcissistic to cause significant impairment in occupational or

Narcissistic
personality disorder (NPD) is one of the four personality disorders in Cluster
B. These four personality disorders are tied together due to similar symptoms. People
with a Cluster B personality disorder are often viewed as overly emotional, self-dramatizing,
and unstable. The other three Cluster B disorders are antisocial, borderline,
and histrionic. NPD is characterized by a pattern of grandiosity, a constant
need of admiration, and a lack of empathy for others (Frey, 2012). According to
Kernberg and Kohut, the roots of NPD can be traced to disturbances in the
parent-child relationship before the child turned three years old (Frey, 2012).
However, Kernberg differed from Kohut in that Kernberg believed that NPD was
rooted in a defense by the child towards an unempathetic and cold parent (Frey,
2012). This paper will explore Kernberg’s theory as it applies to NPD and its
treatment. As well as examine the neurobiology and diversity of NPD.

Theory

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            A
person’s character or personality is made up of various traits (Hertz, 2011).
Some of those traits can be adaptive and useful in one situation yet dysfunctional
in another (Hertz, 2011). A person is diagnosed with a personality disorder when
these character traits become so maladaptive and inflexible that they begin to cause
significant impairment in occupational or social functioning or cause subjective
distress (Hertz, 2011). As previously mentioned, some of the most common
characteristics of NPD include having a constant need for admiration, grandiosity,
and a lack of interest in anyone but themselves (Marissen, Brouwer, Hiemstra, Deen, &
Franken, 2016).  Other patterns of NPD
include a very high sense of entitlement, arrogant, and feeling like they are
very “special” and can only be understood by and associate with other
high-status people like themselves (American Psychiatric Association, 2013). Working
with clients with NPD can be quite difficult as they tend to feel like they can
only work with a therapist that is the best, meaning that the therapist has to
be worthy of working with them. Clients with NPD can often be rude and have a
difficult time depending on the therapist which makes it challenging to work
with them as they want to maintain control of the treatment (Kernberg, 2007).

            Otto
Kernberg’s theory on narcissism was guided by his work with patients with
borderline personality disorder (Palombo, Bendicsen, & Koch, 2010). Much of
Kernberg’s psychoanalytic framework included aspects of Freud’s drive theory as
well as aspects from Klein and Fairbairn’s object relations theories and
Jacobson’s ego psychology theory (Palombo, Bendicsen, & Koch, 2010).
Kernberg concluded that there were three major tasks that children encounter (Palombo,
Bendicsen, & Koch, 2010). A child’s first major task is to identify what is
self from what is other (Palombo, Bendicsen, & Koch, 2010). The second
major task is to conquer splitting and finally, the last major task is to
combine the good and the bad self (Palombo, Bendicsen, & Koch, 2010).
Kernberg’s developmental system differed from Freud’s model in that Kernberg
believed that the level of attained internal object relations was the basic
issue in the developmental progression (Palombo, Bendicsen, & Koch, 2010).

            As
an expansion of the three-stage model, Kernberg proposed his theory of
development which offers a concept of normality (Palombo, Bendicsen, &
Koch, 2010).  For this theory of
development Kernberg proposed that development occurs in five stages. The first
stage is known as normal autism or the primary undifferentiated stage which
occurs from birth to one month. During this first stage, the child constructs
primary self-object representation from interacting with the caregiver (Palombo,
Bendicsen, & Koch, 2010). The second stage occurs from one month to 6-8
months and is normal symbiosis or primary undifferentiated self-object
representation. During this stage, the infant, differentiates between self and
object-images and their emerging egos (Palombo, Bendicsen, & Koch, 2010). Stage
3 occurs between 6-8 months to 18-36 months of age and is called
differentiation of self from object representations. During this stage, the
child, begins differentiation of self and object images with the good and bad
object relations and ends with the child integrating good and bad self-images
and good and bad object-images (Palombo, Bendicsen, & Koch, 2010). Stage 4
is the integration of self-representation and object-representations which
begins at age 18-36 months and through Oedipus. Kernberg believed that during
this stage the result is a definite self-system. Finally, stage 5 is the stage
of consolidation of superego and ego integration which is the end of the Oedipus
and beyond. During this stage Kernberg identified that the superego integrates
into the personality as the superego’s separateness from the ego diminishes (Palombo,
Bendicsen, & Koch, 2010).

            The
second part of Kernberg’s model is abnormal development which consists of three
levels of severity of NPD (Palombo, Bendicsen, & Koch, 2010). In the first
level are the mildest cases, the second level reflects the typical narcissistic
which definitely needs treatment, and finally, the third level consists of a
narcissistic patient that functions at an overt borderline level (Kernberg, 2007).
According to Kernberg (2007), a patient with NPD shows some dominant features
at the second level of severity. In the  pathology of the self, a patient with NPD is
very insecure, self-centered, and over dependent on admiration from others
(Kernberg, 2007). When it comes to relationships with others, the NPD patient
is envious, greedy, exploitative, entitled and lacks empathy (Kernberg, 2007).
A patient with NPD is unable to commit to a relationship let alone establish
joint goals with others (Kernberg, 2007). In the pathology of the superego, the
NPD patient’s self-esteem is regulated by severe mood swings, are incapable of
sadness and mourning, and are driven by a “shame” culture (Kernberg, 2007).

            Many
people with NPD are constantly in a chronic sense of boredom and emptiness (Kernberg,
2007). This leads a narcissistic patient to crave artificial stimulation of
affective response (Kernberg, 2007).  Some
of the complications that come with people that have NPD include drug and
alcohol dependence, sexual promiscuity and sexual inhibition, suicidality and
parasuicidality, social parasitism, and the possibility of brief psychotic
episodes (Kernberg, 2007). This comes with pathological narcissism. Severe narcissistic
pathology occurs when the relationship no longer involves self and object but rather
involves a primitive and pathological grandiose self and the short-term
projection of the grandiose self onto objects (Tuttman, 1981).

            According
to Tuttman (1981), “Kernberg defines normal narcissism as the “libidinal
investment of the self (p. 309). The self is seen as an intrapsychic structure
that consists of multiple self-representations (Tuttman, 1981). “Self-representations
are mental affective-cognitive structures in the form of images which reflect
the person’s perception of himself in real interactions with significant others
and in fantasied interactions with internal representations” (Tuttman, 1981, p.
309). 

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