L8: Antisocial PD, Narcissistic PD, & Psychopathy Flashcards
What are the diagnostic features of Antisocial PD?
Disregard for and violation of the rights of
others starting since age 15
* Not conforming to social norms → repeated unlawful behavior
* Deceitfulness (lying, conning)
* Impulsivity
* Irritability and aggressiveness
* Reckless disregard for safety of self and others
* Consistent irresponsibility
* Lack of remorse
What is the prevalence of ASPD?
- general pop: 0.2-3.3%
- higher prevalence in forensic studies: 30%
- higher prevalence in men
What is a common comorbidity w ASPD?
substance abuse
depression, anxiety, ADHD, sexual deviancy, pathological gambling
What are the diagnostic features of Psychopathy (1950)?
- Superficial charm and good “intelligence”
- Absence of delusions and other signs of irrational thinking
- Unreliability
- Untruthfulness and insincerity
- Lack of remorse or shame
- Inadequately motivated antisocial behavior
- Poor judgement and failure to learn by experience
- Pathological egocentricity and incapacity for love
- General poverty in major affective reactions
- Specific loss of insight
- Unresponsiveness in general interpersonal relations
- Fantastic and uninviting behavior with drink and sometimes without
What is the factor model of psychopathy symptoms?
Factor 1: affective/intepersonal
* Affective: lack of guilt/remorse, emotionally shallow, callous (lack of empathy), failure to accept responsibility for actions
* Interpersonal: glibness superficial charm, grandiose, pathological lying, conning /manipulative
Factor 2: antisocial/lifestyle
* Antisocial: poor behavioral control, early behavioral problems, juvenile delinquency, revocation of conditional release, criminal versatility
* Lifestyle: need for stimulation, lack of realistic long term goals, parasitic lifestyle, impulsivity,
irresponsibility
Others
- promiscuous sexual behaviour
- many short term relationships
What are the diagnostic features of Narcissistic PD?
- grandiose sense of self
- need for admiration
- arrogance
- entitlement
- fantasies of success, power etc
- envious of others
- feels “special”
- lack of empathy
- exploitative
- vulnerable self esteem
- underlying feelings of inferiority
- emotional distress
core psych features - deficits in self definition, self esteem regulation & internal goals/standards
- impaired interpersonal relationhip (lack genuçine intimacy)
- require external validation
- leads to superficial relationships (grandiose types) & social withdrawal (vulnerable types)
What is the prevalence of narcisstic PD?
- general pop: 0-6% but understudied
- high prevalence in forensic studies (30%)
- higher prevalence in men than women (50-75%)
What are common comorbidites with NPD?
ASPD, HPD, BPD, STPD
vulnerable NPD: depression, anxiety, self harm, suicide attempts
grandiose NPD: substance abuse & ASPD and PPD
What are the 3 types of narcissism?
- grandiose (overt) narcissism: dominance, self assurance, grandiosity, attention seeking, entitlement, arrogance, low anxiety, socially charming, exploitative, lack empathy, immodesty, exhibitionism (center of attention), aggression (DSM Narcisstic PD)
- vulnerable (covert) narcissism: inhibition, distress, hypersensitivity to evaluation, chornic envy, secret grandisoity, introversion, negative emotions, interpersonal coldness, hostility, need for recognition, entitlement, egocentricity (DSM BPD?)
- High functioning: grandiosity, competitiveness, attention seeking, while maintaining adaptive functioning & success, hard to spot narcissism
Whats the difference between very severe NPD and low severity NPD?
as severity increases: aggression, interpersonal dysfunction & other defincies increase
- high functioning: rarely seek treatment. just seek admiration & have grandiose sense of self & have transactional relationships
- middle functioning: grandiose sense of self, limted interest in intimacy, exploit others, rarely seek treatment, interpersonal difficulties
- low functioning: unstable self concepts (grandiosity to suicidality), self harm, interpersonal didficulties, covert grandiosity. hard to treat
- malignant narcisissim: typical NPD symptoms + prominent antisocial behaviur and paranoi. very difficult to treat.
What is the dimensional approach to conceptualizing Narcissism (as opposed to DSM)?
Identity:
- uses others for self definition & self esteem regulation
- exaggerated self appraisal
- emotion regulation fluctuates w self esteem
Self Direction:
- goal setting based on gaining apporval
- high/low personal standards
- unaware of own motivation
Empathy
- impared ability to recognise / identify
- excessively attentive to reaction of others (on the self)
- Over or underestimating own effect on others
Intimacy
- superficial relationships
- restrained mutuality (little genuine interest)
What are the pathways that Narcissists use to boost their ego?
- admiration (get positive attention through positive self admiration, charm etc)
- rivalry (push other ppl down, devaluate others in order to make urself look good)
How do you diagnose psychopathy?
often need for secondary source of info:
- file info from criminal investigation
- info from clinical/criminal records
- info from family & others
psychopathy checklist - revised
How does the dimensional approach conceptualize psychopathy symptoms?
Identity
- egocentrism
- self esteem derived from personal gain, power, or pleasure
Self direction
- based on personal gratification
- absence of prosocial internal standards, normative ethical behaviour
Empathy
- lack of concern for others
- lack of remorse after hurting or mistreating another
Intimacy
- Incapacity for mutually intimate relationships
- exploitation is used to relate to others
- use of dominance of intimidation
+ 6/7 pathological traits: manipulativeness, callousness, deceitfulness, hostility, risk taking, impulsivity, irresponsibility
How may NPD, ASPD, & psychopaths present?
encounter them
- usually not voluntarily in therapy, cus fam wants them to go/in forensic setting/ for different issue
appear as
- charming/manipulative
- normal
- externalizing blame
- NPD: subtle egocentrism, emphasizing own suffering, gaslighting
What are the things to watch out for when diagnosing any of these disorders?
- Narcissism is a spectrum
- Sometimes narcissism is used as a mask (for anxiety, insecurity)
- ASPD/psychopathy diagnoses may be damaging
- Situational vs. Personality traits?
- There are cultural differences
e.g., macho culture, individualistic vs. collectivistic cultures - There are generational differences
e.g., the “selfie” generation - There are gender x culture differences
e.g., men might be expected/allowed to be more narcissistic
What are the consequences of these disorders?
- Involvement in criminal justice system
- Poor interpersonal relations
- Negative consequences for others
In close relationships
In work settings - Poor personal outcomes (low quality of life)
What are the treatments avaliable for these disorders?
- need to be tailored
- often BPD treatments used
- good signs: taking responsibility, high emotionality
- otherwise: focus on harm reduction
- very complicated & limited!
- medication may help w psychotic elements
- structured long term hospitalization may work
- accountability & agency must be central
- emphasize mentalizing & internal awareness
- beaware of suicide risk
- beware of outpatient programs (psychotherapy): likely wont help, especially in severe patients
What are the 14 guidelines for psychotherapy in these clients?
- check for ulterior (legal) reasons for them seeking therapy
- use a colleague as a consultant so you have second, objective opinion.
- only start treatment if u feel safe in the treatment context
- dont have too high expectations for improvement.
patients will detect this and use it against you - therapist must be stable, persistent, and thoroughly incorruptible (especially when it comes to structure & ethics)
- Countertransference must be monitored
- repeatedly confront patient’s denial and minimization of
antisocial behavior to raise their awareness - help patient connect actions with internal states of
thoughts and feelings - confront here-and-now behaviour rather than unconscious material from past
- be alert to comorbidities
- promote mentalization and empathy
- do not expect to maintain a neutral position regarding the patient’s antisocial activities
- be prepared that the patient will quit the therapy, undermine
it, or deceive you - emphasize need for honesty and unacceptability of lying or withholding information
What makes treatment more likely to work?
- presence of anxiety
- presence of depression
- treatable psychotic diagnosis
What are the transference & countertransference risks in NPD?
- Client: might try to use
admiration/rivalry, Does not listen, only talks - You: Might get bored, Might get competitive, frustrated
What are the transference & countertransference risks in vulnerable narcissism?
- Client: seems anxious, but
constantly looks for confirmation, Is sentitive to what therapist says - You: Might become
overly invested/empathetic, Might become irritated
What are the transference & countertransference risks in ASPD?
- client: depends on level of emotionality
- you: hopeless, irritated, frustrated
What are the transference & countertransference risks in psychopathy?
- Client: Manipulative/conning
- You: Might think there is
less of a problem, Frustration when therapy does not seem to improve, Overly invested
What are the differences & similarities between antisocial PD & psychopathy?
differences:
- psychopathy not in DSM
- psychopathy often seen as extreme end of the antisocial personality spectrum
- psychopathy more severe in symptoms & treatment resistance
- psychopaths more neuropsych problem
- psychopaths less likely to have comobrid mood & xniety disorders due to lack of amygdala reactivity
- extreme lack of empathy and guilt/remorse, extreme manipulation
similarities
- lots of overlap in symptoms so loads comorbidity: lack of remorse, lack of insight
Whats the difference between narcissistic & antisocial PD?
narcissists are usually able to experience concern & guilt while also showing antisocial traits
usually seen as spectrum starting at narcisism - antisocail behaviour - psychopathy
What is the overlap between cluster B PDs?
antisocial, borderline, histrionic, narcissistic, psychopathy
overlap in symptoms between disorders
How do you diagnose narcissistic PD?
- systematic clinical interview
- key clues can be found in how patients describe SOs (often in dismissive, derogatory, or overly idealized terms, showing superfiical relationship), tend to compare themselves to others
- as clinican you often feel belittled, incompetent or ignored in their presence
What are the diagnostic challenges in NPD?
- highly variable manifestations & severity
- wide range of behaviours & traits (grandisoity, self loathing, highly successful, struggling w employment etc)
What are common differential diagnoses in NPD?
- bipolar: grandiosity often in manic states but admiaration seeking & devalution of others usually absent here
- substance abuse: assess history
- depressive & ADs: overlap w vulnerable narcisism, evaluate sense of self & interpersonal funcitoning
- BPD: distinguished from NPD by instability of sense of self, impuslivity, and self distructiveness
- HPD: both seek attention, but HPDs are more emotionally expressive & dependent, while NPD are more dismissive & see themselves as exceptional
- ASPD: shares traits of exploitation & lack of empathy, but ASp has lack of loyalty, history of conduct disorder, & lack of morality
How can you treat NPD?
- mentalization based therapy
- transference focused PT
- schema focused PT
- DBT
