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PERSONALITY > L8: Antisocial PD, Narcissistic PD, & Psychopathy > Flashcards

L8: Antisocial PD, Narcissistic PD, & Psychopathy Flashcards

1
Q

What are the diagnostic features of Antisocial PD?

A

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

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2
Q

What is the prevalence of ASPD?

A
  • general pop: 0.2-3.3%
  • higher prevalence in forensic studies: 30%
  • higher prevalence in men
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3
Q

What is a common comorbidity w ASPD?

A

substance abuse
depression, anxiety, ADHD, sexual deviancy, pathological gambling

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4
Q

What are the diagnostic features of Psychopathy (1950)?

A
  • 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
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5
Q

What is the factor model of psychopathy symptoms?

A

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

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6
Q

What are the diagnostic features of Narcissistic PD?

A
  • 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)
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7
Q

What is the prevalence of narcisstic PD?

A
  • general pop: 0-6% but understudied
  • high prevalence in forensic studies (30%)
  • higher prevalence in men than women (50-75%)
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8
Q

What are common comorbidites with NPD?

A

ASPD, HPD, BPD, STPD
vulnerable NPD: depression, anxiety, self harm, suicide attempts
grandiose NPD: substance abuse & ASPD and PPD

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9
Q

What are the 3 types of narcissism?

A
  • 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
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10
Q

Whats the difference between very severe NPD and low severity NPD?

A

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.

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11
Q

What is the dimensional approach to conceptualizing Narcissism (as opposed to DSM)?

A

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)

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12
Q

What are the pathways that Narcissists use to boost their ego?

A
  • admiration (get positive attention through positive self admiration, charm etc)
  • rivalry (push other ppl down, devaluate others in order to make urself look good)
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13
Q

How do you diagnose psychopathy?

A

often need for secondary source of info:
- file info from criminal investigation
- info from clinical/criminal records
- info from family & others
psychopathy checklist - revised

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14
Q

How does the dimensional approach conceptualize psychopathy symptoms?

A

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

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15
Q

How may NPD, ASPD, & psychopaths present?

A

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

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16
Q

What are the things to watch out for when diagnosing any of these disorders?

A
  • 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
17
Q

What are the consequences of these disorders?

A
  • 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)
18
Q

What are the treatments avaliable for these disorders?

A
  • 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
19
Q

What are the 14 guidelines for psychotherapy in these clients?

A
  1. check for ulterior (legal) reasons for them seeking therapy
  2. use a colleague as a consultant so you have second, objective opinion.
  3. only start treatment if u feel safe in the treatment context
  4. dont have too high expectations for improvement.
    patients will detect this and use it against you
  5. therapist must be stable, persistent, and thoroughly incorruptible (especially when it comes to structure & ethics)
  6. Countertransference must be monitored
  7. repeatedly confront patient’s denial and minimization of
    antisocial behavior to raise their awareness
  8. help patient connect actions with internal states of
    thoughts and feelings
  9. confront here-and-now behaviour rather than unconscious material from past
  10. be alert to comorbidities
  11. promote mentalization and empathy
  12. do not expect to maintain a neutral position regarding the patient’s antisocial activities
  13. be prepared that the patient will quit the therapy, undermine
    it, or deceive you
  14. emphasize need for honesty and unacceptability of lying or withholding information
20
Q

What makes treatment more likely to work?

A
  • presence of anxiety
  • presence of depression
  • treatable psychotic diagnosis
21
Q

What are the transference & countertransference risks in NPD?

A
  • Client: might try to use
    admiration/rivalry, Does not listen, only talks
  • You: Might get bored, Might get competitive, frustrated
22
Q

What are the transference & countertransference risks in vulnerable narcissism?

A
  • Client: seems anxious, but
    constantly looks for confirmation, Is sentitive to what therapist says
  • You: Might become
    overly invested/empathetic, Might become irritated
23
Q

What are the transference & countertransference risks in ASPD?

A
  • client: depends on level of emotionality
  • you: hopeless, irritated, frustrated
24
Q

What are the transference & countertransference risks in psychopathy?

A
  • Client: Manipulative/conning
  • You: Might think there is
    less of a problem, Frustration when therapy does not seem to improve, Overly invested
25
Q

What are the differences & similarities between antisocial PD & psychopathy?

A

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

26
Q

Whats the difference between narcissistic & antisocial PD?

A

narcissists are usually able to experience concern & guilt while also showing antisocial traits
usually seen as spectrum starting at narcisism - antisocail behaviour - psychopathy

27
Q

What is the overlap between cluster B PDs?

A

antisocial, borderline, histrionic, narcissistic, psychopathy
overlap in symptoms between disorders

28
Q

How do you diagnose narcissistic PD?

A
  • 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
29
Q

What are the diagnostic challenges in NPD?

A
  • highly variable manifestations & severity
  • wide range of behaviours & traits (grandisoity, self loathing, highly successful, struggling w employment etc)
30
Q

What are common differential diagnoses in NPD?

A
  • 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
31
Q

How can you treat NPD?

A
  • mentalization based therapy
  • transference focused PT
  • schema focused PT
  • DBT

PERSONALITY (10 decks)

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