Lecture 7: Antisocial, Narcissistic PD and Psychopathy

Question 1

what are the diagnostic criteria for NPD

Answer 1

For a diagnosis of narcissistic personality disorder (1), patients must have;
- A persistent pattern of grandiosity, need for admiration, and lack of empathy

This pattern is shown by the presence of ≥ 5 of the following:
1. An exaggerated, unfounded sense of their own importance and talents (grandiosity)
2. Preoccupation with fantasies of unlimited achievements, influence, power, intelligence, beauty, or perfect love
3. Belief that they are special and unique and should associate only with people of the highest caliber
4. A need to be unconditionally admired
5. A sense of entitlement
6. Exploitation of others to achieve their own goals
7. A lack of empathy
8. Envy of others and a belief that others envy them
9. Arrogance and haughtiness

Also, symptoms must have begun by early adulthood.

Question 2

what are the 2 types of narcissism and explain them

Answer 2

1. Grandiose, “overt” narcissism = dominance, self-assurance, immodesty, exhibitionism (centre of attention), aggression
2. Vulnerable, “covert” narcissism = introversion, negative emotions, interpersonal coldness, hostility, need for recognition, entitlement, egocentricity

Question 3

what are the 2 pathways of NPD

Answer 3

1. admiration; assertive self-enhancement (self-promotion) –> social potency
2. rivalry; antagonistic self-protection (self-defence), putting others down –> social conflict

Question 4

what are the diagnostic criteria for antisocial PD

Answer 4

For a diagnosis of antisocial personality disorder (1), patients must have;
- A persistent disregard for the rights of others

This disregard is shown by the presence of ≥ 3 of the following:
1. Disregarding the law, indicated by repeatedly committing acts that are grounds for arrest
2. Being deceitful, indicated by lying repeatedly, using aliases, or conning others for personal gain or pleasure
3. Acting impulsively or not planning ahead
4. Being easily provoked or aggressive, indicated by constantly getting into physical fights or assaulting others
5. Recklessly disregarding their safety or the safety of others
6. Consistently acting irresponsibly, indicated by quitting a job with no plans for another one or not paying bills
7. Not feeling remorse, indicated by indifference to or rationalization of hurting or mistreating others

Also, patients must have evidence that a conduct disorder has been present before age 15 years. Antisocial personality disorder is diagnosed only in people ≥ 18 years.

Question 5

what are the 3 factors of psychopathy

Answer 5

Factor 1: affective/interpersonal
- 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

Other
- Promiscuous sexual behavior
- Many short-term relationships

Question 6

explain the dimensional approach for antisocial PD

Identity, self-direction, empathy and intimacy

Answer 6

Identity
- Egocentrism
- Self-esteem derived from
personal gain, power, or pleasure

Self-direction
- Based on personal gratification
- Absence of prosocial internal standards, normative ethical behavior

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 or intimidation

Question 7

what are 4 consequences of these PDs

Answer 7

• 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)

Question 8

malignant narcissism

Answer 8

= paranoid orientation, ego-syntonic sadism, differ from ASPD because they have concern for others and capacity for loyalty

Question 9

callous-unemotional traits

Answer 9

= reduced guilt and empathetic concern, fewer displays of appropriate emotion, result in lack of fear of consequences of actions and feeling comfortable with breaking rules, reduced bonding and attachment

Question 10

what are 8 common countertransference reactions to antisocial patients

Answer 10

1. feeling of hope about patient’s amenability to treatment having higher expectations than is realistic
   –> one never knows if the patient is improving or just a good actor
2. many people tend to be charitable, generous and optimistic and give people the benefit of the doubt down play ore level of sadism and cruelty
3. regarding yourself as being capable to treat the “untreatable”patient
4. disbelief = denial that the patient is as ill as they seems often leads to diagnosis of narcissism over psychopathy
5. collusion = letting the patient corrupt you into behaving unethically
6. conceptualizing the patients behavior as growing out of influence of drugs alcohol, so diagnosing SUD rather than personality pathology
7. feeling unsafe and therefore trying to please the patient
8. assuming psychological complexity in a psychopathic individual, not being able to accept that the patient is fundamentally different from them

Question 11

what are 14 principles to honour when treating antisocial patients

Answer 11

1. Make sure there are no legal complications before treatment (eg. their motive for therapy may be to look good in front of a judge)
2. Therapists should use a colleague as consultant for a second opinion from the start objectivity because of lack of therapeutic relationship
3. Should not start treatment unless you feel safe in treatment context
4. Must not have excessive expectations for improvement (may be used against you by patient)
5. Must be stable, consistent and thoroughly incorruptable
6. Countertransference must be monitered to avoid acting out by the therapist
7. Therapist must repeatedly confront the patient’s denial and minimization of their antisocial behavior
8. Therapist must help patient to connect actions with internal states of thoughts/feelings
9. Confrontations about here-and-now behavior are likely more effective than interpretations of unconscious material from the past
10. Therapists should be alert to comorbidities
11. Mentalization and empathy in the patient should be promoted
12. Therapist cannot be expected to maintain a neutral position regarding the patient’s antisocial activities (eg. its ok to show that you’re shocked)
13. Must be prepared that patient will quit therapy, undermine it or deceive the therapist
14. Must emphasize the need for honesty and the unacceptability of lying, withholding info

Question 12

what are the proposed criteria for narcissistic PD in the alternative DSM-5 model for PDs

Answer 12

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.
2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.

B. Both of the following pathological personality traits:
1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others;
condescension toward others.
2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

Question 13

what are the 4 levels of severity of NPD

Answer 13

1. highest level of functioning: function successfully, but are susceptible to breakdowns in response to setbacks, rarely seek treatment
2. middle level of functioning: obviously distorted, grandiose, little interest in intimacy, function adequately despite interpersonal difficulties
3. lower level of functioning: poorly defined unstable sense of self, frequently oscillate between pathological grandiosity and suicidality
4. greatest level of severity: “Malignant narcissism”, typical symptoms of NPP

Question 14

what are things to look out for in the clinical interview

Answer 14

• patients description of significant others
• dismissive or derogating
• superficial/vague quality of their experience of others
• describing other in how they are similar or different to themselves

Question 15

what are the 3 PDs that are most commonly in the differential diagnosis for NPD and how can you tell them apart

Answer 15

• histrionic; both have a need to be the centre of attention, but histrionic patients have greater capacity for dependent relations and are more emotionally expressive and less dismissive of others
• borderline; relative instability of the sense of self, along with impulsivity and self-destructiveness
• antisocial; share traits of exploitation and lack of empathy, but antisocial patients show total breakdown of moral functioning and absence of any capacity for loyalty, it is also associated with conduct disorder in childhood

Question 16

what are 10 recommendations for treating/dealing with patients with NPD

Answer 16

1. Obtain a thorough symptom picture and assessment of psychological, interpersonal, and vocational functioning in order to make a differential diagnosis
2. Assess for vulnerable as well as grandiose forms of narcissistic pathology.
3. In any patient for whom narcissistic personality disorder is in the differential diagnosis, assess carefully for pathology of moral functioning (dishonesty, exploitation) as well as frank antisocial features
4. Share diagnostic impressions with the patient in the setting of providing psychoeducation and identifying treatment goals. In characterizing narcissistic personality disorder for the patient, focus on problems with self-esteem regulation, lack of satisfaction in their interpersonal lives, and the subjective distress and/or functional impairments that brought the patient to treatment.
5. Anticipate that patients with narcissistic personality dis- order typically show significant impediments to beginning treatment and engaging fully in the treatment.
6. Use the patient’s words, or preface interventions with comments such as “As you said earlier” to help the patient with narcissistic personality disorder more readily accept the clinician’s comments and recommendations.
7. For patients who present with symptoms of depression or anxiety or for substance abuse treatment, adopt standard psychopharmacologic and therapeutic interventions.
8. Attempt to maintain a nonjudgmental and inquisitive stance toward the patient’s difficulties and his or her perception of others, including other clinicians, and steer clear of directly confronting or criticizing the patient’s grandiosity.
9. It is helpful to anticipate that one will have to monitor and contain one’s emotional reactions to the patient. Pitfalls to be avoided are to respond defensively, aggressively, or dismissively to the narcissistic patient or to withdraw and collude with the patient’s denial of pathology through passivity.
10. Attend to negative feelings that the patient may have about the treatment and the clinician.

Question 17

what are 9 things that are present in psychopathy that are not present in ASPD

Answer 17

1. emotionally shallow
2. callous (lack of empathy)
3. glibness/superficial charm
4. grandiose
5. early behavioural problems
6. need for stimulations
7. lack of realistic long term goals
8. promiscuous sexual behaviour
9. many short-term (but very serious) relationships