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General Description
Narcissistic Personality Disorder (NPD) is a psychological diagnostic category defined in the Diagnostic and Statistical Manual of Disorders (5th ed., American Psychiatric Association, 2013) as a personality characterized by a pattern of grandiosity, a need for admiration and validation from other people, and a lack of empathy for others. Which results in the deterioration of the patient’s functioning and interpersonal relationships. Individual’s with NPD may demonstrate:
(a) a grandiose sense of self-importance, (b) a preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love, (c) a belief that he/she is “special” and unique and can only be understood by, or should associate with, other special or high-status people or institutions, (d) a need for excessive admiration, (e) a sense of entitlement, (f) behavior that is interpersonally exploitative, (g) a lack of empathy, (h) envy of others or the belief that others are envious of him/her, and/or (i) arrogant behaviors or attitudes (Riordan, 2012).
Treatment Approaches
A common treatment approach to NPD is transference-focused psychotherapy (TFP). TFP, inspired by psychoanalyst Otto Kernberg’s integrative object relations theory, identifies distorted internal representations of self and others as underlying pathological narcissism. The focus in TFP aims to integrate contradictory aspects of inner experience—as manifest in the transference relationship with the therapist—in order to foster greater identity stability (Ogrodniczuk, 2015). TFP is a biweekly psychodynamic psychotherapy that was created to examine the defensive mechanisms that sustain the patient’s split sense of self, with the eventual gaining an understanding the needs for those defensive mechanisms and of helping patients tolerate a more realistic, flexible integration of positive and negative (i.e., complex) portrayal of self and others (Stern, Diamond, & Yeomans, 2017). For example, a client may exhibit a delusion of superiority over their peers, and feel justified in being verbally abusive, or otherwise disrespectful. A therapist using TFP might consistently remind the client that the lives, plights, and feelings of their peers are equally valid as those of the client.
Treating NPD is especially challenging due to the persistence of the patients’ defensive mechanism, and by the enactment of their entitlement and grandiosity through the avoidance of life tasks and age-appropriate obligations outside of treatment. Research has found when a therapist and patient create a mutually sufficient treatment frame, the interpretive development, through both its containing and communicative function, could be used to connect breaches in the patient’s delusions of sense of self-importance and to begin to examine the transformations in self and object portrayal as patients act out with the therapist (Stern et. al, 2017). The examination of patterns can help patients become more acquainted with some of the themes of their behavior, and how it affects their sense of self, and their relationships. Progressively, they begin to accept a more pragmatic, imperfect portrayal of themselves, as well as identify ways to enhance the fulfillment of their experiences and relationships by making changes to their behavior. This process allows patients to exercise some control over their emotions, have a sense of autonomy, having more options, and experiencing more gratification throughout their lives (Stern et. al, 2017).

Goals of Treatment
According to Diamond and Meehan (2013) the defensive mechanisms used by clients with NPD inhibit a more practical, integrated, adaptive representational combination of self and others. It is the intention of the therapist to utilize TFP to track these undesirable displays of behavior and determine the underlying defensive mechanisms that provoke them. TFP is a useful treatment for NPD, in that it provides patients with a safe place to practice healthy self reflection. Since TFP emphasizes identifying the totality of the patient’s internal combined experience (e.g., grandiose self, devalued other; vulnerable self, idealized other), it is also effective in addressing the outward displays of antagonism and/or more subtle oscillating mental states that may characterize those with extreme NPD, such as from grandiose to vulnerable, from arrogant/entitled to depressed/depleted (Diamond ; Meehan, 2013).
Cross-Cultural Issues
Bailey and Barton (2014) state between 50-75% of those diagnosed with NPD are male.
Men are often encouraged to be dismissive of other people’s feelings, and dominate interactions in the interest of fulfilling their own agendas. This behavior is often characterized as that of a leader, or “a real man.” In 1973 Bowlby linked specific personality disorders to distinctive styles of insecurity, implying that anxious attachment could be linked to dependent and hysterical personalities and that avoidant attachment may later emerge as NPD personality (Levy, Johnson, Clouthier, Scala, & Temes, 2015). Current research has further developed Bowlby’s hypotheses.
MacDonald (2014) describes a narcissistic culture as one where life and relationships are defined by the decadent need to gain the symbols of wealth. This need is sustained by constant cultural changes, meaning that even if a trend hasn’t changed, desires for constant increases in wealth and tangible goods renders this need perpetually unfulfilled. Attention has been drawn to the transitions which are taking place within Western societies, but especially in the United States (MacDonald, 2014). For example, the life of the family has been altered considerably. Among professionals, the correct way to parent is continually changing, impeding on any instinctive knowledge of how to parent a child. In the past, members of extended family provided support in child rearing (MacDonald, 2014).
Society criticizes women who make a conscious decision to pursue a career, and women who decide to stay at home and raise children, which creates anxiety and confusion about parenting and pursuing goals. Parents may view their children as extensions of themselves and rather than set limits with their children, parents may seek to befriend them. There has been a shift away from setting limits and enforcing rules, and allowing children to have all that they desire (MacDonald, 2014). When parents don’t set limits or enforce consequences to undesirable behavior, they may be cultivating narcissistic traits within their child, and possibly fostering an absence of sensitivity to the needs of others. Therefore, narcissistic traits develop as the unforeseen repercussions of the (well-intentioned) self-esteem movement and less authoritative parenting (MacDonald, 2014).
Environmental Issues
According to MacDonald (2014) in psychodynamic theory children who experienced childhood abuse or neglect have narcissistic traits in adulthood. The parent or guardian has experienced disappointments in others and failure to acknowledge the desire of the child to be recognized, thereby imposing the child into compliance with the child’s own narcissistic desires. The child then becomes an echo of the parent or guardian without a sense of identity (MacDonald, 2014). NPD is not commonly diagnosis. However, the traits associated with NPD can be connected to cultural changes within society in this age of entitlement (MacDonald, 2014).

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