Clinical Formulations of Narcissistic PD
Clinical formulations and case conceptualisations are introduced in this post.
These are all generalisations and theories of how NPD develops, not something that is supposed to be true for everyone with NPD.
Freud suggests parents either overvaluing or neglecting (or both) a child can lead to NPD & especially inability to form healthy, lasting relationships and regulate self-esteem
"In other words, [NPD] is the outcome of insufficient gratification of the normal narcissistic needs of infancy and childhood."
Kohut theorises that narcissists' ability to form a cohesive sense of self and others was developmentally arrested in childhood, resulting in grandiosity & idealising others
"Narcissistic injury" = fragmentation of the self
Kernberg suggests grandiosity & exploitation result from maternal emotional abuse
Grandiosity is an "emotional escape valve"
Grandiosity & entitlement mask the "real self" that is "split off"
The real self unconsciously holds rage, fear, envy, deprivation
Defensive structure is same as BPD but difference is grandiosity
NPD is primarily the result of environment, especially "parental indulgence and overvaluation, learned exploitive behavior, and only-child status"
Special treatment from caregivers leads children to believe that the "world revolves around them", and therefore they expect the same outside the home
When special treatment outside the home doesn't happen, they "experiment with demanding and exploitive tactics and subsequently develop considerable skill in manipulating others"
"At the same time they come to believe that most others are inferior, weak, and exploitable."
NPD is self-perpetuating through sense of superiority, lack of self control, sense of entitlement, and dismissing of those who reject their world / self-view
Cognitive-Behavioural model
Key feature of NPD is self-aggrandisement
> Deserving of special treatment
> Not bound by social norms and rules
> Others should be punished for not recognising their specialness
> To maintain that special status others should be subservient to them
> Always strive to demonstrate their superiority
> See themselves as special, superior, entitled to special favors and treatment, and vulnerable to loss of status
> View others as inferior but potential admirers
Main pattern of behaviour is "seeking prestige, power, position, and wealth as a way of reinforcing their image of superiority", using "manipulation and guile" if necessary
The primary schema is superior & special (/ entitlement & grandiosity)
> Superior schema "shaped by flattery, indulgence, and favoritism"
> Special schema shaped by "rejection, limitations, exclusion, or deficits"
> Common denominator is the belief that the individual is different in some way
> Self-centered impulsive type
> Ruthless impression-management type
> Acceptance-oriented impression-management type
> Each type is centred around an impulse control deficit developed in childhood
> "Specifically, these individuals learned to seek reinforcers without having to work for them. This resulted in their development as self-indulgent, egocentric, and impulsive individuals."
> Ruthless & Acceptance-oriented types focus on creating favourable impressions with others, but struggle with long-lasting healthy relationships because of their empathy deficits
People with NPD were raised in an environment of "selfless not contingent" love, leading to insensitivity to others' needs
The caregiver was over-adoring, but there was also a constant threat of a "fall from grace", with pressure to be the perfect child
The constant overbearing love means that any criticism or disappointment hits very hard
"In short, there is extreme vulnerability to criticism or being ignored, together with a strong wish for love, support, and admiration from others. Noncontingent love and presumptive control of others is expected and even demanded. If support is withdrawn, or lack of perfection is evident, the self-concept degrades into severe self-criticism."
People with NPD are hypersensitive
Seen as exceptional children, leading to pressure to perform
As children likely had highly developed speech and interpersonal skills
Life purpose: "I’m special and unique, and I am entitled to extraordinary rights and privileges whether I have earned them or not."
World-view: "Life is a banquet table to be sampled at will. People owe me admiration and privilege."
Goal: "Therefore, I’ll expect and demand this specialness."
Defense mechanisms: rationalisation and projective identification
Parental injunction: "Grow up and be wonderful—for me."
"The illusion of specialness, disdain for others’ views, and a sense of entitlement lead to an underdeveloped sense of social interest and responsibility. This, in turn, leads to increased self-absorption and confirmation of narcissistic beliefs."
- From Sperry, Handbook of Diagnosis and Treatment of DSM-5 Personality Disorders (2016)
