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The character of Rodney McKay on the television show Stargate Atlantis proves to be most interesting. His behavior makes for an interesting blend of comedy and cynicism especially when he displays a blatant disregard for the feelings and needs of others. In one episode of Stargate Atlantis, he is given a heightened sense of perception and is given special powers. His special powers include telekinesis, the ability to read the minds of others, and superior intelligence. These characteristics are essentially the same characteristics possessed by Rodney under normal circumstances but when they are heightened they serve to elaborate his underlying narcissistic personality. He is seen as being able to function in his daily life with a slight impairment in his social functioning. Before we proceed any further, it is prudent that the researcher characterizes Rodney utilizing the DSM-IV-TR multiaxial diagnosis. This diagnosis is as follows:
Axis I V71.09 No Diagnosis or condition on Axis I
Axis II 301.8 Narcissistic Personality Disorder
Axis III None
Axis IV None
Axis V GAF=71 (Current)
To examine the development of this personality disorder it is prudent that the researcher fabricates a childhood for Rodney as the series did not depict any elements of Rodneys childhood. In fabricating the etiology of Rodneys disorder the researcher will rely heavily on the theories of Kohut as well as Svrakic. The researcher would have to say that as a child Rodney experienced a great deal of difficulty in relating with others. This difficulty manifested itself in the grandiose sense of self-evident in the character of Rodney as an adult.
According to Kohut, early childhood environments are noted as being a crucial part of personality development. Kohut elaborated by describing both healthy and unhealthy development. He reasoned that to understand pathology, one must first examine healthy development. Kohut (1971) stated:
Under optimal developmental conditions, the exhibitionism and grandiosity of the archaic grandiose self are gradually tamed, and the whole structure ultimately becomes integrated into the adult personality and supplies the instinctual fuel for our ego-syntonic ambitions and purposes, for the enjoyment of our activities, and for important aspects of our self-esteem and under similarly favorable circumstances, the idealized parent imago, too becomes integrated into the adult personality.
Introjected as our idealized superego, it becomes an important component of our psychic organization by holding up to us the guiding leadership of its ideals, furthermore, if a child suffers severe narcissistic traumas, then the grandiose self does not merge into the relevant ego content but is retained in its unaltered form and strives for the fulfillment of its archaic aims. If the child experiences traumatic disappointments in the admitted adult, then the idealized parent image, too, is retained in its unaltered form, is not transformed into the tension-regulating psychic structure, does not attain the status of an accessible introject, but remains an archaic, transitional self-object that is required for the maintenance of narcissistic homeostasis. (p. 28)
Kohut (1971) also discussed the importance of realizing that although there are many deficiencies to pathological narcissism, there are also assets.
On the debit side, we can say that these patients remained fixated on archaic grandiose self configurations and archaic, overestimated, narcissistically cathected objects. The fact that these archaic configurations have not become integrated with the rest of the personality has two major consequences:
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the adult personality and its mature functions are impoverished because they are deprived of the energies that are invested in the ancient structures,
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the adult, realistic activities of these patients are hampered by the breakthrough and intrusion of the archaic structures and their archaic claims, (p. 3).
In other words, healthy development of the personality structure becomes halted in the development of pathological narcissism; additionally, emotionally charged attachments continue to influence the clients emotions and interactions with the current environment. Kohut (1971) described assets that differentiate them from the psychoses and borderline states, stating that unlike patients who suffer from psychoses or borderline states, those with narcissistic personality disturbances have attained a cohesive self and have constructed idealized archaic objects (p. 3).
He explained that, unlike borderline states or psychosis, those with narcissistic personality disturbances can establish specific, stable narcissistic transferences that allow the therapeutic reactivation of the archaic structures without the danger of their fragmentation through further regression. Kohut noted that it is this specific differentiating characteristic that helps to identify narcissistic disturbances from borderline or psychosis states.
Svrakic (1990), a self-psychology theorist, discussed the functional dynamics of NPD as a two-leveled personality organization. He stated that the first level, which is superficial and manifest, consists of the grandiose self. It is explained that this is a pathological and uniquely narcissistic intrapsychic structure that dominates not only their intrapsychic world but also their interactions with others. Svrakic (1990) also discussed the second deeper and split off level, in which the real self of the narcissistic personality exists (p. 190). This level is often masked to the outside world, and it contains the underlying vulnerable and insecure self.
Furthermore, Svrakic (1990) discussed how the narcissistic structure of the grandiose self is formed in early childhood. He proposed that this grandiose self is formed early in childhood as a defense against early frustrations in the interpersonal realm.
He described how the new unrealistic intrapsychic structure brings about the experience of grandiose self-significance, entitlement, and specialness, such highly unrealistic experiences become, as it were, an inner shelter, that mostly through fantasies of ones own greatness, obtains protection from the frustrating reality (Svrakic, 1990, p. 190). Svrakic described how the fantasy of grandiose self-importance is an efficient defense during childhood. However, this persistence of the grandiose self negatively influences ones personality development. In this, Svrakic (1990) discussed how these negative effects are seen particularly in the development of the ego, superego, and object-relations (p. 190).
Due to the pathological persistence of the grandiose self in the inner world, the narcissistic persons ego consists of two opposite self-concepts. Narcissistic self-object relations are partial and they typically alternate between all good and all bad perceptions of ones self and the external world. The superego of the narcissistic personality is primitive, underdeveloped, and personified because the grandiose self captures some of the structures that should otherwise become a part of the superego (e.g., the ideal object).
As a result, the process of maturation and depersonification of the superego as a whole is interrupted; hence, the narcissistic persons internal system of values is specifically deformed and leads primarily to a constant search for grandiosity in any domain and at any cost. Finally, due to the existence of the grandiose self, the self-esteem of narcissistic personalities is chronically fragile. (Svrakic, 1990, p. 190)
Stevens, Pfost & Skelly (1984) discussed diagnostic criteria and theory according to Kohut. They addressed Kohuts idea that both normal and pathological narcissism originates in the primary narcissism of infancy. The infant, unable to distinguish itself from others, experiences the parents and parental caretaker as part of the self. Unaware that anything other than the self exists, the infant feels omnipotent and is entirely self-absorbed (Stevens et al., 1984, p. 384).
Kohut (1971) described how the:
The equilibrium of primary narcissism is disturbed by the unavoidable shortcomings of maternal care and how the child replaces these shortcomings by establishing a grandiose and exhibitionistic image of the self. He called this the grandiose self, and in addition, by giving over the previous perfection to admire an omnipotent (transitional) self-object, which he called the idealized parent imago (p. 384).
He pointed out that narcissism is defined not by the target of the instinctual investment but by the nature or quality of the instinctual charge or emotional investment. Kohut (1971) elaborated by describing how a small child invests other people with narcissistic cathexes and thus experiences them narcissistically, as self-objects. The expected control over such self-objects, therefore these others, is then closer to the concept of control which he expects to have over others (p. 27). The children view the other person as part of themselves and do not acknowledge that there is another perception besides their own.
For example, they do not recognize that their immediate needs or desires may not be that of the others; rather, the children believe as though the others are there to fill their needs. Kohut (1971) described a feeling of others being an extension of oneself, giving the example I am perfect, you are perfect, but I am part of you (p. 27). By this, Kohut described how the person with NPD, who tends to see others as extensions of oneself, internally creates ones value by the value of others.
According to the DSM-IV-TR (APA, 2000), Narcissistic Personality Disorder is an Axis II disorder estimated to affect approximately 2 16% of the clinical population and less than 1% of the general population. Between 50% 75% of those diagnosed with NPD are male.
The DSM-IV-TR (APA, 2000) characterized NPD as a pervasive pattern of grandiosity, need for admiration, and a lack of empathy for others that begins in early adulthood. Individuals with this disorder tend to have a grandiose sense of self-importance and overestimate their abilities and accomplishments. They may appear extremely boastful of themselves in their interactions with others. These individuals are often preoccupied with fantasies of unlimited success and power, beauty, and ideal love. Those with NPD often require excessive admiration from others because their self-esteem is extremely fragile.
They constantly look for and expect compliments from others. In addition to their sense of entitlement, those with NPD have a lack of empathy for others feelings or needs. They may become impatient or irritated by others who attempt to discuss their own needs and feelings. Individuals with NPD are often envious of others or believe that others are envious of them. They may devalue the accomplishments of others and presume that they are more deserving of the praise or accomplishments. They tend to display arrogant behaviors, possibly patronizing and devaluing others (APA, 2000).
As discussed earlier, the DSM-IV-TR (APA, 2000) categorized NPD as a personality disorder defined as:
an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture, is pervasive, and inflexible, has an onset in adolescence or early adulthood is stable over time and leads to distress or impairment, (p. 686)
The DSM further characterized NPD as a cluster B personality disorder. This cluster includes BPD and other personality disorders that have similar descriptive features; namely, cluster B personality disorders often appear dramatic, emotional, or erratic (APA, 2000, p. 685).
The DSM-IV-TR outlined the following Diagnostic criteria for Narcissistic
Personality Disorder
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
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has a grandiose sense of self-importance (e.g., exaggerates achievements and talents expects to be recognized as superior without commensurate achievements)
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is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
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believes that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
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requires excessive admiration
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has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
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is interpersonally exploitative, i.e., takes advantage of others to achieve his or her ends
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lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
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is often envious of others or believes that others are envious of him or her
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display arrogant, haughty behaviors or attitudes. (APA, 2000, p. 717)
In examining the character of Rodney in light of the diagnostic criteria for this disorder, Rodney fits seven criteriacriteria 3, 4, 5, 6, 7, 8, and 9. As seen by the criteria in the DSM-IV-TR, Narcissistic Personality Disorder carries significant clinical features that often, whether an inpatient or outpatient populations, greatly affect those with this disorder. Because of the characteristics described above, these individuals often have difficulties with interpersonal relationships. In many instances, individuals with NPD only present for treatment at the request of co-workers, family members, or intimate partners due to relational problems.
Treatment
Treatment of narcissistic personality disorders has typically been conducted through psychoanalysis. More specifically, Self Psychology is commonly seen as the analytic treatment of choice for NPD. The following section outlines key aspects of working with narcissistically personality-disordered patients.
Self Psychology
Kohut (1971) described in detail both the origin of normal or healthy narcissism and that of unhealthy or disordered narcissism. In his writings, Kohut described the nature of these conditions and how client/therapist interaction, transference, and countertransference, play an important role in treatment. He also discussed how the origins of the persons narcissism create a pattern of interactions that can be reworked in therapy with the therapist. Kohut described how the underlying dynamic and personality functioning plays out within the therapeutic interaction between client and therapist. In other words, the relational characteristics of NPD eventually emerge in the therapeutic relationship. This allows the therapist to observe how the client relates with others in his life and conceptualize his personality functioning. Kohut (1971) noted:
The patient will attempt to let the analyst know that, at times, especially when the narcissistic transference has become disrupted, that he has the impression that he is not fully real, or at least that his emotions are dulled, and he may add that he is doing his work without zest and that he seeks routines to carry him since he is lacking initiative, (p. 16)
He stated that this is indicative of the:
egos depletion because it has to wall itself off against the unrealistic claims of an archaic grandiose self, or the intense hunger for a powerful external supplier of self-esteem and other forms of emotional sustenance within the narcissistic realm. (Kohut, 1971, p. 16).
When speaking of individuals with NPD, Kohut (1971) suggested that it is of great importance to be mindful of the patient and mirror their experiences during sessions. Although his treatment speaks concerning the psychoanalytic process, the idea of validation is quite clear. Kohut (1971) stated, the archaic nature of the transference accounts, therefore, for certain of the patients experiences and for the formal characteristics of their reaction, and the analyst must, in general, adjust his empathy to the level of the narcissistic regression (p. 92).
To elaborate on this idea, Kohut (1971) offered an example from an interaction between him and a client, Mr. G. After a brief introduction to the clients background, Kohut (1971) discussed a point in the treatment where he realized that his behavior toward the client that was playing a crucial role in the progress in therapy. What had caused the patients withdrawal was not my forthcoming absence, but the tone in which I had announced it (p. 94). Kohut (1971) recalled that the tone, to put it in a nutshell, had been unempathic and defensive (p. 94). He further noted that no progress was made until I could offer my understanding and thus again enable the patient to recathect the idealized self-object (Kohut, 1971, p. 95).
Kohuts example emphasized the significance of the client-therapist relationship and highlights the need for empathy when working with NPD clients. Symptoms improve as therapy and the client-therapist relationship progresses. Kohut (1971) explained
Anything that deprives the patient of the idealized analyst creates a disturbance of his self-esteem he begins to feel lethargic, powerless, and worthless, and, if his ego is not assisted in dealing with the narcissistic disequilibrium by the correct interpretation concerning the loss of the idealized self-object, the patient may turn to archaic precursors of the idealized parent imago or may abandon it altogether. (P- 92)
Because individuals with NPD tend to oscillate between idealization and devaluation, it is not uncommon for clients to eventually devalue their therapists or terminate treatment prematurely. Kohut discussed the need for recognizing this tendency and utilizing the relationship to guide the therapeutic process.
Kohut (1971) also explored the concept of therapeutic regression when working with individuals with NPD. He stated:
If the analyst takes into account the nature of the archaic relationship in which the self of the patient has been grafted onto (the omnipotent therapist), he will then comprehend, on the essential level of the therapeutic regression, the patient reproaches to him concerning a separation are then meaningful and justified. (Kohut, 1971, p. 92)
Here, Kohut noted the difficulties that the therapist may encounter as this regression takes place. The client, threatened by the loss of the idealized therapist, will react and potentially regress concerning symptomology. Kohut noted the importance of using empathy and validation to not only accept the clients behavior and to prevent the therapists own harsh countertransference but to also assist the client in working through this regression by use of the relationship.
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.; text revision). Washington, DC: Author.
Kohut, H. (1971). The analysis of the self. Madison, CT: International Universities Press, Inc.
Stevens, S. J., Pfost, K. S., & Skelly, R. E. (1984). Understanding and counseling narcissistic clients. The Personnel and Guidance Journal, 10(1), 383-387.
Svrakic, D. (1990). The functional dynamics of the narcissistic personality. American Journal of Psychotherapy, 4(2), 189-198.
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