The Almost Untreatable Narcissist Patient

(Kernberg is considered the "gold standard" in psychology. Below is the introduction to his article "THE ALMOST UNTREATABLE NARCISSISTIC PATIENT")

by Otto F. Kernberg

"Clinical experience in the Personality Disorders Institute at Weill Cornell Medical College suggests that patients with borderline personality organization and a narcissistic personality disorder have a more serious prognosis than all other personality disorders functioning at the borderline level, and that those who in addition present significant antisocial behavior have an even worse prognosis (Clarkin, Yeomans, and Kernberg 1999; Stone 1990). This negative
trend culminates in a group of practically untreatable patients with antisocial personality disorder, who represent the most severe cases of pathological narcissism. There are also patients with severe narcissistic personality disorder, functioning at an overt borderline level with significant antisocial features, but not presenting an antisocial personality disorder proper, who at times respond to treatment, while others do not. These patients are explored here, with a focus on particular psychotherapeutic techniques that have proven helpful, as well as on the limits of these
technical approaches.

In order to keep this introductory section reasonably short, a
certain categorical style is almost unavoidable. But because this section provides the organizing frame for what follows, I beg the reader’s indulgence. The narcissistic personality disorder presents, clinically, at three levels of severity. The mildest cases, who appear “neurotic,” usually present indications for psychoanalysis. They typically consult only because of a significant symptom, one that seems so linked to their character pathology that anything but the treatment of their personality disorder would seem inadequate. In contrast, other narcissistic patients at this level present symptoms that may be treated without an effort to modify or resolve their narcissistic personality structure. All these patients seem to be functioning very well, in general, though typically they present significant problems in long-term intimate relationships, and in long-term professional or work interactions.

A second level of severity reflects the typical narcissistic
syndrome, with all the various clinical manifestations to be described below. These patients definitely need treatment for their personality disorder, and here the choice between standard psychoanalytic treatment and psychoanalytic psychotherapy depends on individualized indications and contraindications. At a third level of severity, patients with narcissistic personality disorder function at an overt borderline level: in addition to all the typical manifestations of narcissistic personality disorder, these patients also present a general lack of anxiety tolerance and impulse control, as well as severe reduction in sublimatory functions (that is, in the capacity for productivity or creativity beyond gratification of survival needs). These patients usually show severe and chronic failure in their work and profession, and chronic failure in their efforts to establish or maintain intimate love relations. At this same level of severity, another group of patients do not show overt borderline features but instead present significant antisocial activity, which, prognostically, places them in the same category as those who function on a borderline level.

All of these severely narcissistic patients may respond to a psychoanalytic, transference-focused psychotherapy, unless, for reasons specific to an individual, this approach would seem contraindicated, in which case a more supportive or cognitive-behavioral approach might be the treatment of choice (Kernberg 1997; Levy et al. 2005). Patients whose antisocial behavior is predominantly passive and parasitic present less of a threat to themselves and to the therapist than do those who present severe suicidal and parasuicidal behavior, or violent attacks against others. Aggression against others or self is typical for antisocial behavior of the aggressive type, particularly when these patients fulfill the criteria for the syndrome of malignant narcissism. That syndrome includes, in addition to the narcissistic personality disorder, severe antisocial behavior, significant paranoid trends, and ego-syntonic aggression (this last may be directed against the self or against others).

Let us now briefly review the dominant features of the narcissistic personality disorder as typically represented, particularly at the second or intermediate level of severity (Kernberg 1997).

1. Pathology of the self: these patients show excessive selfcenteredness, overdependency on admiration from others, prominence of fantasies of success and grandiosity, avoidance of realities that are contrary to their inflated image of themselves, and bouts of insecurity disrupting their sense of grandiosity or specialness.

2. Pathology of the relationship with others: these patients suffer from inordinate envy, both conscious and unconscious. They show greediness and exploitative behavior toward others, entitlement, devaluation of others, and an incapacity to really depend on them (in contrast to needing their admiration). They show a remarkable lack of empathy with others, shallowness in their emotional life, and a lack of capacity for commitment to relationships, goals, or joint purposes with others.

3. Pathology of the superego (conscious and unconscious internalized value systems): at a relatively milder level, patients evince a deficit in their capacity for sadness and mourning; their self-esteem is regulated by severe mood swings rather than by limited, focused self-criticism; they appear to be determined by a “shame” culture rather than by a
“guilt” culture; and their values have a childlike quality. More severe superego pathology, in addition to defective mourning, entails chronic antisocial behavior and significant irresponsibility in relationships.

A lack of consideration for others precludes any capacity for guilt or remorse for such devaluing behavior. Malignant narcissism, a specific syndrome mentioned earlier, reflects severe superego pathology characterized by the combination of narcissistic personality disorder, antisocial behavior, ego-syntonic aggression (directed against self and /or others), and marked paranoid trends.

4. A basic self state of these patients is a chronic sense of emptiness and boredom, resulting in stimulus hunger and a wish for artificial stimulation of affective response by means of drugs or alcohol that predisposes to substance abuse and dependency.

Patients with narcissistic personality disorder may present typical complications of this disorder, including sexual promiscuity or sexual inhibition, drug dependence and alcoholism, social parasitism, severe (narcissistic type) suicidality and parasuicidality, and, under conditions of severe stress and regression, the possibility of significant paranoid developments and brief psychotic episodes."