Tag Archive | identity disturbance

PART IV: INTERACTION BETWEEN BPD MOTHER AND CHILD

Dec21

In this article (Part IV) I want to take a deeper look at some of the research that was done regarding relationship between Borderline parent and children in comparison to mothers that don’t suffer from BPD.

Infants

Studies have found that interactions between mothers with BPD and their baby are characterized by insensitivity, high levels of intrusion, and low levels of positive response to infant distress. Mothers with BPD smile less, touch and imitate their infants less, and play fewer games with their babies. They often have difficulty identifying and appropriately responding to their children’s emotional state. These unmet psychosocial needs at critical moments of development increase risk of disorganized attachment and rob children of security, comfort, and safety from the very beginning of their lives. Newman and colleagues found that infants of BPD mothers aged 3 to 36 months were less attentive and less interested in interactions with their mother during a free-play interaction compared to infants of healthy control mothers.

Pre-school
Macfie and Swann examined mother-child attachment in 30 preschoolers (4-7years) in comparison to 30 children with healthy mother-child bond. They discovered that role reversal was significantly more likely to be present in the narratives of children with a BPD mother. More negative parent-child relationship expectations, such as the relationships characterized by danger and/or unpredictability were also found in the preschooler’s narratives. The children also exhibited greater fears of abandonment. Lastly, the children of BPD mothers also showed more incongruent (e.g. the child cleans his/her room then ruins it) and shameful self- representations (e.g. the child says he/she is bad) in the narratives.

School-age children
Different studies showed that children of mothers with BPD have more psychiatric diagnoses, such as ADHD and higher rates of BPD symptoms in childhood. These children also reported more cognitive and interpersonal vulnerability, such as a negative attributional style, ruminative response style, dysfunctional attitudes, self–criticism, insecure attachment style, and excessive reassurance seeking. Adolescents
Adolescents whose mothers had BPD exhibited more attention problems, delinquency, aggression, more anxiety, depression, and low self-esteem. In general BDP mothers reported that they feel less satisfied, less competent and more distressed with their parenting abilities.

DSM IV criteria for Borderline Personality Disorder

  1. Frantic efforts to avoid real or imagined abandonment.
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving).
  5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior such as cutting, interfering with the healing scars (excoriation) or picking at oneself.
  6. Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness and worthlessness.
  8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress related paranoid ideation, delusions or sever dissociative symptoms. (APA, 2000, pp. 292-293)
BPD can often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

My movie recommendation for understanding BPD dynamic: 
Mommie Dearest

In case you want to deepen your understanding of your relationship with your parents, please take a look at my online workshop “Mending our childhood wounds and patterns” HERE.

This workshop will help you with understanding the patterns, roles and attachment you are having in your family dynamic and will shine the light on your behaviors and wounds you are carrying with you. It will also teach you how to deal with your emotions that will evoke through this self-discovery.

PART III: TYPES OF BORDERLINE PARENT

Dec20

Experts wonders whether there are actually distinct types of borderline personalities. The minds are divided but experts still try to distinguish between the different types of BPD in academic literature as well as in popular one. In Part III we will take a look at both of them. Please note that this list of types serves as a guidelines and person who suffers from BPD can have a mix of everything.

Popular Literature
Dr. Christine Lawson in a book Understanding the Borderline Mother introduces 4 types of borderline mothers that fall into high functioning or low functioning category:

High-Functioning BPD Mothers

The Witch
The Witch is someone who acts out viciously when they feel threatened, rejected and criticized. This type of mother seeks power and control over others, and reacts with unpredictable rage. Family members live in fear of triggering her. Unconsciously she is consumed by self-hatred and tends to be extremely hostile and cruel towards their children. She tends to be self-obsessed and has little or no concern for others. The Witch has no remorse and will not apologize for hateful acts she has done to her child. At the base of their need for power and control is their intense desire to prevent abandonment. This particular sub-group of BPD is very resistant to treatment. It is not uncommon for their children to develop depression, shame, insecurity, Post-traumatic Stress Disorder.

  • “There was a problem with my report card, showing I had a 0, even though I knew for a fact I had done the assignment. I didn’t have enough time to tell the teacher about it, so I would do so the next day, in order to fix my grade. I showed my Mother, trying to explain it to her, and even though I had a simple solution to fix it the next day, she proceeded to slap me across the face and scream at me for getting a 0, as well as proceed to call me lazy and not caring about my education. Yeah, I had the proof to show her I had done the assignment, could easily get my grade changed, and even then, I was still getting yelled at, grounded, and getting my things taken away. And slapped across the face.”

The Queen
The children of a Queen Mother are supposed to be her loyal subject. Queen needs to be the center of attention and uses her children to fulfill her own needs. “Pay attention to me! Love me, love me, prove to me you love me and do everything as I say!” If you disagree with her, don’t do as she says or you have your own needs, you don’t love her. Children are not permitted to have their own needs or opinions, and are not encouraged to become individuals in their own right.
She pretends to be a perfect woman who has it all together, independent, powerful, and in control of everything. They can be manipulative and vindictive and have a strong sense of self entitlement. They cross boundaries without recognition or regret. Inside they experience chronic feelings of emptiness and inability to self-soothe when distressed.

Low-Functioning BPD Mothers

The Waif

The Waif portrays the helpless victim, exhibiting how everyone is treating them and how they need protection. They can suffer from depression, anxiety, irrational fears, and feelings of vulnerability, helplessness, hopelessness and are prone to deep despair. But they are rejecting attempts by family members to help them. In this way, they passively control others and are generally unable to nurture anyone. 
They expect from the children to “save her” and believe that people are out there to get them and do not trust others. Children may feel that they can help if only they do more, learn more, and give more. Unfortunately the Waif continues to stay helpless as a means to control and avoid abandonment. She neglects her children, often they feel angry and alone and may develop codependency issues as adults.

The Hermit
Hermits may have a tough exterior and a superficial image of being confident, determined and independent. Except, they’re actually terrified of the world, and distrust everyone and are prone to rage and paranoia. They feel constantly betrayed by others and take criticism as a condemnation of who they are. Perfectionism is a hallmark of the Hermit, and they can rage or criticize (which they often do) when others fail to meet their expectations. They have no desire to go out in the world and have close friends outside of their family, especially their children. They gain their self-esteem from work or hobbies.

  • “My mother often said that as she got older, she became afraid of everything. We could never get her to try and go out with friends unless we took her out for coffee or shopping. We were the only real “friends” she had. And honestly, we were because we had to, or else, who else would she have?”

BPD types in academic literature

There were quite a few attempts to find different subtypes of BPD in academic research.

In The Essential Family Guide to Borderline Personality Disorder, Randi Kreger grouped BPD into:

  • Lower-functioning/conventional types is described as engaging in a lot of self-destructive behavior that requires frequent hospitalization. They are very low-functioning, meaning they may not be able to work or go to school. The author calls this self-destructive behavior “acting in,” an idea that correlates with the concept of internalizing symptoms.
  • Higher-functioning/invisible type is described as functioning well in most contexts, but engaging in a great deal of “acting out” behavior, such as verbal abuse, criticizing others or becoming violent. This description correlates well with the concept of externalizing symptoms.

One study examined types of borderline personalities based on a personality disorders that co-occur often with BPD. They categorized person in one of the 3 clusters:

  • Cluster A tended to engage in more paranoid thinking and eccentric behavior.
  • Cluster B tended to have more dramatic or arrogant personalities.
  • Cluster C tended to be more fearful.

Another study examined BPD subtypes in adolescent boys and girls. Interestingly enough study found reliable BPD subtypes in girls, but not boys. Girls with BPD tended to fall into one of the following categories:

  • high-functioning internalizing
  • depressive internalizing
  • histrionic and angry externalizing

Another study found three BPD subtypes:

  • withdrawn–internalizing
  • severely disturbed–internalizing
  • anxious–externalizing

Individuals with different presentations of BPD may respond differently to the treatment. In this study, individuals from the severely disturbed-internalizing subtype did not see symptom improvement with treatment, where those in the anxious-externalizing and withdrawn-internalizing subtypes did.

The last subtypes of BPD I want to write about is from T. Millon. He lists 4 subtypes of BPD:

  • The Discouraged Borderline looks like individual with Dependent Personality Disorder (codependent). They tend to be clingy, go along with the crowd, and walk around feeling somber and somewhat dejected. Deep inside however, there are often angry and disappointed with the actions of those around them. Scratch the surface, and that anger could explode, but they are much more likely to do harm to themselves by self-harming or even suicide. 
Some of the symptoms common to this subtype are: excessive dependence upon others, cycles of withdrawal and aloneness, passive, permissive, recurrent depression including tearful episodes (more common than rage episodes), anger can feel sudden and surprising to others, paranoia and self-persecution, more likely to deprive rather than indulge oneself, victimized, tendency to evoke sympathy, feelings of abandonment can invoke psychotic episodes, trigger desperation and suicidality, irresponsible behavior, uses drugs, alcohol, food, money, or sex for self-soothing, tendency to use fantasy to escape reality, gives away or destroys belongings, suffers from chronic or recurring illness or somatic complaints.
  • Impulsive Borderline seems to be a first cousin to the Histrionic Personality Disorder. These individuals tend to be flirtatious, captivating, elusive and superficial. They are highly energetic and seek out thrill after thrill. They are easily bored and seem to have it never ending appetite for attention and excitement. As their name implies, they will often act without thinking, getting themselves into all sorts of trouble. Such individuals can often be very charismatic and it’s easy to get caught in their spell. This type of person is in constant conflict with society. Bouts of violence are not uncommon. This person may have antisocial personality disorder as a co-occurring diagnosis. This person is operating in an Abandoned Child mode–a plea for attention, any attention–as well as an Angry Child mode. The Angry Child believes that other people deserve to be punished for his/her pain, and behaves accordingly. This type of person with BPD may have poor impulse control, abuse substances, or self-harm. On the other extreme he or she may not care about himself/herself, it’s all about what the other person thinks. This often results in extreme efforts to avoid disapproval and abandonment.
  • Petulant Borderline is unpredictable, irritable, impatient, and complaining as well as defiant, disgruntled, stubborn, pessimistic and resentful. They are torn between relying upon people and at the same time keeping their distance for fear of disappointment. They vacillate between feelings of unworthiness and anger. This anger can be quite explosive. This is a passive-aggressive person. He or she will injure himself or herself, either physically or emotionally, in an attempt to get needs met. This person has an unstable sense of self, a frantic fear of abandonment. They operate in an Angry Child mode. He or she is angry and will hurt friends and family as a result. They often doesn’t recognize the anger-the world is the problem, not them. They don’t know how to express their needs in a healthy way, so relationships seem to be a game of “If you really loved me” or “You should know what I want”.
  • Self-Destructive Borderline is marked by his constant sense of bitterness which they turn inward. They will often engage in self-destructive behaviors whether it is conscious or unconscious. Their levels of self-hatred can often reach monumental proportions leading them into all types of self-destructive behaviors, ranging from poor healthcare to reckless driving to performing humiliating sexual acts. This person often suffers from depression as a co-occurring diagnosis and is a self-injurer. This is a person who feels that no one cares, and reacts by not caring about himself or herself. They operates in an Abandoned Child mode. Since they don’t feel loved, they reacts in self-destructive ways in an attempt to feel something instead of nothing. They lives in terror of abandonment, is self-loathing, and has no idea who they are inside. Thoughts of self-injury or actions are a given in this type.

In case you want to deepen your understanding of your relationship with your parents, please take a look at my online workshop “Mending our childhood wounds and patterns” HERE.

This workshop will help you with understanding the patterns, roles and attachment you are having in your family dynamic and will shine the light on your behaviors and wounds you are carrying with you. It will also teach you how to deal with your emotions that will evoke through this self-discovery.

NARCISSISTIC PERSONALITY DISORDER (NPD)

Nov7
  1. Definition of Narcissistic personality disorder (NPD)

The term narcissism was first used in relation to human psychology by Sigmund Freud in his essay “On Narcissism” after the figure of Narcissus in Greek mythology (Golomb 2003: 18).
The Myth: One day Narcissus was walking in the woods when Echo (mountain nymph) saw him, fell deeply in love, and followed him. Narcissus sensed he was being followed and shouted “Who’s there?”. Echo repeated “Who’s there?” She eventually revealed her identity and attempted to embrace him. He stepped away and told her to leave him alone. She was heartbroken and spent the rest of her life in lonely glens until nothing but an echo sound remained of her. Nemesis, the goddess of revenge, noticed this behavior after learning the story and decided to punish Narcissus. Once, during the summer, getting thirsty after hunting, the goddess lured him to a pool where he leaned upon the water and saw himself in the bloom of youth. Narcissus did not realize it was merely his own reflection and fell deeply in love with it, as if it was somebody else. Unable to leave the allure of his image, he eventually realized that his love could not be reciprocated and he melted away from the fire of passion burning inside him, eventually turning into a gold and white flower (Source: https://en.wikipedia.org/wiki/Narcissus_(mythology))
Narcissism is “a pattern of traits and behaviors which signify infatuation and obsession with one’s self to the exclusion of all others and the egotistic and ruthless pursuit of one’s gratification, dominance and ambition.” (Vaknin 2003:18) The narcissist constantly tries to repair his injured self-esteem by adoring and admiring his gilded self. (Golomb 2003: 18)

  • Diagnostic criteria

There is a whole range of narcissistic reactions, styles, and characteristics – from the mild, reactive and transient to the permanent personality disorder. NPD is commonly diagnosed with other personality disorders, such as Histrionic, Borderline, Paranoid, and Antisocial Personality Disorders (Vaknin 2003).
The ICD-10 (International Classification of Mental and Behavioural Disorders) defines NPD as “a personality disorder that fits none of the specific rubrics”. It relegates to the category “F60.8 Other specific personality disorders”, together with eccentric, “haltlose” type, immature,        narcissistic, passive-aggressive and psychoneurotic (ICD-10).
American DSM-IV-TR defines NPD as “an all-pervasive pattern of grandiosity (in fantasy or behavior), need for admiration or adulation and lack of empathy”.
The DSM specifies nine diagnostic criteria. Five (or more) of these criteria must be met for a diagnosis of NPD.
Proposed Criteria:

  • ‘Feels grandiose and self-important (e.g., exaggerates accomplishments, talents, skills, contacts, and personality traits to the point of lying, demands to be recognized as superior without commensurate achievements);
  • Is obsessed with fantasies of unlimited success, fame, fearsome power or omnipotence, unequalled brilliance (the cerebral narcissist), bodily beauty or sexual performance (the somatic narcissist), or ideal, everlasting, all-conquering love or passion;
  • Firmly convinced that he or she is unique and, being special, can only be understood by, should only be treated by, or associate with, other special or unique, or high-status people (or institutions);
  • Requires excessive admiration, adulation, attention and affirmation – or, failing that, wishes to be feared and to be notorious (Narcissistic Supply);
  • Feels entitled. Demands automatic and full compliance with his or her unreasonable expectations for special and favorable priority treatment;
  • Is “interpersonally exploitative”, i.e., uses others to achieve his or her own goals;
  • Devoid of empathy. Is unable or unwilling to identify with, acknowledge, or accept the feelings, needs, preferences, priorities, and choices of others;
  • Constantly envious of others and seeks to hurt or destroy the objects of his or her frustration. Suffers from persecutory (paranoid) delusions as he or she believes that they feel the same about him or her and are likely to act similarly;
  • Behaves arrogantly and haughtily. Feels superior, omnipotent, omniscient, invincible, immune, being “above the law”, and omnipresent (magical thinking). Rages when frustrated, contradicted, or confronted by people he or she considers inferior to him or her and unworthy.’ (Vaknin 2003: 19)

1.1.2. Short comparison with other personal disorders
As mentioned earlier NPD is commonly diagnosed with other personality disorders. In this chapter I will introduced short comparison with four other personality disorder.
Opposite from patients with the Borderline Personality Disorder (BPD), the self-image of the narcissist is stable, he or she is less impulsive, self-destructive and concerned with abandonment issues. Also they are not as clinging as BPD patients (Vaknin 2003). Borderline and narcissistic patients both idealize and devalue others. But there is a different between them. BPD patient alternates between idealization and devaluation. For example, first they will idealize you, you will be the best therapist they ever had, and in the next session they will devaluated you, you will be the worst person they had ever know.  Nevertheless, the borderline patient cares about others. The narcissistic patient is more exploitative. Idealization is connected with expectation to satisfied patient’s grandiose fantasy. The minute expectations are not met, narcissist abandons you and looks for another one who will meet his grandiose fantasies (MacKinnon and others).
In short, on surface functioning of the narcissistic personality is much better than that of the average borderline patient. In general, NPD individuals are more capable of high, sustained achievement and will have more successful work history than the person with Borderline Personality Disorder. Both kinds seek attention, but unlike borderline, who seek nurturing attention, narcissist feel they deserve admiring attention because of their superiority (http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).
Histrionic Personality Disorder (HPD) and NPD: Both personality types tend towards the demonstrative, exhibitionistic, dramatic and seductive in their behavior. Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt. While the characteristic distinguishing feature of Histrionic Personality Disorder is coquettishness, the feature of NPD is grandiosity. Person with HPD is warm, playful, and spontaneous and can be dependent on others. These individuals are capable of love, empathy whereas those with NPD are not (Vaknin 2003; look at http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).
While persons with NPD and Antisocial Personality Disorder (ASPD) share tendencies to be tough-minded, glib, superficial, exploitative, and unempathetic, NPD are less impulsive, less aggressive, and less deceitful. All ASPD are assumed to have a narcissistic personality structure, but not all narcissists are ASPD. Unlike a person with ASPD, the person with NPD has not learned to be ruthless or competitively assertive and aggressive when frustrated. A critical distinguishing feature is that in ASPD, there are no feelings of guilt or remorse and as opposed to ASPD, few narcissists are criminals (Vaknin 2003; see http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).
Patients suffering from the range of obsessive-compulsive disorders (OCD) are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical. However, someone with NPD is more likely to believe that he has actually achieved perfection. Shortly, the OCD seeks perfection, the narcissist claims it. The value systems of these two personality types differ as well: person with OCD has deeply held, rigid but genuine moral and socio-political beliefs. In contrast, the person with NPD might exposed such deeply held values but actually lacks any true commitment to them (Vaknin 2003; see http://www1.appstate.edu/~hillrw/Narcissism/differentialdiagnosis.html).

1.1.3. Defense mechanism
Over all narcissists intended to protect true self from hurt and trauma. He creates False Self which is omnipotent, invulnerable, and omniscient, through which he regulates his self (Vaknin 2003). To maintain that state, narcissists develop different defense mechanisms. There are three defense mechanisms that are the most common for narcissists: splitting, graciosity and isolation/distance.
Graciosity: narcissist creates relationships only with people who admire them or who he admires. Consequently he is afraid that others will disappoint him or demand attention for themselves. When attention is turned away from them, they distance themselves and leaves the relationship (Praper 1996: 180).
Distance and isolation: narcissist doesn’t realize that he is hurt and wounded. When they got the feeling that others don’t see them as perfect, feeling of inferiority is awaken in them. They are unable to take criticism and take a distance when this happens (Praper 1996: 180).
Splitting or black and white thinking can be seen as a developmental stage as well as a defense mechanism, which is also common in NPD. Narcissist believe that they need to be admired by others. The ones who don’t admire them are categorized as bad. Their ego is not capable of accepting good and bad objects in one person (Praper 1996, see http://en.wikipedia.org/wiki/Splitting_%28psychology%29#Narcissistic_personality_disorder).

1.1.4. Types of narcissism
We all go through narcissistic developmental stage in our lives. As infants and toddlers we all feel that we are the center of the Universe and it is impossible to imagine that our needs wouldn’t be met (Praper 1996). Here we talk about primary narcissism, where toddler doesn’t separate the mother from himself and he depends on her to satisfy his primary needs (Lasch 1979: 79). Both self and others are viewed immaturely-as idealizations (Vaknin 2003). Gradually toddler gains experiences that everything cannot be the way he wants. He realize that there are obstacles in the world, which brings him little disappointments and make him overcome primary narcissism (Praper 1996).
Secondary or pathological narcissism is a pattern of thinking and behaving in adulthood. It manifests in the chronic pursuit of personal gratification and attention, in social dominance and personal ambition, bragging, insensitivity to others, lack of empathy and/or excessive dependence on others to meet his responsibilities in daily living and thinking (Vaknin 2003). Lasch says that this type of narcissism tries to destroy painful disappointments in childhood and cover the childs rage towards people that hurtled him. (Lasch 1979: 79)
Manfield differentiates the exhibitionist type and cover narcissism, both belonging to secondary narcissism (Praper 1996: 178):
The first type is exhibitionistic type. Children during childhood get a lot of support in their grandiosity but there is no room for individuality and true feelings. This type is common for families with one child. Investment in one child raises grand expectations. The child should be born genius, and should use every opportunity to demonstrate this to others. When not acting as expected, he can be roughly rejected by his parents. Avoiding rejection, he continues to be brilliant, perfect, sweet. He also requires that others treat him as special (Praper 1996: 178).
The second type is the disguised type. The child has experienced that grandiose ideas are unacceptable. He learns to hide any such feeling and behaviors. However, he still develops perfectionism and hypersensitivity to criticism. The need for superiority is suppressed while suffering from feelings of inferiority. The truth is that he in fact doesn’t believe that he is inferior (Praper 1996: 179). The disguised type appears humble and modest, so impressively weak that it isn’t difficult to overlook the hidden grandiose self (Praper 1996: 223).
Also Millon distinguish 4 subtype of secondary narcissism in the following photo:

Table: Narcissistic Personality Subtypes (available at: http://www.millon.net/taxonomy/summary.htm)

  1. Origins of narcissism 

NPD has been considered as pathology of self as formation of pathological development of identity (Praper 1996: 175). Considering the work of Otto Kernberg, narcissism is an ego distortion. Ego functions enable us to observe our self and environment. With narcissism, the ego is unable to develop observations from environment in to cohesive picture of self (look Praper 1996: 176). Kernberg sees narcissism as a defense against feelings of individual anger and abandonment, stemming from the child’s rejection. As a result narcissists are distrustful and incapable of relying on others. Their relationships are marked by jealousy, control, and withdrawal (Žižek 1987: 118-119).
By Kerenberg, pathological narcissism originates from the serious frustrations in separation phase (Praper 1996). Kernberg points out that narcissism is a result of permanently cold parental figures, which express indifference or hostility towards the child. This inadequacy is reflected in their tendency to inflate their self-image (Otway and Vignoles 2006).
Kohut believes that narcissism is a normal aspect of infantile development. The child’s self-grandiosity is supported by mirroring and idealizing relationship between child and parent. If these needs are not met, the child as an adult may appear poorly adapted to adult forms of narcissism (Otway and Vignoles 2006). He also believes that the loss of the object that would allow binding and idealized mirroring force the person to direct fantasy only to himself. Therefore, the NPD is looking for a person who would idealize him. Hoping that through the binding with others, he will achieve the feeling of coherent self. In reality he is looking for mother’s admiration that was not there (Praper 1996, 177). The secondary narcissism happens because the process of archaic infantile narcissism to a healthy adult narcissism is interrupt. (Otway and Vignoles 2006).
By Winnicottu, the reason for narcissism is the lack of empathy and harmony between parent and child. Another reason can be overly intrusive behavior from the parent. Child develops a false self, which protects the true self from intrusion and damage. Therefore, narcissists always offer impeccable false self and protect himself against feelings of inferiority (Praper 1996:177).
Millon’s theory opposes to mentioned theories which believe that negative relationship between child and parent is reason for narcissism. Instead, Millon says that the reason is the excessive attention of parents, over-pampering, forbearance and admiration. Parents show unrealistic judgment of the child’s abilities, thereby increasing children’s self-image, which the environment does not necessarily support. Despite the differences in the theories, all believe that narcissism is a result of dysfunctional childhood experiences. (Otway and Vignoles 2006)

  1. Personal attributes

Main personal characteristics which are normally found in NPD:
Sensitivity to criticism: patients with NPD feel injured, humiliated and empty when criticized. They often react with devaluation, rage, and defiance to any5 real or imagined criticism. They are incapable to tolerate setbacks, disagreement, and criticism. (Vaknin 2003)
In personal relationships narcissist is not capable of attachment to others. He depends only on recognition from others. He doesn’t t trust people because he has pathological fear of over-dependency on others. That’s why he usually have short love relationships that in his mind shouldn’t be too stressful or emotionally demanding (Žižek, 1987). The relationships are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (Vaknin 2003).
Narcissist is unable to enjoy because he connects enjoyment with others. Enjoyments starts when others notice his enjoyment. A narcissist is totally external, which indicates inner emptiness and loss of their identity.
Narcissist is incapable of mourning. They are not able to converting rage, because of the loss, to the mourning. He is only able to forget the lost object, or to determine that in fact he didn’t like them anyway. After that he directs his energy towards new person.
For narcissist, the availability of people is taken for granted. To this type of person you are not a person with feelings, you are a ‘thing’ to feed off and sustain their existence.
Narcissist use manipulation to get what he wants. He knows exactly which manipulative tactic is going to work best in which situation. When he wants something from us he pays attention to us but the moment he doesn’t need us anymore he acts indifferent toward us. Narcissists work within win-lose strategy. They believe their world is positioned to serve their insatiable needs. (Žižek, 1987; Tonia Evans 2008)
Being perfect: narcissist has a fear of failure, for example loneliness and aging. That’s why they take care of their body, trying to stay young  and be under the spotlight-so they won’t get lost in the crowd of average people (Žižek, 1987).  They are either “cerebral” (intelligence or academic achievements) or “somatic” (physique, exercise, physical or sexual prowess and romantic or physical “conquests”) (Vaknin 2003). Which means they are trying to be perfect in physical appearance or in intellectual accomplishments.
Narcissist in society: narcissist sees himself as some kind of an exception. He seems adapted to the social norms but he doesn’t take them seriously. He plays this game just to avoid punishment and be successful in the society. He is convinced that everybody else is doing the same-“everyone is wearing masks, social life is just a game” (Žizek, 1987). A narcissist sees the admired person as “an extension of themselves.” If that person refuses them, they “immediate experience hatred and fear, and devaluate previous Idol” (Lasch 1979: 155-156). A narcissist avoids intimacy and associates only with people who are, like himself-perfect (Praper 1996: 180). Žižek mentions three types of other people, separated by the narcissist:

  1. The ideal-other: they expect approval and recognition, he identified with them
  2. Enemies, who are preventing his narcissistic affirmation, so they must be destroyed
  3. All the rest, the mass of people, ”suckers”: a grey average, which is here only to take advantage off and then reject them (Žižek 1987: 111).

 

  1. Narcissist as a patient

Several different approaches to individual therapy have been tried with NPD patients, ranging from classical psychoanalysis to Gestalt therapy. The emerging consensus is that therapists should set modest goals for treatment with NPD patients. Most of them cannot form a sufficiently deep bond with a therapist to allow healing from early-childhood injuries as a matter of fact they rarely turn to therapy at the first place (Frey, 2010).
“As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms (Frey, 2010).
Kerenberg noticed that narcissistic patients shows excessive self-centeredness, over dependency on admiration from others, prominence of fantasies of success and grandiosity. They avoid facts that are contrary to their inflated image of themselves. A narcissistic patient due to the pain of isolation protects himself with a position of self-sufficiency. They don’t let people emotionally close (Kerenberg, 2007, 505; Praper 1996:223).
They suffer from inordinate envy, which is conscious and unconscious. They show greediness, exploitative behavior, entitlement, devaluation of others, and incapacity to really depend on others. But ironically they need the admiration of others. They show a remarkable lack of empathy, shallowness in their emotional life and lack of capacity for commitment to relationships and goals. Also their self-esteem is regulated by severe mood swings. They have chronic sense of emptiness and boredom which they try to escape through eating, drug and alcohol use. In addition, their tendency to criticize and devalue their therapists (as well as other authority figures) makes it difficult for therapists to work with them (Kerenberg, 2007, 505, Frey 2010).
Patients with NPD 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 (=their aim is not to die). For instance, a patient with NPD tends to become depressed when his feelings are badly hurt, when his defenses have let him down and when he believes his world is collapsing. When wounded, he is at the greatest risk of acting out, either against himself or others. A patient experiencing a narcissistic rage may become homicidal, particularly if he has a need to seek revenge. Under conditions of severe stress and regression, a narcissist can experience significant paranoid developments and brief psychotic episodes (look Kerenberg, 2007, 505; http://www.lmars.com/n-personality-disorder.htm).
Using Heinz Kohut’s self-psychology model, the goal of therapy is to allow the patient to incorporate the missing self-object functions into his internal psychic structure. This process is called transmuting internalization. In this sense, these patients’ psyches are “under construction” and therapy is their building time. Empathy is being the key for making changes in therapy. Without it, the patient whose self is too weak to tolerate more aggressive interpretation, would not benefit from therapy and in fact may suffer more damage (McLean, 2007).
Therapists can recognize narcissistic patients by contratransfer. By feelings of boredom and emotional desertion. The therapist may become sleepy, absent, experiencing shame. He can react as all-knowing expert on life, competing with all the therapists that client had left earlier. When the client devalues him, he feels inadequacy and helplessness (Praper 1996:223).
“The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older.” (Frey 2010)

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