Narcissists: Difficult and Hateful Patients

Uploaded 11/24/2010, approx. 3 minute read

I am Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.

In 1978, a medical doctor by the name of J. E. Groves published in the prestigious New England Journal of Medicine an article titled, Taking Care of the Hateful Patient.

In the article, Groves admitted that patients with personality disorders often evoke in their physicians dislike or even outright hatred. Groves described four types of such undesirable patients, dependent clingers, today called codependents, entitled demanders, today we call them narcissists and borderlines, manipulative help rejectors, typically psychopaths and paranoids, borderlines and negativistic passive aggressives, and what he called self-destructive deniers. He was probably referring to schizoids and schizotypals, for instance, or histrionics and borderlines.

Therapists, psychologists, social workers and psychiatrists report similar negative feelings towards such patients. Many of them try to ignore, deny and repress these feelings.

The more mature health professionals realize that denial only exacerbates the undercurrents of tension and resentment, prevents effective patient management and undermines any therapeutic alliance between healer and the ill. It is not easy to cater to the needs of patients with personality disorders, narcissists especially.

By far the worst is the narcissistic patient, patient with a narcissistic personality disorder.

In my book Malignant Self-Love: Narcissism Revisited, I have described the situation.

One of the most important presenting symptoms of a narcissist in therapy is his or her insistence that he or she is equal to the psychotherapist in knowledge, in experience or in social status.

The narcissist in the therapeutic session spices his speech with psychiatric lingo and professional terms, of which by the way he understands little. The narcissist distances himself from his painful emotions by generalizing and analyzing them, by slicing his life and hurt and neatly packaging the results into what he thinks are professional insights.

His message to the psychotherapist is, there is nothing much that you can teach me. I am as intelligent and knowledgeable as you are. You are not superior to me. Actually we are partners. We should both collaborate as equals in this unfortunate state of things in which we inadvertently find ourselves involved.

In their seminal tome, Personality Disorders in Modern Life, Theodore Millon and Roger Davis wrote, page 308. Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid. Interpretation and even general assessment are often difficult to accomplish.

In the third edition of the Oxford Textbook of Psychiatry, page 128, the author cautions, people cannot change their nature but can only change their situations.

There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character. Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve these modest aims.

And finally, the fourth edition of the authoritative Review of General Psychiatry, page 309, says, people with personality disorders cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them. Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with narcissists, although their use has been controversial.

The narcissist is a hateful and difficult patient.

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Lonely, Schizoid Narcissist

Narcissistic personality disorder is often diagnosed with other mental health disorders, such as borderline, histrionic or antisocial psychopathic personality disorder. Narcissism is often also accompanied by substance abuse and other reckless and impulsive behaviors, and this we call dual diagnosis. There is one curious match, one logic-defying appearance or co-appearance of mental health disorders, narcissism, together with schizoid personality disorder. A minority of narcissists, therefore, choose the schizoid solution. They choose to disengage, to detach both emotionally and socially.

Shyness or Narcissism? Avoidant Personality Disorder

Avoidant personality disorder is characterized by feelings of inadequacy, inferiority, and a lack of self-confidence. People with this disorder are shy and socially inhibited, and even constructive criticism is perceived as rejection. They avoid situations that require interpersonal contact and find it difficult to establish intimate relationships. The disorder affects 0.5 to 1% of the general population and is often co-diagnosed with mood and anxiety disorders, dependent and borderline personality disorders, and cluster A personality disorders.

Asperger's Disorder Misdiagnosed as Narcissistic Personality Disorder (NPD)

Asperger's Disorder can be diagnosed in toddlers as young as three years old, while Narcissistic Personality Disorder cannot be safely diagnosed until late adolescence. However, Asperger's Disorder is often misdiagnosed as Narcissistic Personality Disorder. Both types of patients are self-centered and engrossed in a narrow range of interests and activities, with severely hampered social and occupational interactions. The gulf between Asperger's and pathological narcissism is vast, with the narcissist switching between social agility and social impairment voluntarily, while the Asperger's patient's social awkwardness is an inevitability.

Over-sexed: Histrionic Personality Disorder and Narcissism

Histrionic personality disorder is more commonly diagnosed in women, leading to questions about whether it is a real mental health problem or a reflection of a patriarchal society. Histrionics crave attention and are uncomfortable when not at the center of it, similar to narcissists. They are preoccupied with physical appearance and sexual conquests, and often act flirtatious and seductive. Histrionics are enthusiastic and emotional, but their behavior can be exhausting and off-putting to others.

Signs You are Victim of Narcissistic Abuse, Not Common Abuse (Stress, Depression Management Webinar)

Narcissistic abuse is a subtype of abusive behavior that is pervasive, sophisticated, and can be practiced either covertly or overtly. Victims of narcissistic abuse often experience depression, anxiety, disorientation, and dissociative symptoms. This type of abuse can lead to complex post-traumatic stress disorder (CPTSD) and even elements of post-traumatic stress disorder (PTSD). The way individuals process and react to trauma can lead to either regression into infantile behaviors or personal growth and maturation, depending on their emotional regulation and maturity.

Narcissist: Socially-anxious, Schizoid

Schizoid personality disorder is characterized by a lack of interest in social relationships and interactions, limited emotional expression, and a preference for solitary activities. Schizoids are often described as robotic and uninterested in social bonding. While there are similarities between schizoid and narcissistic personality disorders, the two are distinct in that schizoids are uninterested in bonding, while narcissists are both uninterested and incapable due to their lack of empathy and grandiosity. Narcissism is not about self-love, but rather a broken ego or self that withdraws from society to protect itself.

Narcissist: Is He or Isn't He?

Narcissism is a spectrum of behaviors, from healthy to pathological, and the Diagnostic and Statistical Manual specifies nine diagnostic criteria for narcissistic personality disorder (NPD). A malignant narcissist is someone who has NPD and wreaks havoc on themselves and their surroundings. They feel grandiose and self-important, exaggerate accomplishments, and demand recognition as superior without commensurate achievements. They require excessive admiration, adulation, attention, and affirmation, and are interpersonally exploitative, devoid of empathy, and constantly envious of others.

Drama Queens/Kings: Narcissists, Borderlines

Dramatic behavior is common in cluster B personality disorders, such as narcissistic, borderline, and antisocial personality disorders. Drama serves various psychological functions, including enhancing functionality, distancing oneself from trauma, regulating self-esteem, and manipulating others. It can also be a diversionary tactic or a form of emotional blackmail. While attention-seeking is often associated with dramatic behavior, it is not the primary motivation for most individuals with cluster B personality disorders.

Narcissists and Negativistic (Passive-Aggressive) Personality Disorder

The negativistic, passive-aggressive personality disorder is not yet recognized by the committee that is cobbling together the diagnostic and statistical manual. People diagnosed with a negativistic passive-aggressive personality disorder resemble narcissists in some important respects. Despite the obstructive role they play, passive-aggressives feel unappreciated, underpaid, cheated, discriminated against, and misunderstood. Passive-aggressives may be sullen, irritable, impatient, argumentative, cynical, skeptical, and contrarian.

Attention Whores, Impulse Control, and Munchausen by Narcissist

Attention-bores, mostly women with histrionic and borderline personality disorders, use male attention to regulate their sense of self-worth. They become flirtatious, seductive, and trade sex for even the most inconsequential signs of attention from a man. Male attention serves a few important psychodynamic functions with these women, including reassuring them of their irresistibility and attractiveness, reasserting control and power of a man via her sex, and adrenaline junkies. Impulsive behaviors are addictive, and recurrences and recidivism are very common. As these women grow older, most of the signs and symptoms of borderline and histrionic personality disorder recede, unfortunately only to be replaced with dysthymia, background depression.

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