Kernberg Model of Narcissistic Personality Disorder

Diagnostic definitions for Narcissistic Personality Disorders (NPDs) are important to clinicians for communicating and understanding the symptoms laid out before them through the phenomenon of the patients. Diagnostic criteria recorded in the DSM IV which is used as provisional criteria in the ICD 10 are qualitative in nature, describing 9 traits and behaviors of which 5 have to be observable in the individual in order for the individual to be diagnosed positively for the personality disorder.

When accessing the severity of the consequence of the dysfunctional behavior of the individual, the use of this criteria in the DSM falls short. This is due to the fact that the same weightage seems to be implied for all criteria while some criteria e.g. “interpersonally exploitative; takes advantage of others to achieve his or her own ends” are more destructive to society as a whole as “requires excessive admiration”. From the 2 criteria mentioned one can also see that they are interrelated.

The psychodynamic theory of personality of which a the contribution and influence of Kernberg –whose own roots are in Kleinian theory (Klein, 1957)— is well understood and cited in contemporary literature (Carveth, 2016).

Kernberg’s dimensional model for personality disorders provides a means for us to differentiate the concept of different disorders in relation to the other (Fig.1). In that diagram we can se how NPD belongs to a triad, also called the dark triad, which is continuum of severity in disruption of social function associated with the disorder. Kernberg, in his publications (Kernberg, 2008), also provides us with useful information for differentiating people/adolescents who show antisocial behaviors, if these behaviors are the result of the NPD spectrum, or if it is the result of neurotic defenses and/or social pressures of growing up – of which the latter has better prognosis.

The “dark triad” in NPD – Differentiation Summary

Antisocial Personality Disorder (APD), being the most pathological in the NPD spectrum, constitutes marked distortion, deterioration, or absence of the superego system. These patients have a syndrome of “identification with the aggressor”, and live in an internal world of violence. There is a lack of any good, reliable object relations since these individuals tend to consider the good as weak and unreliable. They respond to disappointment with rage and hatred, which is born out painful state of envy. The paranoid orientation of the APD individual makes it impossible for empathic contact with others (ibid. p. 132).

Patients with syndrome of Malignant Narcissistic Personality Disorder (MNPD) display also antisocial behaviors, paranoid traits and egosyntonic aggression directed at self and others, but without total destruction of the superego functions. The patient has and violent, grandiose self, that has the capacity to idealize significant powerful people, and can themselves depend on sadistic and powerful but reliable parental images. They therefore do have a capacity for loyalty. “Justified indignation” is the justified violence against self and others (ibid. p. 133).

Patients with NPD have the least severe form of pathological narcissism in the triad. There is a certain degree of superego evolution. There is the grandiose self, and the predominating need to protect its integrity. The patient is however able to recognize good aspects of others that they envy and want to incorporate. Antisocial behavior in these individuals reflect the egosyntonic, rationalized entitlement and greed of the grandiose self (ibid. p. 134).

Comments

NPD is something we cannot escape from, since the prevalence of the condition is not getting smaller. Societies in the industrialized world support and reward the narcissists. Those who do not meet the standards of society, ironically, end up on the antisocial end of the same spectrum.  NPDs are there with us in the homes, schools and at work. Coming from Asia, I can see the development of the narcissistic character being generated in school children. There is a lot of competition for grades, and this incites envy, paranoia and distrust. In the business world, there exists bullying of executives to rake in sales at all costs—disregarding ethics or consideration for the environment. These kind of stressors wipe out an individual’s ability to empathize. Even those who do not have the personality configuration, end up having to pick up the narcissistic traits.

 

With this knowledge of what NPD is about, and its underlying affects of shame, guilt, greed and envy it is possible to wean sectors of society out of this trend. With the knowledge of the responsibility of the psychotherapeutic profession to facilitate change, it would be almost unethical to be ignorant on this topic.

 

In her book, Reaching Your Goal, Korber (2017), interview social entrepreneurs, or people whose “prime aim is to find a solution to a social problem by applying entrepreneurial tools” and who understand “the ability to act entrepreneurially and charitably at the same time, to bundle activities, create synergies or open up new knowledge, to recognize societal inequalities and reduce them efficiently (p. 16-17).”  I think this describes well what ultimately society can do to reduce the prevalence of NPD.

Bibliography

Carveth, D. (2016). Freud & Beyond 2016 #8: Narcissism Lacan, Aichhorn, Kohut, Spotnitz, Kernberg. Abgerufen am 2017 von YouTube: https://www.youtube.com/watch?v=dGxS_5A46_4

Interdisciplinary Counsel on Developmental and Learning Disorders. (2017). Psychodynamic Diagnostic Manual PDM 2 (2nd Ausg.). (V. L. McWilliams, Hrsg.) NY: The Guilford Press.

Kernberg, O. (2008). Aggressivity, Narcissism, and Self-Destructiveness in the Psychotherapeutic Rela: New Developments in the Psychopathology and Psychotherapy of Severe Personality Disorders. Yale University Press.

Klein, M. (1957). Envy and Gratitude.

Korber, M. (2017). Reaching Your Goal. (J. Baer-Pasztory, Übers.) Vienna: BoD.

 

Kernberg: Working with the Antisocial and Malignant Narcissistic Personality Disorder Spectrum

 

Kernberg (2008) writes that for the treatment of any case in which antisocial features of the personality disorder (PD) are suspect, the following should be evaluated by the therapist. Such evaluation makes it possible to access his/her ability to rely on the patient’s ability to sustain the therapeutic relationship and also to access the safety of the sessions:

  • The presence or absence of pathological narcissism.
  • The extent to which the superego pathology dominates (i.e. which part of the spectrum of the triad).
  • The intensity of egosytonic aggression and whether it is directed against the self in the form of suicidal/self mutilating behavior, or violent behavior against others / sadistic perversion.
  • Severity of paranoid tendency.
  • Stability of the person’s reality testing (ibid. p. 130).

The prognosis for Antisocial PD is not expected to be good in psychotherapy, in particular, if the client has severe aggressive pathologic behavior, and /or if the patient has no social support which the therapist can work with. According to Kernberg, therapists should begin work with client only after gathering the facts surrounding the clients’ coming for therapy, social support, ability to proceed with therapy in safety.

The treatment of malignant narcissistic PD (MNPD) has somewhat better prognosis than APD. A precondition for treatment is also strict control of antisocial behavior, and removal from social environment that facilitates his/her current behavior—e.g. exposure to the street gang.

General Psychotherapeutic Strategies

Kernberg’s suggestions are:

  • Establishment of solid, unbreakable treatment frame.
  • Systematic interpretation of psychopathic transference.
  • Guiding the patient to communicate honestly (if at all possible) about their behavioral problems outside the session.
  • Combining the above narrative with the developed regressive behaviors experienced during the sessions.
  • Gradually making it possible to connect the pathological behaviors interpretively into cognitive and affective experiences in the transference.

Highly deceptive clients make this work almost impossible. In such cases family members or other informants may be of help. The therapist should always make it prioritize urgency of intervention:  1. Danger to self/others, 2. Threats of treatment disruption, 3. Dishonesty in communication, 4. Acting outside and inside sessions, and 5. Trivialization of the communication.

Kernberg also states that it is essential to look for affects through verbal and nonverbal communication, nonverbal behavior, and the transference. The content of what the client says is usually a weaker source of affective information than what goes in these realms (ibid. p.140).

Treating Personality Disorders with Gestalt Therapy

Considering Kernberg’s suggestion, I notice the congruence of his method to Gestalt therapy practice:

Gestalt therapy is focussed on the process of the therapeutic dialogue, i.e. non-verbal interaction / body language. Therapist also encourages the client to enact situations that cannot be talked about. Poor functioning personality disorders prevents the individual from communicating with the therapist on a contactful level. As Kernberg notes, there is a tendency for such a client to deceive / idealize and devalue/ play victim or rescuer or persecutor with the therapist. The awareness of the therapist of this phenomena is essential. He /she is most effective when he/she can contain the clients behavior without getting roped into the game.

For this reason, in gestalt work, we focus of body language / tone of voice together with what is said, and we also focus on our (the therapists) own personal reactions. What the therapist tells the client is not analysis, but a descriptive reflection of what the therapists sees hears and senses.

The client benefits from this kind of honest interaction, because he/she too are not going to be caught up in games. In the beginning, there will of course be discomfort and frustration. If the client sticks to the work, there will be progress made.

Read also

Symptom Relief in Psychotherapy

Psychotherapy is about Uncovering the Truth of the Self

Former Patients’ Conception of Psychotherapy 

Bibiliography

Kernberg, O. (2008). Aggressivity, Narcissism, and Self-Destructiveness in the Psychotherapeutic Relationship: New Developments in the Psychopathology and Psychotherapy of Severe Personality Disorders. Yale University Press.