05 Dec Working with Borderline Personality Disorder & Narcisistic Personaility Disorder at Trauma Recovery Institute
Narcissistic Personality Disorder (NPD)
Otto Kernberg’s description of the pathological narcissistic individual centers around a set of paradoxes: self-inflation existing alongside a limitless need for praise, a charming and engaging surface covering a ruthless interior, and a persona of self-sufficiency defending against underlying feelings of intense envy . For Kernberg, the diagnosis of the narcissistic character also depends on the quality of the person’s object relations and the pattern of his or her intrapsychic defenses. Narcissistic individuals experience their relationships with others as exploitative and parasitic. They divide the world between those who contain something that they can extract and those who do not. They distinguish between extraordinary people on the one hand – in association with whom narcissistic individuals experience a sense of greatness themselves – and mediocre or worthless people on the other. Narcissistic individuals idealize the former and are contemptuous of the latter. Yet those they idealize they also fear, as they project onto them their own exploitative wishes and experience them as potentially attacking and coercive. They thus are unable to rely on any object and fear dependence on another person, rendering all their object relations empty and dissatisfying.
Like the borderline character, Kernberg’s narcissistic individual uses primitive defenses of devaluation, projective identification, omnipotence, and primitive idealization in his or her efforts to preserve self-esteem and self-coherence and to combat the intense feelings of envy and rage that threaten to undermine them. The narcissistic individual is distinguished from the borderline individual by his or her sense of object constancy, better impulse control, and better social and professional functioning, although these too may be fragile and hollow beneath a surface of apparent solidity. Although splitting as a defense is found in narcissistic pathology, its use is less prominent than in borderline pathology.
The grandiose self further differentiates the pathological narcissist from the borderline personality. In Kernberg’s theory, the grandiose self represents a pathological fusion of the ideal self, the ideal object, and the real self. It is a defensive structure designed to maintain self-admiration and avoid dependence on any real object by effectively eliminating a need for it from intrapsychic life. Although often toxic in its effects on interpersonal relationships, the grandiose self serves to maintain the narcissist’s otherwise tenuously coherent sense of self.
Criteria for NPD
1) Grandiose sense of self importance
2) Fantasies of success and power
3) Believes self to be special and unique
4) Requires excessive admiration, adoration (Tribute)
5) Sense of Entitlement
6) Interpersonally exploitative
7) Lacks empathy
8) Envious of others at the cost of intimacy with anybody
9) Shows arrogant, haughty behaviors/attitudes
Borderline Personality Disorder
BPD is a complex clinical syndrome that has three core features: emotional instability, impulsive behaviours, and interpersonal turmoil. These basic features, as well as cognitive symptoms, are captured by the DSM-IV-TR diagnostic criteria for BPD (American Psychiatric Association 2000). The DSM-IV-TR considers 9 diagnostic criteria in total, but only 5 are required to make a diagnosis of BPD. Below, we briefly describe each of the 9 criteria.
1) Avoidance of Abandonment
People with BPD have a strong fear of abandonment, and are thus very sensitive to any cue (real or perceived) that they are being rejected or abandoned. This can include strong reactions to seemingly minor rejections by others (e.g., becoming enraged when someone cancels plans). People with BPD will often engage in behaviours designed to reduce concerns that they are being abandoned (e.g., frequently calling someone they are in a relationship with to “make sure” that there are no signs of impending abandonment). Unfortunately, this type of behaviour may actually create the feared outcome, leading to failed relationships and even greater fears of being abandoned.
2) Unstable and Intense Interpersonal Relationships
Individuals with BPD attach rapidly and profoundly to others, even early on in relationships. Their perception of intimacy is greater than that of the other persons, and in many cases, it is inappropriate. Moreover, their perception of others often alternates between over-idealization and devaluation, which is also known as splitting. Splitting refers to difficulty holding opposing thoughts, feelings, or beliefs about one self or others. In other words, positive and negative attributes of a person are not joined together into a cohesive set of beliefs. For example, a person with BPD may view her boyfriend as “good” one minute, but shift to seeing him as all “bad” or even evil the next. Because of splitting, it is difficult for individuals with BPD to recognize that “good” people sometimes do things imperfectly or make mistakes.
3) Identity Disturbances
Unexpected and sudden changes in goals, interests, preferences, and values are portrayed by persons afflicted with BPD. These unanticipated changes can range from relatively minor things, such as changes in appearance, to aspects central to the life of the individual, such as career paths and goals. These sudden changes usually accompany interpersonal turmoil. Realistic or unrealistic perception of abandonment, feelings of loneliness, emptiness, and hopelessness are usually the specific triggers of these changes. Identity disturbances in individuals with BPD usually reflect efforts to preserve a sense of self-worth in the presence of interpersonal turmoil.
Impulsivity is a tendency to act quickly without thinking about the consequences of one’s actions. Impulsive behaviour usually occurs in reaction to some event that has caused the person to have some kind of emotional response. Unprotected promiscuous sex, substance abuse, reckless driving, and binge eating are some examples of the impulsive behaviours seen in people with BPD. The impulsivity of individuals with BPD may be the consequence of their perception that they are not valued by others. As such, impulsive self-damaging behaviours are used to shield themselves from possible abandonment by a significant other. Alternatively, impulsivity in people with BPD may be caused by an inability to control motor responses (Nigg et al. 2005). These behaviours can increase the risk of suicide, and thus are of great concern.
5) Recurrent Suicidal Behaviour, Gestures, or Threats, or Self-Mutilating Behaviours
Emotional instability, behavioural impulsivity, and fears of abandonment put individuals with BPD at a high risk for self-harming behaviours. It is believed that suicidal behaviours, gestures, or threats are meant to retain the attention and affection of significant others. Although these threats are usually regarded as manipulative tactics on the part of the individual with BPD, they are very difficult to ignore. Therefore, such behaviour is reinforced by the success of bringing the other person closer and eliminating the sense of abandonment. On the other hand, if the threat is ignored, an actual attempt at ending their lives might be carried out with a great probability of being successful.
Self-mutilating behaviour involves the direct and deliberate destruction or alteration of the body. This is also referred to as self harm or self injury. Examples of self harming behaviours include cutting, burning, needle sticking, and severe scratching. Self-mutilating behaviours are seen as coping mechanisms used to regulate negative emotions such as pain, loneliness, and extreme anger (Klonsky and Olino 2008). These behaviours are generally not conducted with the intent to commit suicide.
6) Affective Instability
A key feature of BPD is affective instability (also called emotional lability or affective dysregulation). People with BPD experience a lot of dramatic shifts in their emotional states. They may feel okay one moment but then feel angry, sad, lonely, afraid, jealous, or shameful moments later. These emotional shifts are intense and frequent. Changes in mood can last for hours and in rare cases for days. People with BPD experience changes in their affect more readily when confronted with interpersonal stress. This being said, it is rare that others can persuade these individuals out of their mood states. Instead, people with BPD may react with intense anger to the efforts of those attempting to provide some emotional relief.
7) Chronic Feelings of Emptiness
Persistent feelings of emptiness are often expressed by individuals with BPD. They are usually unable to express their aspirations and desires. To an outside observer, a person affected with BPD may appear as shallow and unmotivated. The feeling of emptiness and the inability to express what they desire in life brings upon feelings of anxiety and self-defeating behaviours. Individuals with BPD often believe that their feelings of emptiness will push significant others away, thus, increasing their fear of abandonment. This can elicit behaviours that are meant to attract others, while in reality these behaviours usually trigger interpersonal conflict.
8) Inappropriate, Intense, Uncontrollable Anger
Intense, inappropriate anger is one of the more troubling symptoms of BPD. Anger in BPD is deemed inappropriate because its level is usually more intense than is warranted by the situation or event that triggered it. For example, a person with BPD may react to an event that may seem small or unimportant to someone else (e.g., a misunderstanding) with very strong feelings and manifestations of anger (e.g., yelling or becoming physically violent). The stability of social relationships is constantly threatened due to the explosive nature of the anger.
9) Paranoid and Dissociative Symptoms
Paranoid thoughts and dissociative symptoms are common in BPD. They are typically transient and appear at times of extreme stress. Perceived abandonment from a significant other frequently serves as the cause of these symptoms. Paranoid thoughts of someone with BPD may involve unrealistic ideas about others trying to harm him/her, or that everyone around is purposefully abandoning him/her as part of a conspiracy plan. Dissociative symptoms reflect depersonalization experiences whereby the person feels as an observer in his or her own life, and able to observe his or her life from outside their own body. Generally, by taking away the trigger of the stress it is possible to end the paranoid or dissociative experiences. Consequently, the paranoid and dissociative episodes characteristic of BPD patients differ significantly from those experienced by patients with psychotic disorders whose symptoms are more stable.
Are you or someone you know living with borderline personality disorder? It’s possible if at least five of the following symptoms are present:
1) Extreme reactions to the idea of abandonment, such as panic, depression, rage, or frantic actions
2) A pattern of intense and stormy relationships with family members, friends, and loved ones
3) A distorted and unstable self-image or sense of self
4) Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse (drugs and/or alcohol), reckless driving, and binge eating
5) Recurring suicidal behaviors or threats or harming oneself, such as cutting, hitting, or head banging.
6) Intense and highly changeable moods, with each episode lasting from a few hours to a few days
7) Chronic feelings of emptiness and/or boredom
8) Inappropriate, intense anger or problems controlling anger
9) Having stress-related paranoid thoughts or strong feelings of being cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Working with Personality Disorders at Trauma Recovery Institute
Trauma Recovery Institute offers unparalleled services and treatment approach through unique individual and group psychotherapy. We specialise in long-term relational trauma recovery, sexual trauma recovery and early childhood trauma recovery. We also offer specialized group psychotherapy for psychotherapists and psychotherapy students, People struggling with addictions and substance abuse, sexual abuse survivors and people looking to function in life at a higher level. Trauma recovery Institute offers a very safe supportive space for deep relational work with highly skilled and experienced psychotherapists accredited with Irish Group Psychotherapy Society (IGPS), which holds the highest accreditation standard in Europe. Trauma Recovery Institute uses a highly structured psychotherapeutic approach called Dynamic Psychosocialsomatic Psychotherapy (DPP) with an added focus on Transference as with transference Focused psychotherapy mentionaed above. This is a highly effect treatment approach with positive treatment outcomes for people suffering with personality disorders.
Dynamic Psychosocialsomatic Psychotherapy (DPP) at Trauma Recovery Institute Dublin
Dynamic Psychosocialsomatic Psychotherapy (DPP) is a highly structured, once to twice weekly-modified psychodynamic treatment based on the psychoanalytic model of object relations. This approach is also informed by the latest in neuroscience, interpersonal neurobiology and attachment theory. As with traditional psychodynamic psychotherapy relationship takes a central role within the treatment and the exploration of internal relational dyads. Our approach differs in that also central to the treatment is the focus on the transference and countertransference, an awareness of shifting bodily states in the present moment and a focus on the client’s external relationships, emotional life and lifestyle.
Dynamic Psychosocialsomatic Psychotherapy (DPP) is an integrative treatment approach for working with complex trauma, borderline personality organization and dissociation. This treatment approach attempts to address the root causes of trauma-based presentations and fragmentation, seeking to help the client heal early experiences of abandonment, neglect, trauma, and attachment loss, that otherwise tend to play out repetitively and cyclically throughout the lifespan in relationship struggles, illness and addictions. Clients enter a highly structured treatment plan, which is created by client and therapist in the contract setting stage. The Treatment plan is contracted for a fixed period of time and at least one individual or group session weekly.
“Talk therapy alone is not enough to address deep rooted trauma that may be stuck in the body, we need also to engage the body in the therapeutic process and engage ourselves as clients and therapists to a complex interrelational therapeutic dyad, right brain to right brain, limbic system to limbic system in order to address and explore trauma that persists in our bodies as adults and influences our adult relationships, thinking and behaviour.”