Situation: Patient arrives late; persists with dramatic storytelling; breaks into sobs when therapist redirects to agenda setting.

Emotion: Frustrated / Disappointed / Uncertain / Embarrassed

Automatic thought(s): This patient will never get it! / We are making no progress using cognitive therapy. / I don’t know what to do next. I must be ineffective with this approach.

Rational response: Contempt on my part will not help, so I could avoid such eternalized judgments and be more sympathetic. She is showing more skill in labeling affect, and identifying thoughts. Also, I’m focusing on the importance of making a list when her obvious priority is interpersonal support. I need to respect her values, help her learn to define problems, and not give up. Just because I feel uncertain does not mean I am ineffective, or have committed any shameful action. My discomfort comes from believing all patients must change quickly, and if they don’t, it’s my fault. Does it make sense that an effective therapist “never” feels uncertain? I can brainstorm some options to try next.

Paranoid individuals have a strong tendency to blame others for interpersonal problems, usually can cite many experiences which seem to justify their convictions about others, are quick to deny or minimize their own problems, and often have little recognition of the ways in which their behavior contributes to their problems. Thus, when an assessment is based on the client’s self-report, it can easily appear that the client’s suspicions are justified or that the problems are due to inappropriate actions by others. In addition, because the characteristics of paranoia are understood to some extent by most laymen, paranoid individuals are likely to recognize that others consider them to be paranoid, and to realize that it is prudent to keep their thoughts to themselves. When this is the case, indications of paranoia tend to emerge only gradually over the course of therapy and may easily be missed.

Often it is easiest to identify paranoid individuals by watching for characteristics other than blatantly unrealistic suspicions. Table 6.2 presents a number of possible signs of a paranoid personality style which may be early indications of PPD. Individuals with PPD are typically quite vigilant, tend to interpret ambiguous situations as threatening, and are quick to take precautions against perceived threats. They frequently are perceived by others as argumentative, stubborn, defensive, and unwilling to compromise. They also may manifest some of the characteristics they perceive in others, being seen by others as devious, deceptive, disloyal, hostile, and malicious.

Thus, antisocial patients’ automatic thoughts and reactions are frequently distorted by self-serving beliefs that emphasize immediate, personal satisfactions and minimize future consequences. The underlying belief that they are always right makes it unlikely that they will question their actions. Patients may vary in the degree of trust or mistrust they have in others, but they are unlikely to seek guidance or advice on any particular course of action. A person with ASPD who wants something will take it without either understanding the possible consequences or manifesting concern about possible consequences.

For example, the therapist noticed that magazines were disappearing from his waiting room, and he suspected Randy, his ASPD patient. He checked that the magazines were there prior to Randy’s session. Afterward they were gone. Asking Randy at the following session about the missing magazines, Randy at first vigorously denied the action. He then switched to the position that he must have inadvertently taken them. But, he reasoned, the magazines were there for the patients, and as a patient he was then justified in taking “his” magazine home to read. Thus, the behaviors of individuals with ASPD tend to elicit negative responses from others without awareness or concern that what he was doing was stealing from someone who was trying to help him.

Because the problems that they manifest are generally chronic and ego-syntonic, the patients themselves are often baffled by the responses of others and unable to see how present circumstances arose. For example, Randy was genuinely astounded that the therapist made such a “big deal” about a “stupid” magazine. Further, even after Randy offered to pay for the magazines, the therapist still saw a need for discussion of the behavior. Typically, the patient with ASPD will see the locus of the difficulties that they encounter in dealing with other people or tasks as external and independent of their behavior, viewing themselves as victims of unfair, prejudiced, or hostile systems.

Given that other people hold the key to survival in the world, histrionic patients tend to also hold the basic belief that it is necessary to be loved by everyone for everything one does. This leads to a very strong fear of rejection. Even entertaining the notion that rejection is possible is extremely threatening to these individuals, because this reminds the patient of his or her tenuous position in the world. Any indication of reje tion at all is devastating, even when the person doing the rejecting was not actually that important to the patient. Feeling inadequate yet desperate for approval as their only salvation, people with HPD cannot relax and leave the acquisition of approval to chance. Instead, they feel constant pressure to seek this attention in the ways they have learned are ef- fective, often by fulfilling an extreme of their sex-role stereotype. Female histrionics (as well as some of the males) seem to have been rewarded from an early age for cuteness, physical attractiveness, and charm rather than for competence or for any endeavor requiring systematic thought and planning. The more “macho” male histrionics have learned to play an extreme masculine role, being rewarded for virility, toughness, and power rather than interpersonal competence or problem-solving ability. Understandably, then, both male and female histrionics learn to focus attention on the playing of roles and “performing” for others.

People with a HPD view themselves as sociable, friendly, and agreeable, and, in fact, they are often perceived as very charming at the beginning of a relationship. However, as the relationship continues, the charm seems to wear thin and they gradually are seen as overly demanding and in need of constant reassurance. Given that being direct involves the risk of rejection, they often use more indirect approaches such as manipulation to try to gain attention but will resort to threats, coercion, temper tantrums, and suicide threats if more subtle methods seem to be failing.

Histrionic people are so concerned about eliciting external approval that they learn to value external events over their own internal experience. With so little focus on their own internal life, they are left without any clear sense of identity apart from other people and see themselves primarily in relation to others. In fact, their own internal experience can feel quite foreign and uncomfortable to them and at times they actively avoid self-knowledge, not knowing how to deal with it. Having some vague sense of the superficial nature of their feelings may also encourage them to shy away from true intimacy with another person for fear of being “found out.” Because they have paid little attention to their own in- ternal resources, they have no idea how to respond when depth is required in a relationship. Thus, their relationships tend to be very shallow, superficial, and based on role playing.

Narcissistic personality disorder (NPD) is an extensive pattern of distorted regard for self and others. Although it is normal and healthy to take a positive attitude toward oneself, narcissistic persons exhibit an inflated view of self as special and superior. Rather than strong self-confidence, however, narcissism reflects aggrandizing self-preoccupation. The narcissist is very active and competitive in seeking status, as outward signs of status are used as the measure of personal worth. When others fail to validate the special status of the narcissistic person, he or she is apt to view this as intolerable mistreatment and become angry, defensive, and depressed. The failure to be superior or regarded as special ac- tivates underlying beliefs of inferiority, unimportance, or powerlessness and the compensatory strategies of self-protection and self-defense.

Narcissistic individuals take pride in their social standing yet show some startling lacunae in adhering to norms and expectations of social reciprocity. Self-centered and inattentive to the feelings of others, the narcissist can turn a friendly exchange into an irritating display of selfpreoccupation. A deceptively warm demeanor may be marred by arro- gant outbursts, heartless remarks, or insensitive actions. Attention to the needs and feelings of others is lacking, whether in simple matters such as recognizing the contributions of others or in respecting more complex and deeply meaningful emotions. They may begrudge the successes of others and jealously judge or discredit those they view as encroaching competitors. The narcissist can also be masterful in twisting confrontations toward attributing blame and fault to other people.

[...] However, Baumeister notes that “narcissists are no more aggressive than anyone else, as long as no one insults or criticizes them” (p. 101).

Bushman and Baumeister (1998) apply a psychodynamic, motivational theory to discriminate between high self-esteem per se and narcissism, separating emotion from cognition. They note that “high self-esteem means thinking well of oneself, whereas narcissism involves passionately wanting to think well of oneself” (p. 228). They consider narcissism to be a subcategory of high self-esteem where the self-image is inflated and stable, albeit reactive to external ego threats. The specific role of cognition is not elaborated in their formulation.

Although self-esteem and narcissism are correlated, the two traits are not the same. Individuals with high self-esteem are not necessarily narcissistic but rather confident of their personal worth. Their esteem is apt to be based on realistic self-appraisals of demonstrated talents, achievements, and relationships viewed in a context of social norms and opportunities. Corrective feedback does not trigger a dramatic loss of self-esteem. For the patient with NPD, self-esteem is established by outward success, and any experience that challenges this success becomes a threat to self-esteem. He or she remains firmly rooted in the importance of a flawless or powerful image, much the same as Narcissus remained rooted to the spot while admiring his reflection. Without a flawless image, core beliefs of inferiority become activated.

DSM-IV-TR Diagnostic Criteria for Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration,
and lack of empathy, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate
achievements)
(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
(3) believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
(4) requires excessive admiration
(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
(8) is often envious of others or believes that others are envious of him or her
(9) shows arrogant, haughty behaviors or attitudes

Other people are viewed as objects or tools in the quest for distinction, and the narcissistic patient expends a great deal of mental energy comparing him- or herself and judging the worth of others. If others have the potential to advance the narcissist in some way, they will be idealized and pursued. If others are perceived as ordinary or inferior, they will be dismissed, or perhaps exploited for some gain, then discarded. As one narcissistic patient stated, “Very few people are worth my time. The rest bore me.” The value of others rests in how they can serve or admire the narcissistic person. If they fail to treat the narcissist as special, this may be viewed as an indication of others regarding them as inferior, triggering defensive reactions. Narcissistic patients also experience anxiety if they believe someone else is commanding special attention from a person they hold important, and this may create a relationship crisis. Friendships can crack or family relationships become strained and fail simply because other people have legitimate competing interests. For example, a narcissistic man responded to the loss of attention from his partner when their child was born by initiating an affair with someone who provided unremitting admiration.

Misty rated the worth of people on a hierarchy, with looks, celebrity, and competitive victory being the prevailing criteria for superiority. She only wanted to associate with people who were “in style,” or “winners.” She was heavily invested in competing for opportunities to validate her good looks as better than others. She felt quite humiliated by being rejected by a man and perceived this as a terrible loss of status.

The narcissistic person assumes that certain circumstances or tangible assets provide evidence and validation of superiority, special status, and importance. Thus, this patient believes that “I must succeed in order to prove my superiority.” Such proof might include community influence, income level, physical attractiveness, material trappings such as the “right” car or living in the “right” neighborhood, personal awards, or associations that are exclusive or coveted by others. Not everyone, however, regards these things as markings of a generalized personal superiority. It is a narcissistic assumption to believe that achievements, position, possessions, or public recognition indicate personal value, or lack thereof. Conversely, the narcissist also assumes that “If I’m not successful, then it means I’m not worthwhile.” Thus, self-esteem may plummet if these outward signs are lost, compromised, or unattainable.