A CASE OF Narcissistic Personality Disorder
By: THEODORE MILLON
et al.
Notes:
(1) Numbers mark aspects of the case most consistent with DSM
criteria as follow, and
do not necessarily indicate that the case
“meets” diagnostic criteria in this respect.
(2) Patient's name has been changed in respect to
confidentiality, and names mentioned are not of a real existent person.
Case of Leonardo
Leonardo
is a second-year resident in the Department of Psychiatry. He is handsome,
fair-skinned, with piercing blue eyes and blonde hair. His family owns several
banks scattered throughout Spain. Both parents are noted for their service on
the boards of charitable organizations. “My family is one of the richest in
Spain,” he says. “My father greatly influenced the history of that nation, as
will I, and my sons after me.” (1)
Leonardo
has been asked to speak with a therapist because he believes psychotherapy
training to be ridiculous. Apparently as a defensive maneuver, he attempts to head
off a possible diagnosis by stating frankly, “I am, without doubt, a
narcissistic personality. Everyone has a personality, and the narcissistic is
the most adaptive. Were I in the disordered range, I would not be capable of
such insight.” When asked how he had arrived at this conclusion, Leonardo
explains, “I am unique in many ways. I am well aware of my good looks. I’ve
been successful with every woman I ever really wanted.” Adjusting his tie, he
immediately assumes the posture of a superior individual, with the therapist as
his captive audience.
(2) “Medical school was easy,” he continues. “I
believe in destiny, and I believe that I am destined to be successful in
everything I do. (2) Furthermore,
I have a very high IQ, and I doubt that there is anything of which I am not
capable.” (1)
Apparently
because the therapist was male, Leonardo began to use the session to discuss
something of which he was truly proud, his many “conquests.” Glowing with pride,
he bragged about the women he had “bedded,” (4) offering
details of their performance, giving each one a rating from 1 to 10 based on
their looks and performance.
(6) He remarks that after sex, he makes them sleep
on the couch, asserting, “I require the whole bed, or almost certainly will not
awaken feeling refreshed.”
(7)
Over
the course of many sessions of therapy, Leonardo showed virtually no
understanding of how his “narcissistic style” might lead to interpersonal
problems, instead maintaining that “reality contact requires that I acknowledge
my superiority. Anything else would be delusional.” Moreover, he shows no
insight into the pain those he had seduced and exploited might feel, even
though he made them undying promises of love. (7) When the point is pressed, he becomes angry,
apparently believing that his looks and charm entitle him to such liaisons.
“You wish only that you were like Leonardo,” he charges, leaving the session in
a huff.
(5)
DSM-IV Criteria
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 (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
References
(1) Personality Disorders in Modern Life, second edition,
2000, 2004 by John Wiley & Sons, Inc.
(2)Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. Copyright
1994 American Psychiatric Association.
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