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작성자  simonshin 작성일  2016.09.16 13:18 조회수 1512 추천 0
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 신현근 박사 강의안 - 자기애적 성격 장애  
첨부파일 : f1_20160916131847.pdf
 

과목:  진단과 평가

주제자기애적 성격 장애 (Narcissistic Personality Disorders)

강사: 신현근 박사

내용강의안

교재: PDM Task Force. (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations

 

1.       Developmental levels

1.1.    Narcissistic personality disorders exist along a continuum of severity, from the border with neurotic personality disorders to the more severely disturbed levels.

1.2.    Toward the neurotic end of the severity spectrum, narcissistic individuals may be socially appropriate, personally successful, charming and, although somewhat deficient in the capacity for intimacy, reasonably well adapted to their family circumstances, work, and interests.

1.3.    In contrast, people with narcissistic personalities who are organized at the most pathological level, whether or not they are personally successful, suffer from frank identity diffusion, lack a consistent sense of inner-directed morality, and may behave in highly destructive ways.

1.3.1. Kernberg (1984) has described such patients as suffused with “malignant narcissism” (that is, narcissism blended with sadistic aggression), considering them closely related to those with psychopathic personality disorder.

 

2.       Need for external confirmation of  importance and value

2.1.    The characteristic subjective experience of narcissistic individuals is a sense of inner emptiness and meaninglessness that requires recurrent infusions of external confirmation of their importance and value.

2.2.    Classical depictions of the “as-if personality” (Deutsch, 1942) probably belong in the general area of pathological narcissism.

2.3.     When the narcissistic individual succeeds in extracting such confirmation in the form of status, admiration, wealth, and success, he or she feels an internal elation, often behaves in a grandiose manner, and treats others (especially those perceived to be of lower status) with contempt.

2.4.    When the environment fails to provide such evidence, narcissistic individuals typically feel depressed, shamed, and envious of those who succeed in attaining the supplies that they lack.

2.4.1. Their lack of pleasure in either work or love can be painful to witness.

 

3.       Subtypes  of the disorders

3.1.    The DSM depiction of the narcissistic personality disorder describes the more arrogant version of this kind of psychopathology (Reich, 1933).

3.2.    It omits consideration of the many persons therapists see who appear overtly diffident and often less successful, who are internally preoccupied with grandiose fantasies (Akhtar, 1989; Cooper & Ronningstam, 1992; Gabbard, 1989; Hunt, 1995; McWilliams, 1994; Rosenfeld, 1987).

3.3.    Less overtly arrogant patients may demand that the therapist teach them how to be “normal” or popular, or complain that they want what more fortunate people have.

3.4.    These subtypes correspond roughly to more introjective and more anaclitic versions of narcissism.

 

4.       Preoccupations with bodily integrity

4.1.    Narcissistic individuals frequently have hypochondriacal preoccupations and tend to somatize.

4.2.    The clinical literature suggests that having experienced early attachment to others as unrewarding and full of hidden agendas (Miller, 1975), people who become markedly narcissistic may have responded by divesting themselves of meaningful emotional investment in others and becoming preoccupied instead with their bodily integrity.

 

5.       Idealization and devaluation

5.1.    Individuals with narcissistic personality disorder spend considerable energy evaluating their status relative to that of other people.

5.2.     They tend to defend their wounded self-esteem through a combination of idealizing and devaluing others.

5.3.    When they idealize someone, they feel more special or important by virtue of their association with him or her.

5.3.1. When they devalue someone, they feel superior.

5.4.    Therapists who work with such individuals tend to feel unreasonably idealized, unreasonably devalued, or simply disregarded.

5.4.1. Effects on the therapist may include boredom, mild irritation, impatience, and the feeling that one is invisible.

 

6.       Etiology and therapy

6.1.    The clinical literature on narcissistic personality disorder includes diverse speculations about etiology and consequently diverse treatment recommendations, ranging from an emphasis on empathic attunement and exploration of the therapist’s inevitable empathic failures (e.g., Kohut, 1971, 1977) to a focus on the systematic exposure of defenses against shame, envy, and normal dependency (e.g., Kernberg, 1975).

6.2.    Like persons whose character structure is more psychopathic, narcissistic patients may be easier to help in therapy if they have reached mid-life or later, when their narcissistic investments in beauty, fame, wealth, and power have been disappointed and when they may have run into realistic limits on their grandiosity.

 

7.       Summary

7.1.     Contributing constitutional-maturational patterns: No clear data

7.2.    Central tension/ preoccupation: Inflation/ deflation of self-esteem

7.3.    Central affects: Shame, contempt, envy

7.4.    Characteristic pathogenic belief about self: I need to be perfect to feel okay.

7.5.    Characteristic pathogenic belief about others: Others enjoy riches, beauty, power, and fame; the more I have of those, the better I will feel.

7.6.    Central ways of defending: Idealization, devaluation

7.7.    Subtypes:

7.7.1. P104.1 Arrogant/Entitled

7.7.1.1.                      Reich’s (1933) “phallic narcissistic character,” Gabbard’s (1989) “oblivious narcissist,” Rosenfeld’s (1987) “thick-skinned narcissist,” Akhtar’s (1989) “overt narcissist,” also described by Cooper & Ronningstam (1992).

7.7.1.2.                      Behaves with overt sense of entitlement, devalues most other people, strikes observers as vain and manipulative or charismatic and commanding.

7.7.2. P104.2 Depressed/Depleted

7.7.2.1.                      Gabbard’s (1989) “hypervigilant narcissist,” Rosenfeld’s (1987) “thin-skinned narcissist,” Akhtar’s (1989) “covert” narcissist, or the “shy narcissist” of Cooper & Ronningstam (1992).

7.7.2.2.                      Behaves ingratiatingly, seeks people to idealize, is easily wounded, and feels chronic envy of others seen as in a superior position.

 
 
 
 
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