Narcissism vs. Lack of insight

[F0nzie]

So I have been thinking about difficult patients with the following characteristics:

1. Their experiences are 100% right. Everybody else is wrong.
2. Nobody else knows what is good for them.
3. There is only 1 explanation for what happened. Their explanation.
4. They never misunderstand others experiences.

This can at times come off as a narcissistic flare (not necessarily NPD). It will make us throw up our hands and get annoyed or maybe even give up on them.

We know that insight is affected by frontal lobe executive functioning. We also theorize that this type of thinking can be influenced by emotional development and past trauma.

Curious to know what we are doing in med management and therapy. Are we restoring insight, fixing narcissism or both?

This grey zone is really fascinating to me.

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[F0nzie]

What triggered me to think about this was seeing a homeless man at Wendy's that had a very strong smell of urine (with odor filling the room). Initially I thought it was the fries but it wasn't. First thing that came to mind is this guy was SMI and must have some severe cognitive deficits in executive functioning. Then I thought "is he choosing this?" I gave him an extra hamburger that they accidentally gave me. He graciously accepted my burger. My wife then caught a lady giving me bad looks!

 

[whopper]

Like with delusional disorder, it's not a delusion if it's true. Getting to the point, here's Sherlock Holmes


The problem here is Holmes usually is 100% right!
In medicine there'll always be people smarter than you in something. The good guys will work with you and guide with patience.

Forensically, all of you may find this interesting, if one has a personality disorder, one could successfully use it as a defense with the Americans with Disabilities Act. That is if they're fired for being difficult, they could claim the PD is a disability and demand concessions such as their own office so people don't have to interact with them much.

 

[PikminOC]

Like with delusional disorder, it's not a delusion if it's true. Getting to the point, here's Sherlock Holmes


The problem here is Holmes usually is 100% right!
In medicine there'll always be people smarter than you in something. The good guys will work with you and guide with patience.

Forensically, all of you may find this interesting, if one has a personality disorder, one could successfully use it as a defense with the Americans with Disabilities Act. That is if they're fired for being difficult, they could claim the PD is a disability and demand concessions such as their own office so people don't have to interact with them much.

They can ask for them.
Doesn't mean they will get them.

 

[nitemagi]

Curious to know what we are doing in med management and therapy. Are we restoring insight, fixing narcissism or both?

It depends a bit on your therapeutic bend. I don't know that meds do a whole lot, unless the person is particularly on the defensive/hypervigilant, in which case softening anxiety/hypervigilance can be effective.

After that many would say it's about building trust/rapport, to the degree that they feel alternative ideas from you are not a threat.

I view the goal as being one of cognitive flexibility, and moving towards ownership of a role in dynamics, even in ones they don't like. Because it's much harder to change someone else than oneself. As we can get someone to consider another POV, whether that be of me the psychiatrist, their spouse, their boss, or someone they don't even know, that changes their functioning to a degree. The impairment comes from their rigidity in thinking. At least that is one perspective.

Now I will also mention that some people will be rigid for a purpose, and if you figure it out and state it to them, it defuses the situation. Such as the person who needs to be right to get you to take them seriously or respect them (like the patient who over endorses symptoms for a similar reason). I've found that when I tell them that I already respect them for XYZ, they soften significantly.

Essentially get outside of the one-person psychology, and think about what this way of functioning must be trying to accomplish for them. Play into that, and then it becomes unnecessary when they're in the room with you.

 

[nitemagi]

Forensically, all of you may find this interesting, if one has a personality disorder, one could successfully use it as a defense with the Americans with Disabilities Act. That is if they're fired for being difficult, they could claim the PD is a disability and demand concessions such as their own office so people don't have to interact with them much.

Is there case law to show that has ever been successful with a PD?

 

[heyjack70]

Like with delusional disorder, it's not a delusion if it's true. Getting to the point, here's Sherlock Holmes


The problem here is Holmes usually is 100% right!
In medicine there'll always be people smarter than you in something. The good guys will work with you and guide with patience.

Forensically, all of you may find this interesting, if one has a personality disorder, one could successfully use it as a defense with the Americans with Disabilities Act. That is if they're fired for being difficult, they could claim the PD is a disability and demand concessions such as their own office so people don't have to interact with them much.

But don't they still have to be able to perform, I don't remember the language exactly, something like "critical job requirements?" And interacting with people is a critical job requirement so the ADA doesn't cover that. It would be like if you had to carry 50 lb bricks, and you had a bad knee, the company doesn't have to make accommodations for that because carry the 50 lbs is a crucial requirement and you can't do the job at all.

Edit: It's Essential Functions of the job. So a narcissistic salesman who can't deal with people could certainly be fired because dealing with people is essential to the job.

 

[Shikima]

It depends a bit on your therapeutic bend. I don't know that meds do a whole lot, unless the person is particularly on the defensive/hypervigilant, in which case softening anxiety/hypervigilance can be effective.

After that many would say it's about building trust/rapport, to the degree that they feel alternative ideas from you are not a threat.

I view the goal as being one of cognitive flexibility, and moving towards ownership of a role in dynamics, even in ones they don't like. Because it's much harder to change someone else than oneself. As we can get someone to consider another POV, whether that be of me the psychiatrist, their spouse, their boss, or someone they don't even know, that changes their functioning to a degree. The impairment comes from their rigidity in thinking. At least that is one perspective.

Now I will also mention that some people will be rigid for a purpose, and if you figure it out and state it to them, it defuses the situation. Such as the person who needs to be right to get you to take them seriously or respect them (like the patient who over endorses symptoms for a similar reason). I've found that when I tell them that I already respect them for XYZ, they soften significantly.

Essentially get outside of the one-person psychology, and think about what this way of functioning must be trying to accomplish for them. Play into that, and then it becomes unnecessary when they're in the room with you.

They see you rollin'.... with da resistance!

 

[whopper]

They can ask for them.
Doesn't mean they will get them.

hold on...
They can count.
I was pretty sure of this because I had to memorize this for the forensic board exam, but I double checked. Yep, page 357 of my AAPL Forensic board review book from 2009 specifically states one could use a personality disorder as a defense with the Americans with Disbabilities Act and sue the employer to make them give "reasonable concessions."

E.g. if the employee doesn't get along with other people due to the PD the employee could argue he needs his own office.

Traits of a PD do not count, and that has been specifically stated.

Further one could get SSI or SSDI for a personality disorder too!

So what exactly is reasonable? It hasn't been clearly defined, and it's one of those things that gets defined over time by common law, which in English means later court cases will hammer out what's reasonable or not reasonable, but again a PD could be used.

Some other requirements, the PD has to be definable as it "substantially limiting" a life activity. So one could argue that dealing with others is a "life activity," they can't do it well because of their PD, now they require their own office, possibly their own personal assistant to further limit their interactions with others.

Others: the employer cannot be put into "undue hardship" in making a concession, and the employer could use the defense that the employee is a "direct threat," and therefore no concessions should be made.

But I have seen cases where someone getting their own office was considered a "reasonable" concession by the employer.

 

[Ceke2002]

So I have been thinking about difficult patients with the following characteristics:

1. Their experiences are 100% right. Everybody else is wrong.
2. Nobody else knows what is good for them.
3. There is only 1 explanation for what happened. Their explanation.
4. They never misunderstand others experiences.

This can at times come off as a narcissistic flare (not necessarily NPD). It will make us throw up our hands and get annoyed or maybe even give up on them.

We know that insight is affected by frontal lobe executive functioning. We also theorize that this type of thinking can be influenced by emotional development and past trauma.

Curious to know what we are doing in med management and therapy. Are we restoring insight, fixing narcissism or both?

This grey zone is really fascinating to me.

You probably would have found my late father to be a rather fascinating study, especially in determining exactly where the line between delusion, narcissism, egocentricity, a trauma fueled need to both construct and control the internal and external environment, and plain, sheer old bull headed stubbornness lies. I have never encountered anyone who held so rigidly to their beliefs, even in the face of overwhelming and incontrovertible evidence to the contrary, as my dad did. In all the years I knew him there were only two clear incidents I can recall where he had an apparent sudden flash of insight and actually looked at an issue from several points of view before arriving at his own understanding/conclusion.

And it wasn't like we're talking about issues such as racism and other prejudicial attitudes (let's just say my father's bigotry extended as far as holding ideologies that were in line with white supremacism), that would have at least partly been both a product of the times he grew up in, and the influence of prior generational attitudes being passed on, which isn't typically something that is easily fixed. My dad held fast to ideas that were simply outright wrong on an objectively factual level.

Such as - 'All music you hear on the radio is actually being played live in the studio at that very moment' (despite the fact that it is physically impossible for a musical artist who may be in the midst of a concert tour in the northern hemisphere, to somehow also manage to appear live on an Adelaide radio broadcast) --- 'The entire theory of man's evolution is preposterous, because scientists attempted to raise a chimpanzee in the same manner as a human child, and the monkey did not literally morph itself into a human being' --- 'There is a Doctor's mafia responsible for putting hits out on patients if they dare to lodge a complaint' --- And one of my all time personal favourites...'Women give birth via their rectums'. I mean you could have bought in a veritable army of renowned experts, presented him with page after page of correct information, even shown him clear, physical proof, and he still would have sat there and not budged an inch.

Add to the above my father's propensity for creeping around the house at all hours of the night,wielding a knife or baseball bat (intruders might be gathering at the doors and windows you see), and digging through garden beds in search of hidden recording devices (amongst other things), and as you can probably tell my upbringing was the epitome of stability and normality.

 

[whopper]

Ceke very interesting post. Thanks.

And by the way, I don't necessarily ethically agree with anyone with a PD getting disability or ADA concessions. Several (not all) of the PDs, part of the treatment is to hold the person responsible for their inappropriate behavior.

Another factor is IMHO a legitimate argument is if one requires an office due to a PD, and they must be moved away from others, it's a fair argument to state that if others cannot get an office, than this employee ought to have lower pay to pay for the rent of said office. Again, it's up to the courts.

 

[F0nzie]

Thanks for sharing Ceke

 

[Ceke2002]

Ceke very interesting post. Thanks.

Thanks for sharing Ceke

Thanks, you're welcome. I always like to try and make a meaningful contribution on here whenever I can.

When I said I'd only ever seen two instances where my father was able to reason properly, with insight, I probably should have added the caveat "without being on medication". In my Dad's case it eventually became clear that much of his issues were a combined result of childhood neglect and trauma disrupting a normal development of personality and self, along with having a family history of Schizophrenia (and other Psychosis Spectrum Disorders) making him more prone to schizotypal/paranoid type thinking. I'd a hazard a guess that, in modern terms at least, if we'd ever been able to get him into treatment it probably would have been something that concentrated on dealing with the developmental impact of past neglect and trauma, and looked to gradually challenge and shift his false perceptions/beliefs. The only problem with that is trauma based therapy, or DBT, or whatever else might have been deemed appropriate in my Father's case, simply would not have worked because he was just so completely rigid and fixed in how he viewed things. It was only after he was diagnosed with Vascular Dementia, and eventually became floridly psychotic as a result of the disease's progression, that I actually got to see my Dad displaying true insight, and having a real ability to be more flexible in his views, for pretty much the first time in my life, and that was mainly due to him being placed on Risperidone. The change in him with medication was really quite astounding, not just in terms of bringing the symptoms of psychosis under control, but in also bringing forward a real sense of awareness and insight that I don't think anyone had seen in him for a very long time, if ever. Just personally I think my Dad's case is a good example of when a Psychiatrist needs that knowledge and experience to really know, even if therapy alone was indicated in 99.9 out of a 100 other cases, when medication does become a necessity.

 

[smalltownpsych]

Always love these clinical questions that you pose. I would vote for Nitemagi as being the best response for this. I was formulating my own response as I was reading through and then read that answer and thought "beat me to it". Along the lines of Ceke's post being able to decipher a delusional or schizotypal aspect to the narcissism can guide the need for medication instead of psychotherapy. Also, the line between narcissism and mania can be tough to differentiate especially since both can be psychological defenses as opposed to signs of a malfunctioning brain. The other type of narcissism that is commonly encountered is that of the addict and that can linger long after the addict stops using although it usually becomes much more subtle.

 

[touchpause13]

How often would you actually be treating a patient with narcissistic personality disorder though? I mean, part of it is that they lack insight, they don't think that anything is wrong - so why would they be seeking treatment? Is it more that someone else in their life is asking them to get treatment/they are seeking treatment for something else?

 

[heyjack70]

How often would you actually be treating a patient with narcissistic personality disorder though? I mean, part of it is that they lack insight, they don't think that anything is wrong - so why would they be seeking treatment? Is it more that someone else in their life is asking them to get treatment/they are seeking treatment for something else?

Many patients have co-morbid mental illness. Depression + NPD, etc.