Pathological Vulnerable Narcissism Case Study | Battle Between Grandiose and Vulnerable Narcissism

welcome to my scientifically informed insider look at mental health topics if you find this video to be interesting or helpful please like it and subscribe to my channel oh this is dr. Grande today's question asks if I can analyze a case study involving pathological vulnerable narcissism now the definition of narcissistic personality disorder as we see in the DSM really highlights the importance of behavioral observations as opposed to private inner experiences and conflict so it's no surprise it seems to miss the construct of vulnerable narcissism essentially there is no diagnosis that is associated with vulnerable narcissism individuals with this type of narcissism of course could still get diagnosed with narcissistic personality disorder they may get diagnosed with borderline personality disorder sometimes they get diagnosed with antisocial personality and I've even seen a few cases where people with vulnerable narcissism get diagnosed with avoidant personality disorder so with all this in mind makes it all the more interesting to take a look at a case study that features pathological vulnerable narcissism now a case study is when a clinician documents their experiences in treating a client they do this with the clients consent sometimes case studies are called clinical vignettes or case reports it's essentially a report that has the clients presentation what treatments were attempted how the client responded and other related information the case study I'm using for this video was published in a journal article and I'll put the reference to that article in the description for this video now this case report conceptualized pathological narcissism in a psychoanalytic way with this point of view is essentially characterized by stunted development of identity narcissists are developmentally trapped in an early stage of maturation so a person with pathological narcissism would have infantile characteristics in a sense they would view themselves at an unconscious level as existing in a parasitic economy so they want to receive from others but they don't want to give anything in return now the report notes that this is an extreme conceptualization of narcissism but it does capture some of the elements we see in clinical practice quite well we do tend to see pathological narcissism as a dysregulation of self-esteem which is consistent with an interruption in development another important note here this report looks at pathological narcissism as containing both grandiose and vulnerable traits so it really doesn't make the distinction between grandiose and vulnerable types of narcissism this conceptualization is not arguing that there needs to be a new diagnosis for vulnerable narcissism like vulnerable narcissistic personality disorder or something like that rather it argues for an expanded definition of the diagnostic category we already have essentially this report argues that the majority of narcissists have both grandiose and vulnerable characteristics however the grandiose traits are more obvious so that's why we see the diagnosis of NPD structured the way that it is so let's take a look at this case the client in this case report was a 28 year old male college student of mixed ethnicity I'll refer to this client as Jim the psychotherapist was male he treated Jim for 20 months using psychodynamic therapy he had four clinical supervisors while he was working on this case now I'm a big fan of supervision I've mentioned that many times but this seems like a little much for separate supervisors for one case or for one therapist for that matter just seems like a lot of different advice coming at the clinician and intake Jim reported that he worked part-time at a convenience store he lived with his mother some of the time and the rest of the time he lived with his grandfather and grandmother so really we see two different houses here that he lived in the grandfather had taken custody of Jim when Jim's mother's served time in prison when Jim was younger and Jim's father passed away when Jim was younger now when Jim came into therapy he typically dressed in black or earth tone colors and wore black combat boots he had long unkempt hair he was of average height and he was about 40 pounds overweight typically he was overly cooperative cynical submissive anxious cordial self-critical and humorous from the age of nine he had received individual group and family psychotherapy on several occasions at a community mental health agency he reported that this therapy was unhelpful and occasionally intrusive and scary he did not like group dynamics he felt like when he was in group therapy he was being demeaned or manipulated by the other group members he also said that the group tended to focus on his mother's psychopathology instead of his own Jim reported that his mother had a history of borderline personality disorder major depressive disorder and bipolar disorder now an interesting note here of course MD D major depressive disorder and bipolar disorder can't be diagnosed in the same person at the same time if somebody meets the criteria for bipolar disorder then they no longer have major depressive disorder right so that takes the place of that disorder now could have been that when Jim was going through his mother's history she did have major depressive disorder at one point in time and then later on was diagnosed with bipolar disorder so he just listed both even though only the bipolar disorder would be current now right before the therapy that was captured in this case report Jim was treated by a female therapist for seven months both Jim and the therapist seemed to have attendance problems he would miss an appointment then she would miss one this is kind of troubling that really she couldn't make the appointments he didn't receive good therapy from this clinician the therapist indicated that she didn't have time for every client and that she was trimming the fat from her caseload Jim took this trimming the fat comment personally due to his history of being ridiculed about his weight this other therapist would also end sessions early saying she had to catch up on other work after all these bad experiences with that other therapist Jim's therapist left the agency suddenly right so there were a lot of problems here Jim was then referred to the therapist who wrote the case report I'm talking about now informally this current therapist the writer of this case report confirmed that the prior therapist was contending with mental disorders of her own which interfered with her ability to provide care the current therapist worked with Jim to help him process the termination of the prior therapy I thought this was a really smart move I think a lot of therapists would have skipped the step but it's important that Jim could really process what happened in that prior therapy so even though they worked through some of the issues from the prior therapy Jim was still mad at himself for allowing himself to be exploited by the previous therapist that's how he thought about it and that of course plays a part as we look at the current therapy now during the first few months of the current treatment again the treatment covered in this case report that therapist had to miss two sessions because of an emergency surgery Jim missed the next scheduled session after the therapist returned so the therapist confronted him about this missed appointment Jim was defensive and disgusted that the therapist would assume that Jim had a strong reaction to the therapists absence Jim said that he wouldn't fall apart when the therapist left him he was fine without him the therapist interpreted this as being an important moment revealing Jim's attempt to appear grandiose while indicating that he was actually vulnerable after this point the counseling really focused on stressful situations and relationships that Jim was contending with Jim was diagnosed with major depressive disorder recurrent in partial remission and social anxiety disorder the therapist noted that Jim had fantasies about his academic performance Jim was failing one or two classes each semester but still had this belief that he would be admitted into a prestigious medical school the therapists explored Jim's desire to be a physician Jim really couldn't explain why he wanted to be a physician he also didn't seem to understand how difficult that process would be he didn't understand all the steps of becoming a physician as the topic was explored further Jim changed his interests he decided he wanted to be a coroner and he had two reasons for this or getting with patients who were deceased would not create any social anxiety and he could not disappoint these patients exploring Jim's academic endeavors revealed some interesting information about Jim's personality he often identified with his most recent level of academic achievement so his grades seemed to determine his self-worth for example he was distressed if he received the lowest grade in the class but interestingly he became anxious and defensive when he would get the highest grade in the class on an assignment Jim really wanted to be in the middle of the pack he didn't want to stand out for a negative or a positive reason he was afraid that if he was successful people would expect things from him and he didn't want to risk letting them down this is such an excellent example of the paradox of having both grandiose and vulnerable narcissistic characteristics Jim wanted to succeed he wanted to be the best he had fantasies of this at the same time he was afraid of success afraid of the ridicule and the scrutiny that might come with success we can see the narcissism pushing and pulling Jim in different directions we see an internal conflict eventually these opposing forces reach a stalemate which keeps the person stuck developmentally they can't grow as a person they can't change what they want they can't change their desire and they can't get what they want they can't achieve their goals we see after a few months of therapy touching on these various issues Jim becomes increasingly resistant he feels pressured to bring interesting stories into therapy to impress the therapist when Jim did not have funny stories to share he would get quite anxious so we see almost a performance anxiety starting to develop here with Jim after a year of treatment the focus of the sessions moved from daily events to looking at Jim's childhood experiences Jim recounted one particular memory he had when his father was still life Jim's mother and father divorced when Jim was quite young Jim's father married another woman and had a son with her Jim's brother was about two years younger than him during one Christmas season Jim's father got into an argument with Jim's mother Jim's father took all the presents that he had purchased for Jim load them into his car and took them over to his wife eventually giving them to Jim's brother Jim recalled spending time with his brother shortly after Christmas and seeing all the toys that he had asked for from his father so Jim's brother was playing with the toys that would have been Jim's now Jim was envious and angry but he viewed the toys as tainted he did not desire to possess the toys or play with the toys we see in this particular story how Jim was neglected and mistreated and it starts to make sense how he would develop a narcissistic personality after being in treatment for 15 months Jim seemed to be improving he was thinking about moving out of both of his two homes and finding an apartment he was issued a driver's license and he was active in several social clubs at the college where he attended it was at this point he started to explore his relationship with his mother Jim couldn't decide what he wanted to believe regarding his mother he didn't know if he want to blame her poor parenting on her drug use or if he wanted to acknowledge that she was vindictive dismissive and manipulating when she was not using substances as well Jim's mother was using his identity to open up credit cards and she was using his money to fund her drug use Jim allowed both of these behaviors he also bought groceries for her the therapist reminded Jim that one of Jim's goals was to leave his mother Jim became defensive and irate and said that his mother needed him he stated that without him his mother would die under a bridge so it would appear that Jim's mother had a tight grasp on him abusing him emotionally and economically but we see that Jim derived a sense of power from having his mother depend on him she needed him and in doing this she served as a narcissistic supply for Jim this key relationship was left unexplored for 15 months of treatment after they started looking at it we see a major change in Jim's behavior Jim starts rescheduling kin slang and failing to attend appointments over a period of about two months when he cancelled he would cancel at the last minute saying he just want to make sure the therapist was there then he would reschedule he came into the clinic twice without an appointment and asked to see the therapist but the therapist wasn't there either of those times Jim indicated to the staff that he was frustrated that the clinician was not there but therapists met with one of his supervisors and they decided to terminate treatment at many agencies Jim would have been terminated after two or perhaps three missed appointments so this agency waited kind of a long time to end this treatment so this is an interesting case what can we learn from this so it's worth noting here that of course I didn't treat this client there's undoubtedly a lot of information that I don't know about the case that the treating therapist who wrote the report would know I'm basing the following seven points on the information that was available so the first point although I have some criticisms of the therapy it would appear for the most part Jim received fairly good therapy from the writer of this case report but Jim was treated poorly by the prior therapist so the takeaway here is may add therapy causes damage that therapist was not a good fit for the field regardless of the reason if a therapist is not competent they should not be treating clients point number two the case report notes that it would require a liberal interpretation of the definition of narcissistic personality for the diagnosis to be given to Jim the report indicates that he really only met two of the criteria a grandiose sense of self-importance and believing oneself to be special or unique I disagree based on the information in the report I would say it's fairly clear that in addition to those two criteria we see entitlement so he was angry when he showed up at the clinic and a therapist wasn't there we see that Jim's arrogant and that's really seen in that same situation with being indignant about the therapist not being there we see manipulation rescheduling and cancelling the appointments we see fantasy that was straight from the narrative and requiring access raishin was straight from the narrative it's unclear if he would meet the last two criteria being envious and lacking empathy but again there's more information that might reveal that those symptoms would be endorsed but of course not seeing that information I'd have to say I'm not sure about those two I agree that narcissistic personality disorder doesn't capture vulnerable narcissism well but in this case I think the diagnosis would have made sense seven of nine symptoms endorsed of course is enough only five are required point number three this case is yet another example of how an individual can fluctuate between grandiose and vulnerable narcissistic traits in a sense Jim was struggling to be grandiose but the vulnerability was holding him back this is why I tend to think of vulnerable narcissism as a failed attempt at grandiose narcissism point number four these types of cases are difficult this therapist had four supervisors again maybe too many but either way a lot of people were paying attention to what he did and even still treatment was a struggle here point number five the case report indicated that this case represented a partial treatment success I would tend to agree it's not unusual that when there is a less-than-ideal termination a therapist will look at the whole situation say wow that was really a waste of time I didn't help that person at all but even therapeutic relationships that terminate poorly could still have been helpful also even though it's not the case here sometimes an abrupt termination indicates that the client is feeling better point number six boundaries are extremely important especially with personality disorders we see this clinic taking two months to terminate this client when it sounds like he normally would have been terminated in about three or four weeks to some therapist it seems unkind or unfair to terminate a client who exhibits this type of behavior but it's not it's necessary to keep the boundary in place as part of the termination of therapy a clinician indicates the conditions under which the client could return and a referral is provided to another provider when cancelled to the last moment for those sessions the therapist was just sitting there for an hour with nothing to do instead of treating another client so if Jim had not scheduled or if he had cancelled with enough time in advance the therapist could have had a client during that same time so really we see by not terminating in a timely manner there is a waste of resources so moving to point number seven my last key takeaway from this case report I'm really surprised that the exploration of the relationship of the mother did not take place earlier now this isn't necessarily a criticism but in psychodynamic therapy it's just hard to believe that wouldn't come up it's really a key part of that type of therapy on a related note if the therapist knew that the mother was manipulating Jim at least that component of the relationship should have been discussed there is an environmental aspect to recovery with the mom manipulating Jim and Jim feeling a sense of power and control over his mom we have this destructive dynamic asking Jim to recover from narcissistic tennessee's while in a situation that encourages those tennessee's is like telling a client with alcohol use disorder to stop drinking even though they work in a liquor store right sometimes the environment can make recovery difficult so there are my thoughts on this case study it's kind of an interesting case study looking at the pathological vulnerable narcissism these types of studies are fairly uncommon now I know whenever I talk about vulnerable narcissism there will be a variety of opinions please put any opinions and thoughts in the comment section they always generate an interesting dialogue as always I hope you found my analysis of this topic to be interesting thanks for watching

Channel: Dr. Todd Grande

Views: 138,815

Keywords: case study, pathological vulnerable narcissism, narcissistic personality disorder, vulnerable narcissism, grandiose narcissism, covert narcissism, overt narcissism, shame, anger, aggression, hypersensitivity, introverted, defensive, avoidant, anxious, depressed, socially awkward, neurotic, shy, manipulative, blame-shifting, gaslighting, self-esteem, dominant, confidence, arrogance, Cluster B Personality Disorder, lack of empathy, fantasy, entitlement, envious, admiration

Id: -DD81jTGM9U

Length: 19min 30sec (1170 seconds)

Published: Wed Apr 15 2020