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How can the same object become split when viewed by different groups of observers? What is the relationship between conflict and consensus, and the ritual and the rational? I interrogate these questions through the case of narcissistic personality disorder (NPD) in Germanophone Europe and North America. I interviewed forty-five practitioners from Germany, Austria, Switzerland, the US and Canada. These conversations were semi-structured and ethnographically inflected. I attempted to take the informant’s perspective earnestly and to read any available works by that author in advance of the interview. To gain a sense of how science differed when not immediately concerned with the treatment of patients, I included an assessment specialist and a social-personality psychologist. Non-expert practitioners, who had not published any books or articles on pathological narcissism, were included to test whether theory is solely alluring to the academician or if it holds sway over the psychotherapist on the street. These respondent pools were matched as closely as possible across the two contexts to facilitate comparison. Approximately six psychotherapeutic schools emerged as important amongst my respondents. After a brief introduction to the different psychotherapies, I begin with the native understandings of NPD or pathological narcissism. These definitions and the wide range of narcissistic patients seen pose the puzzle: How can these definitions be so disparate, and all ostensibly be concerned with NPD as a clinical or scientific object? My concern is less oratorical and more earthy: What precisely do practitioners do? Opening with assessment (Ch. 5), we find some common signs. Diagnostic procedures may employ different technological mixes, but ultimately all follow a single pattern. Chapter 6 addresses empathy and the therapeutic alliance. The notion of a minimal medical model underlying all treatment types I encountered was unearthed despite many methods’ active denial of the ‘medical model.’ The patient-practitioner boundary is, however, far from the final frontier. Conceptualisation helps to guide the ways in which clinicians interact with one another, and ultimately the broader science of psychopathology. Chapter 8 addresses the ways in which different classificatory schemes relate to one another, and how this helps to shape the science of narcissism. What ultimately emerges is a story of (1) the minor differences of narcissism and (2) the narcissism of minor differences. The narcissism (2) can be said to obscure the (1) minor differences. Competition is inherent in the process at multiple levels: between models for both students and patients (attention-space), and through scientific exchange and the effort to gain evidence for one’s theory. I suggest that science serves less to find the best description or explanation for pathological narcissism, and more to legitimate one’s conceptualisation. Evidence of this sort gives a theoretical school means to command more financial and attentional resources. Psychotherapeutic technology is, however, path dependent, limiting the distance between any two methods.

Die Narzisstische Persönlichkeitsstörung (NPS) wird aufgrund der inkonsistenten Konzeptualisierung stark diskutiert. Ziel der Studie war es, NPS-Patienten zu untersuchen, um mit empirischen Daten die Validität und klinische Relevanz der NPS zu diskutieren. Es wurden zwei epidemiologische Studien durchgeführt. Studie 1 betrachtet die allgemeine psychische Belastung und Komorbidiätsraten, Studie 5 schaut auf die Stabilität und Remissionsrate der Diagnose und der diagnostischen Kriterien. Studie 1 fand eine erhöhte allgemeine psychische Belastung und hohe Komorbiditätsraten für affektive Störungen und Störungen durch Substanzkonsum, Studie 5 fand eine moderate Remissionsrate von 53%. In Studie 2 und 3 wurden selbstbezogene Kognitionen und Emotionen untersucht. Studie 2 erforschte die explizite und implizite Selbstwertschätzung. Es zeigte sich, dass die NPS mit einem niedrigen expliziten aber einem unbeeinträchtigten impliziten Selbstwert einhergeht. Studie 3 betrachtete Schamneigung bei der NPS. NPS-Patienten zeigten eine höhere explizite und implizite Schamneigung. Das indiziert, dass die narzisstische Vulnerabilität (niedriger expliziter Selbstwert, hohe explizite und implizite Schamneigung) bei NPS-Patienten eine Rolle spielt. In Studie 4 wurde die kognitive und emotionale Empathie untersucht. NPS-Patienten zeigten eine niedrigere emotionale Empathie aber eine unbeeinträchtigte kognitive Empathie. Die Ergebnisse passen zur aktuellen Kritik, dass die diagnostischen Kriterien zu eng sind, um die NPS adäquat zu beschreiben. Studien 1–3 geben Hinweise für die narzisstische Vulnerabilität, die nicht in den diagnostischen Kriterien repräsentiert wird, Studie 4 bringt Hinweise für eine ungestörte kognitive Empathie, was konträr zum diagnostischen Kriterium „Empathiemangel“ ist, und Studie 5 stellt die Beschreibung der NPS als stabiles andauerndes Muster in Frage. Implikationen für weitere Forschung und für die klinische Praxis werden diskutiert. / Narcissistic personality disorder (NPD) is discussed due to its inconsistent conceptualization. The aim of this study was to investigate a sample of NPD patients to collect empirical evidence and discuss the validity and clinical relevance of NPD. Two epidemiological studies are included in this thesis. Study 1 focused on the general mental stress of NPD patients and assesses comorbidities, Study 5 looks at the stability and remission rate of the diagnosis and its criteria. Study 1 found that NPD is associated with general mental stress and high comorbidity rates for affective disorders and substance use disorders, Study 5 found that NPD demonstrates a moderate remission rate of about 53%. In Study 2 and 3, self-related cognitions and emotions were examined. Study 2 investigated explicit and implicit self-esteem. It was determined that NPD is associated with a lower explicit self-esteem and an unaffected implicit self-esteem. Study 3 focused on shame-proneness in NPD. Patients with NPD showed significantly higher explicit and implicit shame-proneness. These results indicate that the narcissistic vulnerability characterized by low explicit self-esteem and high explicit and implicit shame-proneness is necessary in inpatients with a NPD. In Study 4 cognitive and emotional empathy were examined. NPD patients displayed impairment in emotional empathy while cognitive empathy was unaffected. In summary, the findings are in line with the critique that the diagnostic criteria are too narrow to describe the entire manifestation of the disorder. Study 1-3 presented evidence for the narcissistic vulnerability that is not represented by the current diagnostic criteria, Study 4 provided evidence for an unaffected cognitive empathy that is contrary to the seventh diagnostic criteria “lack of empathy”, and Study 5 calls the stable pattern of long duration into question. Implications for further research and clinical practice are discussed.

Personality disorders have traditionally been considered refractory to psychological interventions. Two of the most common, and potentially harmful personality disorders are antisocial personality disorder / psychopathy, and narcissism. Although a great deal of conceptual overlap exists between psychopathy and narcissism, the empirical study of these constructs has proceeded largely independently of one another. Further complicating the discrimination of these constructs is the identification of the bi-factorial nature of psychopathy - conceptualised as primary and secondary psychopathy - as well as the identification of two distinct forms of narcissism, overt and covert. The recent resurgence of interest in the sub-clinical manifestations of these two constructs has led to the development of a number of easily administered instruments to measure each of the psychopathy and narcissism constructs, as dimensional traits, within normal populations. This has provided empirically validated and reliable instruments to further explicate these two overlapping constructs. The first of the two studies reported sought to discriminate between psychopathy and narcissism through the recharacterisation of these constructs in terms of the early maladaptive schemas outlined in Young’s early maladaptive schema theory (Young, 1999). Two hundred and ninety one participants completed questionnaires measuring primary and secondary psychopathy, overt and covert narcissism, and early maladaptive schemas. Findings are consistent with the hypothesis that psychopathy and narcissism are discriminable in cognitive-interpersonal terms, as operationalised by early maladaptive schemas. Findings also call into question the earlier observed hierarchical structure of the Young Schema Questionnaire. The current analysis identified a two-factor structure to the schema questionnaire, rather than the previously stated 5-factors. Having demonstrated the usefulness of understanding psychopathy and narcissism in cognitive-interpersonal terms, the second study sought to further clarify the association between psychopathy and narcissism through the reconceptualisation of these constructs in cognitive terms, through the identification of the cognitive distortions operative in each disorder. One hundred and thirty two participants completed a cognitive distortions questionnaire developed by the author, along with the same measures of primary and secondary psychopathy, and overt and covert narcissism, as those administered in study 1. Findings were interpreted as providing support for the notion of psychopathy representing a sub-category of narcissism. Findings also provide further supportive evidence for the validity of the primary / secondary psychopathy, and overt / covert narcissism distinctions. The further clarification of the factor structure of the Young Schema Questionnaire, and the replication of the reliability and construct validity of the measure of cognitive distortions developed for this research are highlighted as areas for future research.

“The relationship between the criminal and victim is much more complicated than the law would care to acknowledge. The criminal and his victim work on each other unconsciously. We can say that as the criminal shapes the victim, the victim also shapes the criminal. The law differentiates distinctly between the attacker and the victim. But their relationship may be, and often is, quite close, so that their roles are reversed and the victim becomes the determining person, while the [victimiser] in the end becomes his own victim.” (Abrahamsen, 1973:35). This research was directed at establishing whether narcissistic individuals will go to extreme levels of violence, specifically murder, if their self-image is threatened. The aim was to determine the extent of pre-existing narcissistic personality disorder (NPD) in these individuals and how this contributed to the murderous action they committed. Emphasis was placed on the psychological motivation of the perpetrator, as well as the relationship that existed between the perpetrator and the victim prior to the event. As the subject of the research was a relatively unknown phenomenon, a qualitative research approach was used. The research focused on analysing specific cases of murder, more particularly cases where rage-type murders were committed. It endeavoured to identify the underlying personality dynamics to determine whether an association between rage-type murder and NPD exists. Case studies illustrating rage-type murderers who had been admitted to Weskoppies Psychiatric Hospital for a 30-day observation period were identified and analysed. These cases were selected through reviewing the case history of each individual to determine whether the murder fitted the outlined definition of a rage-type murder. The cases that met the outlined requirements were deemed suitable for the purpose of the research, where after the Minnesota Multiphasic Personality Inventory (MMPI-2) results of the selected cases were examined to determine the personality organisation of the individuals. This information was then used to determine the possible association between NPD and rage-type murder. The MMPI-2 was selected as the assessment tool as it is the most widely used personality assessment available. For the purposes of this research a two-point code type was used to indicate the presence of narcissistic personality traits. A two-point code type implies an elevation of two scales, for the purposes of this research specifically the Pd (Psychopathic deviance) scale and the Pa (Paranoia) scale, also referred to as the 4-6/6-4 code type. As interpretation based only on a two-scale elevation was considered to be overly simplistic, all the MMPI-2 clinical scales were interpreted independently, and a clinical interpretation provided in the context of each individual’s background. The 4-6/6-4 code type individual was used to indicate whether the individuals did have narcissistic personality traits, and thus were classified as having NPD. Nine cases were identified of individuals thought to be rage-type murderers, who were admitted for a 30-day period of psychiatric observation to Weskoppies Psychiatric Hospital in Pretoria. Only five cases were acknowledged as rage-type murders. All the cases selected were referred to Weskoppies Psychiatric Hospital by order of the court and involved males over the age of 20 years. The individuals involved were admitted to the Forensic Unit of the hospital and were subjected to standard psychiatric hospital observations, which included psychiatric interviews, psychological interviews, psychological testing, as well as general behavioural observations in the ward. All the information obtained during the standard psychiatric hospital observations is held in the clinical case files in the archives at the hospital. All the standard psychiatric hospital observation evaluations were completed prior to the initiation of the research, and the case records had been closed. Although more research is necessary, this research has established an association between the selected cases of rage-type murder and NPD and there is historic documented evidence suggesting that individuals with NPD will most likely react in a similar manner in similar circumstances, as a result of their underlying personality disorder. This suggests that incarceration in a correctional facility is not the most appropriate place to rehabilitate individuals. It also serves as support to why a person with NPD who commits a rage-type murder should be acquitted because of their personality disorder and subsequently be committed to a psychiatric facility as a patient of the state president. / Dissertation (MA)--University of Pretoria, 2010. / Social Work and Criminology / unrestricted