David Kealy

Depressive tendencies and pathological narcissism among psychiatric outpatients

This study examined the relationship between components of pathological narcissism and types of depressive tendencies among a sample of 117 psychiatric outpatients. Findings revealed that depressive themes concerning dependency were associated with narcissistic grandiosity. Depressive tendencies concerning self-criticism were positively associated with narcissistic vulnerability.

Marginalization of borderline personality disorder.

Individuals with borderline personality disorder (BPD) face considerable difficulties, both in terms of their symptom and functional status, as well as in attempting to obtain professional help. Their exclusion from appropriate mental health care and opportunities for recovery can be examined using the social construct of marginalization. Pervasive attitudes among clinicians, health care administrators, and policy-makers perpetuate the marginalization of BPD within systems of mental health care. Patients with BPD may be regarded as not suffering from a legitimate disorder, comprising a minority of the clinical population, and/or being a chronic drain on health care resources. Lack of suitable mental health services may be rationalized based on these attitudes. Considerable development in the empirical understanding of BPD challenges these stigmatizing attitudes and calls for critical questioning of the marginalized status of patients with BPD. (Journal of Psychiatric Practice 2010;16:145–154)

Burnout among Canadian Psychiatry Residents: A National Survey

Objective: Burnout is a serious problem for health care providers that has implications for clinical practice and personal health. While burnout is known to affect residents, no studies have examined the prevalence or impact of burnout among Canadian psychiatry residents. Method: Residents in all Canadian psychiatry training programs were surveyed between May 1, 2014, and July 1, 2014. The survey included a well-validated, single-item measure to assess symptoms of burnout, several demographic questions, and Likert-scale items to assess residents’ appraisals of empathic functioning and strategies for coping with stress from patient encounters. Results: Responses were obtained from 400 residents, for a response rate of 48%. Twenty-one percent (N = 84) of residents reported symptoms of burnout. Burnout was reported more frequently by residents in postgraduate year 2 than by those in other years and was associated with engagement in personal psychotherapy during residency. No association was found between burnout and age, gender, or location of residency program. Residents who endorsed symptoms of burnout reported higher levels of compromised empathic functioning, were less likely to consult with supervisors about stressful clinical experiences, and were more likely to engage in unhealthy coping strategies. Conclusions: Symptoms of burnout affect one-fifth of Canadian psychiatry residents. The associations between burnout symptoms and problematic clinical and personal functioning suggest areas of concern for those involved in the training of Canadian psychiatry residents.

A view from the trenches: a survey of Canadian clinicians' perspectives regarding the treatment of borderline personality disorder.

Objective The goal of this study was to develop a sense of how borderline personality disorder (BPD) is treated in the community. The focus was on psychotherapeutic treatments. Methods A 13-item online questionnaire was distributed to 291 clinicians in the province of British Columbia, Canada. Participants were asked about treatment provision, their opinion of optimal treatment, and clinician confidence using both fixed and open response questions. Results The response rate was 43%. Of the respondents, 64% indicated that they provided treatment to patients with BPD, although two thirds of those responses indicated use of ill-defined treatment approaches. In the responses that involved what could be described as well-defined treatment approaches, dialectical behavior therapy (DBT) was the most frequently mentioned (20%). Most treatments were offered in an individual therapy format (60%); 38% described providing treatment on a long-term basis. Responses concerning optimal treatment for BPD favored DBT (45%), a combined individual-group therapy format (48%), and long-term duration of treatment (42%). Clinician confidence in treating BPD was low and there was a strong desire for further training. Conclusion The community mental health clinicians who were surveyed were aware of the serious nature of BPD and seek to treat the disorder. However, much of the treatment they provide does not conform to what respondents indicated they considered optimal. Clinicians who responded to the survey seemed relatively unaware of empirically supported psychodynamic treatments for BPD. There is a need for improved training and education regarding BPD and for further dissemination of information concerning empirically supported treatments for BPD. (Journal of Psychiatric Practice 2009;15:449–453)

Therapists' Perspectives on Optimal Treatment for Pathological Narcissism.

This study used Q methodology to explore clinicians’ perspectives regarding optimal psychotherapy process in the treatment of pathological narcissism, a syndrome of impaired self-regulation. Participants were 34 psychotherapists of various disciplines and theoretical orientations who reviewed 3 clinical vignettes portraying hypothetical cases of grandiose narcissism, vulnerable narcissism, and panic disorder without pathological narcissism. Participants then used the Psychotherapy Process Q set, a 100-item Q-sort instrument, to indicate their views regarding optimal therapy process for each hypothetical case. By-person principal components analysis with varimax rotation was conducted on all 102 Q-sorts, revealing 4 components representing clinicians’ perspectives on ideal therapy processes for narcissistic and non-narcissistic patients. These perspectives were then analyzed regarding their relationship to established therapy models. The first component represented an introspective, relationally oriented therapy process and was strongly correlated with established psychodynamic treatments. The second component, most frequently endorsed for the panic disorder vignette, consisted of a cognitive and alliance-building approach that correlated strongly with expert-rated cognitive–behavioral therapy. The third and fourth components involved therapy processes focused on the challenging interpersonal behaviors associated with narcissistic vulnerability and grandiosity, respectively. The perspectives on therapy processes that emerged in this study reflect different points of emphasis in the treatment of pathological narcissism, and may serve as prototypes of therapist-generated approaches to patients suffering from this issue. The findings suggest several areas for further empirical inquiry regarding psychotherapy with this population.

Narcissism and Relational Representations Among Psychiatric Outpatients

Pathological narcissism is associated with maladaptive interpersonal behavior, although less is known regarding the internal relational representations of narcissistic patients. The authors examined the relationship between pathological narcissism and two constructs that reflect internal representations of relational patterns: quality of object relations and attachment style. Patients attending a psychiatric day treatment program (N = 218) completed measures of narcissism, general psychiatric distress, and attachment style in terms of attachment avoidance and anxiety. A semistructured interview was used to assess quality of object relations. Multiple regression analysis was conducted, controlling for general psychiatric distress. Pathological narcissism was associated with anxious attachment, but not with avoidant attachment. Narcissism was also associated with lower levels of quality of object relations. The implications of these results are discussed in terms of internal representations of self-other relations.

Object relations and emotional processing deficits among psychiatric outpatients.

The aim of this study was to investigate the association between object relations and emotional processing deficits among a general sample of psychiatric outpatients. The sample consisted of 104 patients consecutively referred to 2 outpatient clinics. Participants completed measures of object relations, emotional processing deficits, and general psychiatric distress. After controlling for the effect of current symptom distress, we found that object relations impairment was significantly associated with emotional processing deficits relating to unregulated emotions, signs of unprocessed emotions, and emotion suppression. These findings support the notion that patients with impoverished mental structures possess maladaptive strategies for modulating intense affects.

On overvaluing parental overvaluation as the origins of narcissism

Understanding the developmental roots of narcissism has inspired much theorizing but little systematic inquiry. In this light, the longitudinal study by Brummelman et al. (1), which found that early socialization experiences in the form of parental overvaluation predicts the development of childhood narcissism, is a notable contribution to the empirical literature. Establishing a link between childhood narcissism and parental overvaluation has important implications for helping parents foster appropriate and realistic self-views in their children.

Pathological narcissism and somatic symptoms among men and women attending an outpatient mental health clinic

Abstract Objective: To explore the relationship between types of pathological narcissism and somatic symptoms among psychiatric outpatients. Methods: Patients (N = 95) completed measures of somatic symptoms, narcissistic grandiosity and vulnerability, and psychiatric symptoms. Relationships among variables were analysed using t-tests and correlations, controlling for psychiatric distress. Results: Somatic symptoms were positively associated with two types of narcissistic dysfunction. Among women there was a positive association between somatic symptoms and narcissistic vulnerability, but not grandiosity. Among men, somatic symptoms were positively associated with narcissistic grandiosity, but not vulnerability. Conclusions: The connection between narcissistic pathology and somatic symptom severity appears to differ based on gender. Further research is needed to confirm and extend this preliminary finding.

Pathological Narcissism and the Obstruction of Love

Pathological narcissism is a form of maladaptive self-regulation that impedes the capacity to love. Although narcissism is often construed as excessive self-love, individuals with pathological narcissism are impaired in being able to love themselves as well as others. With the subject of impaired love in mind, we review selected conceptualizations from an enormous and diverse psychodynamic literature on narcissism. Major theoretical approaches illustrate a number of psychodynamics associated with narcissistic self-regulatory problems. This paper provides a concise overview of major conceptual themes regarding pathological narcissism and impaired capacity to love.