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lo this is dr. Grande today's question
asks I can analyze a case study
featuring comorbid narcissistic and
antisocial personality disorders so a
case studies when a clinician documents
their experiences in treating a client
they do this with the clients consent
sometimes the case study is referred to
as a clinical vignette or a case report
these reports can be transmitted in a
variety of ways for example published in
a journal published in a book that
contains many case studies were
presented at a training the case study
I'm using here today was published in a
journal and I'll put the reference for
that article in the description for this
video so let's take a look at this case
the client here is a 35 year old male
I'll refer to him as Steven Steven was
treated in a closed forensic setting
after he was found responsible for
fraudulent bank transactions involving
25 million euros so I looked up the
conversion to US dollars and that's
about twenty-seven million three hundred
thousand dollars I'm not sure what they
meant by the word involving like it
involved 25 million euro but clearly he
had obtained some of this money or all
this money and again he did this through
criminal activity so right away this
case study stands out a bit in many
jurisdictions if somebody's arrested for
stealing this much money the court isn't
really going to be too concerned about
personality pathology rather they're
just going to simply send the person to
prison evidently this case took place in
the Netherlands and in this jurisdiction
the court was willing to take into
consideration severe personality
pathology and ensure that the client
received treatment it was noted in the
case report that according to Dutch law
a forensic patient must be treated until
they have improved to such a degree
where reoffending is unlikely now Steven
used the money that he had stolen on
expensive cars expensive clothes
he lived in first-class hotels so he
wasn't being discreet at the time of his
arrest
it wasn't specified in the case report
how long his original sentence was but
it did indicate that he was supposed to
be reevaluated every two years now
during the intake into the facility he
went through an assessment during this
assessment he did not display any
indication of shame guilt or nervousness
he appeared to be cooperative the case
report said he feigned cooperation he
provided information that was incorrect
or incomplete and he would give very
detailed but unimportant information to
the crashing so we get the sense here
that he liked to hear himself talk and
he'd like to dominate conversations so
now to take a look at its early history
I think it's important to keep in mind
here that much of this information
probably came directly from him I
imagine some of it was also verified but
either way I would be a little bit
skeptical about how accurate it would be
given his propensity for not telling the
truth
so we see in his early history that
Steven's parents were career focused
individuals who tended to ignore him his
father was described as an industrialist
and his mother was an actress Stephen
had no siblings and no real friends and
grew up feeling quite lonely drifting
off into a world of fantasy Steven was
raised by a nanny and he did form a
special bond with her when Steven would
ask his father for help he would be
criticized in a hostile manner Steven
was also criticized by his peers they
teased him because he was shy withdrawn
and appeared to be depressed
so we see a number of threats here to
his ego and we also see insecure
attachment in addition to this we see
something called insecure autonomy this
is where one rejects the world by
constructing an imaginary one where they
have a tremendous amount of power
Steven develops this fantasy of
unlimited power which of course is one
of the symptoms we see with narcissistic
personality disorder now Steven started
to develop a pattern of disobedience he
became angry and aggressive and he
started stealing and got into forgery
which i think is an interesting way to
go for somebody so young right I mean
the aggression and the stealing that
wouldn't be unusual so he had a tough
upbringing beginning into forgery I
found that to be a little bit unusual
Stephen began to develop a great respect
for well-known real and fictional
characters he started to identify with
people like Robin Hood train robbers and
master swindlers he developed a genuine
interest in fraud and how to deceive
people he viewed his ability to deceive
people as powerful it was a power that
could grant him revenge against his
parents a power that could grant him
revenge against his peers it would allow
him to maintain his fantasy world after
dropping out of high school he had many
lower-level jobs from which he was fired
or quit and when he was fired it was
because of deceptive and irresponsible
behavior or failure to complete his job
from the ages of 18 to 35 we see that
Stephen was a prolific criminal engaging
in fraud extortion illegal trade and
dealing drugs so he had an extensive
history here
that is consistent with antisocial
personality disorder now taking a look
at the time he spent in the facility so
he covered his early years up to 35 now
we're looking at when he is incarcerated
an important note here this facility
used a psychoanalytic approach so their
understanding of narcissism is that it
develops to protect a fragile ego
Stephens behavior in the facility was
fairly interesting he attempted to
dominate and manipulate members of the
staff and other patients by using
creative language and being subtle in
his vocal qualities he also tried to
appear elegant and stately at the same
time his mannerism was immature cold and
vindictive he generally tried to avoid
social and interpersonal problems he was
fearful that other people wanted to hurt
him so we see an interesting dichotomy
here being dominant and manipulative
while at the same time being fearful so
he was doing things that placed him in
harm's way
all the while wanting to avoid
confrontation Stephen pretended to be
highly educated evidently he forged a
doctoral degree in the arts
I guess putting those forgeries skills
to good use Stephen like to borrow
features from individuals that he viewed
as high status he imitated the
unblinking
aristocratic and dominant behavior of a
famous French actor he would take
idealized characteristics of famous
people and incorporate them into his
fantasies and essentially into his
identity while he was doing this however
he was not having delusions he was fully
aware that he did not have any
connection with those famous people so
essentially he constructed a grandiose
self with all these wonderful and
amazing traits of people that he
respected an unrealistic self-image
London in his mind probably approximated
perfection the difficulty for Stephen
was that he could not maintain this view
of his high self-importance every now
and then he would become doubtful about
how important he was he would start to
believe that he was not really popular
and this would lead to feelings of self
hate and low self esteem
even though Stephen was not delusional
he did demonstrate a profound lack of
insight he didn't realize how other
people were viewing him even though he
was behaving in a polite and even gentle
manner some of the time the other
patients and staff members saw right
through him they were unable to have
meaningful interactions with him so we
really see how in his narcissistic
grandiosity Stephen becomes more
disconnected from other people more
isolated necessitating a movement to
even a higher level of grandiosity and
fantasy in order to maintain his
self-esteem there is no external
validation of his behavior like for
other people it all has to come from
inside it's now specifically looking at
Stephens response to treatment while in
the facility so Stephen maintained an
attitude of distrust and stubbornness
with his therapist which came more
pronounced when he was being confronted
about his bad behavior it was clear that
Stephen was highly intelligent able to
solve complex problems and think in
terms of abstraction so I'm picturing
somebody really high and openness to
experience he wanted acknowledgement
from his therapist regarding his
perfection and interestingly the
therapist kind of gave into this a
little as part of the psychoanalytic
strategy it
was done in order to create a safe
environment where Stephen could trust
this is a little bit controversial in
terms of therapy in general but I can
see how it's consistent again with
psychoanalytic thought Stephen
frequently lost his temper in session he
was verbally abusive and he would return
to his cynical attitude very quickly
Stephen was very sensitive to what he
viewed as empathic failures this is when
he believed the therapist wasn't
understanding his point of view but as
the therapy progressed he learned that
the therapist was in fact empathizing
and this helps Stephen to develop more
insight eventually the therapist was
able to explore traumatic memories of
parental rejection and neglect believed
to be ideological to Stephens narcissism
meaning the parental rejection neglect
were thought to cause Stephens
narcissistic personality Stephen
recounted one particular time when he
returned home from school early one day
to discover another man was with his
mother she was having an affair Stephen
was only nine years old at the time and
he made an effort to be close to his
mother and she rejected him with a
cynical gesture he recounted that this
was one of the worst memories of his
life as therapy progressed Stephen
started to realize how he was thinking
of other people as either inferior or
superior this is actually pretty common
with narcissism usually there are a
large number of people that the
narcissist views is inferior and a small
number they view as superior he also
started to frame his deviant behavior as
an attempt at revenge at his parents he
could never be good enough for them he
viewed himself as an undesired child
Stephen was particularly envious of
other people who lived a comfortable
life were socially and financially
successful and were able to meet their
goals without manipulating people or
lying to people this is actually a
remarkable level of insight for somebody
with comorbid NPD and ASP D Stephen
understood that he didn't have the
social skills to be successful in lawful
careers and he was frustrated that he
didn't obtain a higher educational level
the therapist put together a pro
him and which Steven would complete high
school which he did quite rapidly and
then he would attend University classes
for three to four days a week and study
art history he lived on the campus for
those days on the university campus
although of course he was still
considered to be incarcerated this is
much different than what we would see in
the United States for example right a
person who is essentially a prisoner
being allowed to leave for half the week
and attend University classes at the
same time Steven was in a program that
was designed to improve his relational
skills Steven really struggle with this
part he was exceptionally intelligent
and he did well at the University but he
maintained a high level of skepticism
regarding his professors and classmates
my guess would be that he was also
condescending toward them he was looking
down on them due to his superior
academic performance he started to
receive positive attention from his
professors and classmates he experienced
this initially as narcissistic
gratification so really we see that
there was a risk taken here in terms of
his treatment the therapists knew he
would perform well academically and
would receive this positive attention
and then you see this kind of feeds the
narcissism however eventually he started
to experience this attention as the
foundation for trust not long after this
he was able to process constructive
criticism from other people he earned
his doctorate within three years and
graduated with honors Stephen had
finally earned legitimate success and
then he recognized how destructive his
narcissistic behavior was he began to
develop a contempt for his narcissistic
self he viewed that entity that part of
him as undesirable disturbing & Moring
not surprisingly he was still unhappy
about being incarcerated he viewed this
as an attempt to control him and violate
his privacy this wouldn't be a problem
for long because shortly after this he
was released he served a total of seven
years he never really occurred to the
case report he remained symptom free he
eventually became a recognized scholar
so a few thoughts on this case as I was
reading this case report and seeing all
these adjustments that Steven made
throughout the years two steps forward
and one step back it was easy to put
this together with his extremely high
level of intelligence and think he
basically just played everybody in this
facility so he could get a PhD in art
history and get released from custody
now that's the cynical side of this case
analysis it's difficult to believe
somebody could actually have the level
of narcissism that he had and go to
being symptom free which again is what
the case report specified it didn't say
he had some symptoms from time to time
and got into some trouble
it said symptom free that's a bold
proclamation to make when dealing with
somebody who started out with comorbid
NPD and a SPD perhaps the clinicians and
the staff at the facility saw what they
wanted to see it's impossible to know
for sure even still with my skepticism
duly noted
I'm inclined to believe that this case
report was for the most part accurate
this facility treated somebody with MPD
and a SPD and that person experienced a
substantial recovery I'm not convinced
he fully recovered but I think it's
plausible to believe that he did have
dramatic improvement and even with an
incomplete recovery this is an amazing
case I can understand why it was written
up and published the success rate with
comorbid MPD and a SPD is quite low the
case report may be wondering is the
treatment success rate so low because in
most countries someone who committed
these offences would never have been
given quality treatment or is it solo
because they don't tend to change those
are two theories that come to mind I
imagine it's really because of both I
think both of those contribute to the
low success rate what really impressed
me about this case report was the
commitment to help this individual to
face the grim prognosis and confront the
reality of harm that Steven caused and
yet still invest substantial therapeutic
talent to reform him a challenging case
by any definition at the same time
though the lack of punishment
for his crimes is a little worrisome yes
he served seven years but he also got to
live on a university campus for half the
week for three of those years even if
one were to look at his particular
circumstances and find this to be just
there would be the concern about what
type of deterrent this really offers
what's the message to other people who
are considering committing crimes like
this manipulate and deceive people steal
the equivalent of 27 million dollars
live the high life then spend seven
years in a treatment facility and earn a
PhD it doesn't really seem to add up
when insight from a therapeutic
perspective I had when looking at this
case was the idea of the direction of
anger we see that Stephen had a lot of
anger for other people but as he
recovered he pointed that anger inward
not in his entire self but rather just
at his narcissistic self again we see
these psychoanalytic conceptualization
prominent here so in a sense the
narcissistic Tennesse to experience
disgust and to have intense anger is
still seemingly useful in recovery as
long as that anger is directed at the
narcissistic part of one's identity so
those are my thoughts on this case
report looking at NPD and a SPD I know
whenever I talk about case studies
involving personality disorders 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