The Dependent Self in Narcissistic Personality Disorder in Comparison to Dependent Personality Disorder: a Dialogical Analysis

Many manifestations of human dependency are adaptive, such as looking for proximity, care, and support when in distress, or establishing stable bonds in which others are perceived as a safe haven that can shield us against many difficulties and dangers. In spite of these adaptive manifestations, dependency can be maladaptive. Psychiatric classification has generally labelled dependency “Dependent Personality Disorder”, but empirical evidence supports the notion that maladaptive dependency symptoms are positively related to the majority of DSM-IV PDs from all three clusters. A disorder in which only a few thinkers have noted the presence of severe aspects of unhealthy dependency is Narcissistic Personality Disorder. This is completely lacking in the DSM description of the disorder. In this paper we highlight maladaptive dependency features in NPD and comparing them with unhealthy dependency in DPD. Our analysis will make use of diary and session fragments involving patients with severe manifestations of both NPD and DPD, and will be carried out within the framework of Dialogical Self Theory. Human beings have an innate need to establish and maintain dependency bonds, largely through the activation of the attachment system. This drives them during their life cycles to look for the protection and proximity of another, whom they look on as stronger and reassuring (Bowlby, 1988). Many manifestations of dependency are therefore adaptive, such as looking for proximity, care, and support when in distress, or establishing stable bonds in which others are perceived as a safe haven that can shield us against many difficulties and dangers. In spite of the adaptive value of relying on others, dependency can be maladaptive. Bornstein (2005) distinguishes between unhealthy and healthy dependency: the former characterized by intense, undermodulated strivings, exhibited without the necessary reflexive effort across a broad range of situations and the latter by strivings – even intense – exhibited selectively (i.e. in some contexts but not others) and flexibly (i.e. in situation-appropriate ways). Persons exhibit dependent behaviours because these are rewarded, were rewarded or – at least are perceived by them as likely to elicit rewards (Dollard & Miller, 1950). Cognitive models of pathological dependency focus on the ways in which AUTHORS’ NOTE. Please address all correspondence regarding this article to Giampaolo Salvatore, Centro di Terapia Metacognitiva Interpersonale, Piazza Martiri di Belfiore, 4, 00100 Roma, Italy. Email: [email protected] SALVATORE, CARCIONE, & DIMAGGIO 32 a style of thinking and processing information helps foster and maintain dependent behaviour. Over time persons develop internal working models of attachment (Bowlby, 1988), which are often cognitively and consciously represented, thus creating images such as self as ineffectual and weak facing a powerful and critical other. When schemas like this become generalised and suppress other representations such as self-as-aneffective-agent and other-as-a-supporter, a person can over-rely on dependency on others and generate dependency-fostering automatic thoughts, such as “I can’t handle this on my own” and “I’ll fall apart completely unless someone helps me” (Beck, 1976; Beck & Freeman, 1990). Bornstein (1992, 1993, 1996) described an interactionist model of unhealthy interpersonal dependency, according to which dependency consists of four primary components: cognitive, i.e. a perception of oneself as powerless and ineffectual and of others as powerful and potent; motivational or a strong desire for guidance, approval and support from others; affective, i.e. becoming anxious when required to function autonomously; and behavioural, displayed in the use of an array of relationship-facilitating self-presentation strategies to strengthen ties to others, such as ingratiation and supplication. Psychiatric classification has generally labelled dependency “Dependent Personality Disorder” (DPD; American Psychiatric Association, 2000), in which the fundamental dimension is a pervasive and excessive need to be taken care of, leading to submissive and clinging behaviour and fears of separation in a variety of contexts. This pattern provokes subjective suffering and interpersonal malfunctioning (Carcione & Conti, 2007). A more fine-grained analysis shows that many other personality disorders (PD) feature aspects of unhealthy dependency, with borderline, histrionic and avoidant being the most obvious examples and all of them co-occurring frequently with DPD. Moreover, empirical evidence supports the notion that other PDs do co-occur with DPD at high rates (Becker, Grilo, Edell & McGlashan, 2001; Blais, Hilsenroth, Castelbury, Fowler & Baity, 2001), and DPD symptoms are positively related to the majority of DSM-IV PDs from all three clusters (Barber & Morse,1994; Meyer, Pilkonis, Proietti, et al., 2001; Sinha & Watson, 2001; Bornstein, 2005). These data suggest not only that current DPD diagnostic categories lack discriminant validity (Bornstein, 1998) but also confirm Bowlby’s intuitions that dependency is a typical human functioning and malfunctioning dimension (Benjamin, 1996; Fernandez-Alvarez, 2000). A disorder in which only a few thinkers (Kohut, 1971, 1977) have noted the presence of severe aspects of unhealthy dependency is Narcissistic PD (NPD). This is completely lacking in the DSM description of the disorder (2000), which stresses the pervasiveness of grandiosity, need for admiration, lack of empathy, disdain and envy. Kernberg’s description contains similar features and pinpoints a grandiose and envious individual, prone to anger and seeking others’ attention and admiration (Kernberg, 1974, 1975). NPD sufferers are often seen as self-reliant, independent, unable to form attachment bonds and, at the end of the day, not needing others’ help when in distress.