JANILEE:  Welcome, friends. You found just Janilee at the corner of Am I crazy? And no, you're not. Here's the science to prove it! These are miniature episodes that will be coming out once a week in between our main episodes where we talk with Larissa. Now, in these mini episodes, I like to dive deep into the nitty gritty of what actually the science articles are saying. In the main episodes, I often reference that I've done a lot of research and that I've found things, and here's some science that I've learned. And the reason that we have these conversations with Larissa is because it gives us more of an experiential applicable way to understand and process what we've been through. But when I was conceptualizing this podcast, I didn't want to alienate anyone with getting too detailed about the science. But I also wanted to get nerdy about the science. So this is the compromise I came up with. Once a week we talk with Larissa, and then once a week, it's just me nerding out to myself. I mean, my dog is listening, so maybe my dog is appreciating the nerdiness. But I just dive into the science and I like it, and it makes me happy.

A couple of things I just wanted to touch on. Because this is our first episode, I wanted to just briefly cover the types of articles that I look for and what qualifies a good research study. In the worldview of JJ, of Just Janilee, there's a couple of different types of studies that can happen:

big ones,

small ones,

ones that are really specific,

ones that are more broad.

There's also studies where people will study a whole bunch of different studies and then put together what conclusions they found. Like, oh, this same thing was mentioned in four other studies that other people did. We'll go through different studies as we come across them. I don't want to overload you with too much information at the start, but the biggest factor that's important is peer reviewed. Now, peer reviewed is essentially scientific. Peers of the same fields of expertise will perform the same study with the same parameters and see if they come up with the same result.

A second thing I look for is multiple authors. I know that sometimes when we hear authors, at least, I always think of books. And usually the more authors involved in a book, the weirder and more disjointed the story is, especially if it's fiction. But we're dealing strictly nonfiction, which is non fake. That's how I remembered it when I was a kid. Fiction is fake. Nonfiction is non fake. So when we're dealing with real world science, we want multiple authors, and it helps kind of control any sort of bias that might creep its way into an actual study. The reason these things are important is sometimes studies will happen, and they'll be funded by people with ulterior motives who want to see a certain outcome to help support their personal view on things or to help sell certain products. And by having a peer reviewed study, you filter out a lot of those.

A reference that I use a lot. I guess reference isn't the right word, but a resource I use to find these different articles is. I love the NIH. If something is put out by the NIH, I pretty much trust it. I still check for the multiple authors and peer reviewed stuff, but NIH is really good at monitoring their own stuff. NIH, for those who don't know, stands for National Institute of Health and is based in the United States. Now, NIH has something called PMC, which stands for PubMed Central. They have this explanation on their website, which is, it's a free, full text archive of biomedical and life science sciences journal literature at the US National Institutes of Health, the National Library of Medicine. PMC is the library of NIH. Boom. That's it a lot of fancy words, but that's all it means, I swear. That's a really good place to look if you wanted to do any research on your own. They have a lot of really cool stuff. If you get really nerdy into things like I do, you might end up with your own personal library of articles on stuff. I have my own personal library.

One of the most unique articles I have in there because I just went down a rabbit hole one day. It talks about the biological difference between the difference in the chemical makeup of tears that humans cry when they are emotional versus tears that are cried because of yawns or because something stuck in your eye. So non emotional tears, it's really specific, doesn't really apply to anything, but I find it cool. So if you can handle reading a bunch of sciency words, go for it. A brand new world is open to you. Explore your curiosities. It's going to be fun for here. Now, we're talking about things that relate to conversations that happen in the main episodes.

This current first episode is episode 1.5, so it's coming out between episodes one and two. Now, in episode one, we talked about, am I a narcissist? And so in this episode, we're going to talk about NPD, narcissistic Personality Disorder. Now, for someone to be actually diagnosed with NPD, they actually have to have met with a licensed clinical psychologist. Now, how do we prevent one clinical psychologist from and another one from not diagnosing? I mean, no system is perfect, but there is a resource that is called the DSM.

DSM stands for a Diagnostic and Statistical Manual. This is basically a dictionary of mental disorders and it's used. A lot by, like, everyone. Later on, we are going to go through the criteria listed in the DSM for someone to be diagnosed with NPD. But I wanted to start today with a case study on two individuals who received actual diagnoses of NPD. So a case study. Remember, there's a lot of different types of studies and articles and everything. The case study is an in depth look at person in a real life environment.

So the case study that I'm using today is called Narcissistic Personality Disorder in Clinical Health Psychology Practice Case study of Comorbid, Psychological Distress and Life Limiting Illnesses.

A lot of words. I want to break it down. Okay, so narcissistic personality disorder we talked about in relation to clinical health psychology. Clinical Health Psychology Practice is when people have physical ailments and they need help processing what they're going through. There are psychologists that come in and help them. Case studies we just went over of comorbidy. Comorbidy is a fancy sciencey word way of saying simultaneous genius. More than one thing happening at once. The things happening at once in this title are psychological distress and life-limiting illnesses. So this particular study covers two patients. They're referred to as Mr. X and Mrs. Y. So anonymity is totally still there, and they both have life-limiting illnesses, and they have some psychological distress because of it. Now as they've interacted with these psychologists that come in. These psychologists have been like, “Yeah, no, you got, you definitely have NPD.” How did they come to these conclusions? That is what we are introduced to. So I'm going to be spending the majority of my time in this particular case study in the method section because I feel like it really helps paint a picture of what actually happened. And that relates more to the conversation that Larissa and I had earlier this week in the main episode. A couple of things I want to touch on in the introduction section first.

Okay, side note really quick, if you wanted to follow along, all of these are going to be noted on our website. So go to vilifiedpod.com and in the upper right hand corner there will be main episodes and JJ episodes. JJ stands for just Janilee. So click on Just Janilee because it's me, Larissa is not here. And go down to 1.5 because this is the first one, right? And at the top it will have a player with audio embedded so that you can just listen on that one web page if you don't want to use a podcast app. And then there will be a transcript where everything I'm saying is typed out. And then at the very bottom in a blue section, it will say Show Notes. Now the Show Notes will have everything listed and linked. So you see the title of the article, you want to click on it. Boom. You click on it and you're out of it, pulling up in a new window and you're following right along.

Okay, cool. Now that you have it open, introduction, it talks about a couple of things. It talks about NPD, it defines it according to the DSM, and it talks about kind of how prevalent it is, right? So a fun fact is that NPD like the prevalence of how common or rare it is. It ranges from about zero to 6.2% in community samples. And I'm not going to lie, when I read this, I was like, Yo, that seems low. And it probably is because remember, it has to be diagnosed by a licensed clinician for it to be a personality disorder. There's narcissistic traits and there are emotionally immature traits. And we talked a little bit about it this week and we're going to talk more about it next week and it comes up often. So hopefully as you keep listening, you'll get a better idea of the differences of the nuances there. But for an actual clinical diagnosis, it doesn't really surprise me that this particular diagnosis is so low because narcissistic tendencies don't tend to lead to seeking professional, licensed help. If we keep going through the introduction, it talks about how there's NPD and how it has caused certain side effects. And I wrote in this margin of my notes here NPD leads to these effects. It's not the other way around. So some of the effects it lists are like: multiple suicide attempts, lethal means to suicide attempts, making suicide attempts in proximal relationship to being fired or experiencing domestic financial or health related problems. So in relating to things having gone wrong. And so remember as well the bottom of that same paragraph. Like these people have like criminal they're more likely to have criminal convictions, time spent in prison, history of interpersonal violence, which is violence not just to themselves and cause pain or suffering to others.

Right? All of these things I just really felt it was important for myself to keep my mind straight, that I was understanding what this was is that these are things that are caused by NPD. And it doesn't mean that these things mean you have NPD. It works one way and one way only people who have NPD statistically have these other things. But just because you have these other things doesn't mean you have NPD. Just remembering that it flows in that one direction. So in terms of treatment, that's the paragraph I'm on right now. It talks about basically this is how we're planning on treating these patients as we see them. So it sets up what they're wanting to do. Near the end of this paragraph there's this line these authors highlight the core feature of narcissism: {they} struggle to form intimate relationships as a significant barrier to positive treatment outcome. Due to the patient's potential inability to form a safe and trusting relationship with the therapist. I found that phrase “Struggle to form intimate relationships” pretty telling. And it made me a little curious. “How do we quantify what causes a person to struggle with that?” And it gets into it, so we'll keep going through it.

One method of treatment as well is written here. It's called the Frames technique, which stands for feedback, responsibility, advice, menu of strategies, empathy and self efficacy. So it basically is, “We're going to try and highlight these behaviors in all these different ways.” So hopefully this creates some sort of understanding. So under methods. Right. And remembering that we have two people, it's a small sample size, but we're going to get some really detailed information. I'm not going to keep going through this paragraph by paragraph. Otherwise these episodes would be the longest episodes that have ever existed. So, Breezing through the last part of this. Mr. X. Who is he? He's a middle aged Caucasian male who was referred to this clinic where these studies took place for treatment of depression because of a history of suicidality and involuntary psychiatric admission. So this guy basically was put in an institution against his will and has a history of depression, some suicide attempts, and lack of adherence to behavioral recommendations. Right? Now, remember, these are just the symptoms we still need to prove the actual diagnosis as NPD. So hold your judgments in reserve for a second. Okay, we keep going around. I love the fact that one of the first things mentioned about this person was their unique personality was appreciated immediately. And it was not until many months into treatment when behavioral patterns suggestive of a personality disorder emerged. So even with all of these symptoms, right, and the reason that they were referred to this clinic, blah, blah, blah, it wasn't until many months later that {they realized that} maybe something's off here. So it mentions here that the most salient features of NPD that interfered specifically with Mr. X and his treatment progress were: thoughts of grandiosity {or a} need for admiration or special treatment, and fantasies of unlimited power or importance. If you've ever heard the phrase Hindsight is 2020. I love these studies because they take care to note things as they go through. So now that we're many months into the treatment, we're considering that this guy has NPD and then, “Boom!”

We actually know what this dude talked about in the first episode because notes were taken. So in this very first session that he had, he was describing many illustrious mental health providers from whom he had received treatment. Right? So, okay, well, you're in psychotherapy. So what are your goals? I want to grow my religious faith and practice. Okay. What else? Explore lifelong questions regarding intimacy. Okay. Anything else? I would like to increase the size of my social network. No. I mean, I'm sure he didn't say it in those words because I haven't really met anyone who talks that way, but that's essentially what happened in that first episode. Episode is that first meeting with a psychiatrist.

Okay, so now we get to meet our second person that's involved in this case study, Ms. Y. So, Ms. Y: another middle aged Caucasian person, this time a female, who was referred by her oncologist for evaluation {regarding} managing the distress of being diagnosed with cancer. Okay, now, Ms. Y had received a cancer diagnosis and was like, “Nah,” and then went somewhere else and received a cancer diagnosis and was like, “Nah,” and went somewhere else and received a cancer diagnosis and was like, “Nah, I don't think so.” And she was told multiple times at multiple places that the longer you stay and these weren't the words used, but, "The longer you stay in denial about the fact that you have cancer, the less likely we're going to be able to do anything about it. Because the cancer is still growing inside of you, while you sit here seeking out an opinion, trying to find a doctor who's going to tell you it's not cancer.” So coming into this situation with this sort of reputation of even having a clinic that refused to treat her because of this history, so there's some other sort of histories that is found, like social histories, having a young child that she lost custody of, a lot of multiple ex boyfriends. So, like ex romantic relationships where they hadn't exactly been peaceful. The word used is, I believe, “Tumultuous.” Another interesting fact about Ms. Y, that I thought was interesting, was she sought to convince everyone that she knew what she was talking about because she had gone to school for medicine. An important aspect that upon further investigation from the people at this clinic, it was revealed that she actually had been dismissed from her graduate school training and had been barred from actually seeking a practitioner license. So, yes, yes, she attended med school. But she was kicked out of her school and barred from ever getting a license. So again, another thing.

Whereas Mr. X we had to kind of see over time. Maybe it's NPD, maybe it's not.

For Ms. Y from the very beginning, from her intake into the clinic, she called everyone incompetent. She insisted that she would only see the most important person: the attending. Right? Once the attending was in the room, she was like, “I've been treated so badly. I've been victimized.” Some of the other things listed that helped these clinicians know that NPD was a very real possibility included: volatility, a lot of demands for special treatment, disdain for others, a lot of emotional experiences, but no empathy at all. And this is something that I honestly hadn't considered. As a term, at least until I read this, but a lot of hypersensitivity, right? Of course, looking back on a lot of things I've said and a lot of things I've experienced with narcissists, “Yeah, they're really sensitive,” but I never actually thought about it in terms of that being a requirement for an actual clinical diagnosis. So I thought that was a cool thing. One other thing mentioned about Mr. X here near the end, right before we get into the results, and I'm going to actually read this one as an exact quote:

“As an aside, Mr. X demonstrated similar tendencies towards paranoia in terms of presuming that even subtle changes within the dynamics of existing within the dynamics of existing interpersonal relationships were indicative of negative underlying motivations on the part of others for both patients. (So, Mr. X and Ms. Y.) This resulted in volatile relationships and personal medical contexts.” So an know that we talked about this in the general episode, but you do something that this narcissist doesn't like, it's because you're out to get them, right? Remember the fox and the churchickens and all of that stuff? So yeah, I was not surprised to see that in here.

Okay, so now that we're getting to a little bit of the results and how this went, I'm just going to cover the sum up of what these results are. But if you wanted to, again, find this article and read it yourself, it goes into specific situations about okay, so, for example, one thing is low distress tolerance, right? And so with this low stress tolerance, it talks about how Mr. X demonstrated it and how Ms. Y demonstrated it, right. And it goes through the rest of those throughout the rest of the article. So if you're interested in more of the details, definitely look it up yourself. But there were two things that they found, two crucial aspects of NPD. The first was how it manifests within psychotherapy and healthcare settings, right? So not what we generally think of when we hear therapy, but with this physical ailment as well.

And the second thing that they discovered about NPD were specific ways in which these cognitive behavioral patterns interfere with both the medical and the psychological treatment. So having how NPD impacted. Negatively impacted their ability to treat the patients both psychologically and physically. So how NPD manifests in this field? So there's a lot of superlative self talk, self aggrandizement expectations of special treatment, poor behavioral health adherence and difficult relationships with providers, and low distress tolerance. And again, this is within the context of it helps me to imagine like an actual hospital where you'd be in a hospital bed because that's where a lot of people with physical ailments end up. And how were these behaviors actually negatively impacting their ability to be helped by others? Poor boundaries with the therapist, ambivalence about change associated with fragile self esteem, cognitive distortions, (so for example, black and white thinking and help rejecting behaviors), and then this other last quote “An additional barrier to treatment progress underlying each of the above issues resulted from both patients tendency towards hypersensitivity and paranoia in therapy and in their everyday lives. Both patients experienced interpersonal instability due to perceived insults and injuries of varying seriousness, which emphasize content that is clearly tied to core beliefs associated with the narcissistic pathology.” And again, that was a bunch of fancy words, but it basically is: that hypersensitivity aspect that I mentioned before. Clearly that hypersensitivity aspect stood out to me when I was reading it through this time. Okay? And then as I mentioned, if you go through it talks about the low distress tolerance and the poor boundaries and ambivalence to change and help rejecting behaviors, cognitive distortions. It goes into more details about specifically how those things presented themselves.

And then at the end of this article, it has kind of a summary of results. And then there's a discussion where it basically is like, okay, so now that we've presented to you how this happened, here's what we think could change, whether it's in context of just the discussion questions that we have about it or how this could help us with treatment going forward. Ahead. All right, so we're getting to the end of this episode. There's a couple of different articles that I was reading through and referencing. I chose to go through this case study, one here on the podcast, but I'll reference a couple of others that you can go through on your own. If these end up becoming popular, I might make them longer, but I want to make them manageable, for now at least, it okay. So the reason I wanted to start with the case study rather than the DSM is because of the conclusion of this paper. So, the conclusion I find interesting. I'm just going to read from the paper now.

“The diagnostic framework used to explore pathological narcissism in the above cases was organized according to the DSM 5 criteria. These criteria were developed with an underlying assumption that personality disorders can be characterized into independent clusters and independent clinical syndromes. Recent consideration has been given to an alternative model working under the assumption that personality disorders have significant clinical overlap. The dimensional approach argues that pathological personality features may represent a wide range of fluid presentations that begin with the normal personality function. So this alternative model is explicit in an appendix to the DSM 5 and describes the ways in which personality function may vary between individuals on four dimensions identity: self direction, empathy, and intimacy. Additionally, further consideration is made regarding the personality function on a five dimensional scale negative: affectivity, detachment, antagonism, disinhibition and psychoticism. The exploration of these dimensional scales may allow clinicians to conceptualize patients in a way that they are able to work around limitations in categorical diagnostic criteria in order to improve the likelihood of symptom reduction and improved quality of life.”

Okay, I literally just read that entire paragraph, and so if you have the article up, you probably were following along. Why did I read the entire thing? Because, honestly, I don't think I could have said it better. But this was my reason for going over the case study first. What this article is saying, “We conducted these studies based on the DSM 5 criteria, and DSM 5 is the current DSM.” But what if there was a better way to categorize this in a way that helps people better? So I thought it would be a really cool idea to end this episode of the podcast by comparing the DSM definition for NPD. And there is a table at the end of this paper, this study, that talks about core NPD features. So I thought it'd be interesting to compare the two and kind of see how they line up. And I'm curious what other people think. There's a reason I nerd out about this, and it does involve learning about things from other people's perspective.

Let's start with the DSM 5:

Grandiosity and self importance

Persistent fantasies of: success, power, attractiveness, intellectual superiority or ideal love

Sense of superiority and specialness

Wish to be admired,

Strong sense of entitlement

Manipulates and exploits others

Lack of empathy

Believes others are envious of him, her, and envy of others.

Arrogant and contemptuous attitudes and behaviors.

Now, if we turn our attention to the table that's found in this case study, there are two specific features listed in the DSM that are referenced in this table. The first one is: the grandiosity and self aggrandizement.

And the second one is the need for admiration or special treatment.

Okay, so these things are what caused these treatment challenges that were talked about and again, that are gone into in greater detail. Right? Poor boundaries. Ambivalence about change. Cognitive distortions. So in this table, we can kind of see more specifically with these examples, right? So let's just take one. So let's start with the top one. Poor boundaries. Mr. X’s excessive calls asking for extra time during session, requesting personal information about the therapist, disregarding professional guidelines for interaction with the therapist. And Ms. Y’s discussions about inappropriate topics with medical providers, engaging in sexual relationships with inappropriate individuals involved in her care, expressing racist attitudes towards her therapist. Right? These things that, if we think about it, it does prevent these healthcare providers from providing good health care to these people who are treating them so badly.

Okay, so I hope that this has been helpful or at the very least, interesting to hear. I'm going to be referencing or linking two other documents in the show notes to this episode. One is just going to be there's, the American Journal of Psychiatry, and it has this narcissistic personality disorder challenges, and it kind of goes through it's more of like the layman's terms, so it's a little less technical. And then another one: this one is an article that's found in this one is an article from the BJ Psych Advances that was published by Cambridge University Press. And I like this one too, because it goes into the history, right? And this is something that Larissa brought up in our main episode about the legend of narcissus in Greek mythology, right? It also talks about how people have perceived narcissism in historical context. It does reference the DSM as well. It talks about how it is important to have that licensed clinician being the one doing the diagnosis. It talks about challenges in the treatment in people who have the diagnosis. It. It talks about the epidemiology, about this diagnosis, right? It goes into some pretty good detail about just the diagnosis in general, right? So if you wanted to just understand the diagnosis from a little bit of a less specific example, but a more broad understanding of how the diagnosis functions and how it can be applied to different people in different circumstances, this is another good one for that.

This has been fun for me to explain to my dog, all of these fun, these fun things that I've learned about Narcissism. So I hope that it has been enjoyable to you as well. Tune in with us next Monday, Larissa will be back, so it won't just be me and we'll chat, it'll be fun. Hope to see you there and remember friends: as you go through your life, that this life, you're doing your best and if you end up being Vilified, you're in great company. And again, you can also come join Vilified Pod on all of the social medias. You can come to our website, we even have a Patreon if you wanted to message directly with me or Larissa. Just lots of things that are there for us to do what we can to help you. So this has been just Janilee and I am signing off. See you next week on Vilified.