An Analysis with a Latency-Age Girl with Posttraumatic Stress Disorder Resulting in a Secondary Narcissistic Personality Disorder

I have always felt uncomfortable making use of Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) diagnoses in my work. I never felt that such labels were useful in helping me to understand and subsequently help my patient. However, when I began to see 7-year-old Karen, it quickly became evident that she fit the criteria for the diagnosis of posttraumatic stress disorder (PTSD) and a secondary narcissistic personality disorder. With the guidance of my supervisor, I began to better understand how a young child can present with such a complex diagnosis. As I came to comprehend and empathize with Karen's inner life and her problematical dynamics, I was able to attempt to reach behind her defense of grandiosity and her mean, nasty exterior to the traumatized child within. This article explores how psychoanalysis with a latency-age child who presented with PTSD and a narcissistic personality disorder was successful and how Karen's pathological narcissistic structure slowly receded in favor of a more age-appropriate narcissism, which in turn, allowed her to get back on track developmentally.

Kohut (1968) explained how the child's narcissistic balance is disturbed by inevitable limitations of maternal care:

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But the child attempts to save the original experience of perfection by assigning it on the one hand to a grandiose and exhibitionistic image of the self: the grandiose self, and, on the other hand, to an admired you: the idealized parent imago. (p. 86)

Kohut further described how under good-enough circumstances this grandiosity and exhibitionism and the idealized parent imago are gradually restrained and integrated into the adult personality. If the environment is not optimal and the child suffers severe narcissistic trauma, “then the grandiose self does not merge into relevant ego content but is retained in its unaltered form and strives for the fulfillment of its archaic aims” (Kohut, 1968, p. 87). If