Inquiétudes excessives et personnalité narcissique : étude de cas

Within the context of psychological assessment, the use of diagnostic tools such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) is common practice. Without denying the usefulness of such descriptive reference tools, cognitive-behavioural assessment acknowledges their evaluative limit. Specifically, a thorough cognitive-behavioural assessment also includes a functional analysis that takes into account the cognitive, behavioural and emotional characteristics of the person, as well as the factors that explain their presence and maintenance. The present case study supports this comprehensive approach by highlighting the fact that the patient's symptoms do not necessarily reflect the fundamental nature of his difficulties and suffering. This case study presents the assessment and treatment of a 42-year-old patient who initially appeared to suffer from generalized anxiety disorder (GAD). Indeed, the patient reported a long history of excessive worry and anxiety about a number of events and activities such as school performance, finances, meeting the expectations of others, punctuality and other minor matters. Three standardized self-report questionnaires were used to assess the patient's main symptoms, and these produced scores that were consistent with a diagnosis of GAD. During the first part of therapy (i.e. the first six sessions), the first modules of a GAD treatment protocol developed by Dugas and Ladouceur (2000) were used to treat the patient. The main goal of this modular treatment is to help patients with GAD develop greater tolerance for uncertainty in their everyday life. This is primarily accomplished by using strategies such as role-play, behavioural experiments, problem-solving training, and cognitive exposure. However, after six weeks of treatment, new information regarding the patient's distress came into light and led us to question our initial diagnostic impression. Specifically, two clinical observations supported the relevance of reconsidering our conceptualization of the patient's difficulties: (1) the relative lack of concern for the welfare and happiness of others (absence of “empathetic” concerns); and (2) the presence of several behaviours that were incompatible with the notion of intolerance of uncertainty as it is typically seen in GAD. In addition, the presence of narcissistic personality traits was becoming more and more obvious with each therapy session, suggesting that what initially looked like GAD worry was in fact the result of narcissistic preoccupations. Consequently, despite the fact that the patient met DSM-5 diagnostic criteria for GAD, his problematic personality traits and rigid worldview appeared to be at the root of his anxiety. The treatment was therefore reoriented to target his narcissistic traits and preoccupations. The goal of therapy was shifted to helping the patient become more aware of his rigid belief system, his problematic behavioural patterns, and the negative impact of these beliefs and behaviours on the attainment of his personal and professional objectives. Following the reorientation of treatment, the patient felt that we were definitely addressing the root cause of his distress. He also significantly benefited from this new therapeutic direction. This case study highlights the importance of conducting a personalized functional analysis to clearly identify the processes underlying the patient's difficulties, and thereby effectively guide treatment. Our case study also underscores the importance of pursuing the assessment of the patient's difficulties throughout treatment, of remaining flexible in the case conceptualization in the light of new evidence, and of adjusting the therapy goals and procedures when needed.