Clinical experience involving the treatment of patients with severe narcissistic pathology suggests that this patient population is among the more treatment refractory within the personality disorder spectrum. Recent studies have suggested that patients with Narcissistic Personality Disorder (NPD) now encompass about 6.2% in community samples (Dhawan et al. 2010) and up to 35.7% of clinical populations (Zimmerman et al. 2005). There are also some indications that NPD is more prevalent among young adults in the U.S. (Stinson et al. 2008), and that narcissistic personality traits in the nonclinical young adult population are on the rise (Twenge & Campbell 2009). In addition numerous studies have shown a high degree of co-occurrence of NPD with other Axis II disorders, especially cluster B (borderline, anti-social, histrionic personality disorders), and Axis I disorders, particularly affective disorders (unipolar and bipolar depression), substance use disorders, anxiety disorders, and eating disorders (Fossati et al. 2000, Simonson & Simonson 2012, Zimmerman et al. 2005). Complicating the diagnostic picture is the fact that pathological narcissism spans a spectrum of pathology from neurotic to borderline levels of organization. Indeed, there has been increasing attention to conceptualizing narcissistic disorders as dimensional disorders with varying degrees of pathology of self and object relations, reflected in the current drafts of the DSM-5 (www.dsm-5.org; Bender et al. 2011). The high level of comorbidity along with increasing attention to the dimensional as well as categorical aspects of personality disorders suggest that narcissistic pathology may be a major factor across the personality disorder spectrum (Ronningstam, 2010, 2011).
The current DSM V proposal puts new emphasis on structures and mechanisms related to impairments of self and interpersonal relations in all personality disorders including NPD. Narcissistic disorders are thought to involve 1) Impairments in identity, characterized by a specific pattern or style of unrealistic self experiences, including particularly exaggerated self appraisals; grandiosity expressed either covertly or overtly (exaggerated sense of superiority or inferiority or shifts between the two); and, in some patients, an overreliance on others for shaping the patient’s sense of identity and self definition; 2) Impairments in interpersonal functioning, particularly the use of others for self esteem regulation; superficial, shallow relationships, lacking in empathy, and designed to fulfill the patient’s need for admiration, attention, and validation; and antagonism as opposed to agreeableness in relationships (shown to be associated with narcissistic personality disorder in DSM-5 field trials). Such difficulties in the regulation of aggression along with other impairments in self and interpersonal functioning for individuals with NPD stem from a particular configuration of self and object representations, the pathological grandiose self, which involves a condensation of ideal self, ideal other, and real self representations. Such a self structure excludes the possibility of engaging in relations in depth – there is a “dismantling” of relations with others because of chronic devaluing of others. Negative affects, particularly devalued aspects of self are split off, denied and projected onto others leading to antagonism towards others and an inner sense of emptiness. As Kernberg (1975) stated, “Pathological vicissitudes of aggression may determine the failure of such … an integration of object representations, with the subsequent development of pathological object relations and a pathological, grandiose self.” (p. 246)
Transference Focused Psychotheapy (TFP) is a psychodynamic approach to psychotherapy developed to treat patients with a range of personality disorders at different levels of severity, including individuals with NPD. Borderline and narcissistic personalities share core structural features, specifically, identity pathology, supported by the operation of “primitive” defensive strategies for the unconscious management of intolerable self-states and affects. The central focus of TFP is the identification and naming of maladaptive, distorted self representations, along with their complementary distorted object representations, in the service of interpreting and ultimately resolving the splitting and other primitive defensive operations which prevent a more realistic, integrated, differentiated assessment of self and others. Through the tracking of these self-object dyads in the patient’s internal world, and identifying the defensive processes which support them, through working with negative affects (antagonism) and the object relational dyads that fuel them, TFP constitutes an effective treatment for a spectrum of narcissistic disorders from low to high functioning, i.e., grandiose, vulnerable, malignant. In addition, since TFP emphasizes the identification with both self and object poles of the object relational dyads that comprise the internal world (e.g. grandiose self, devalued other; vulnerable self, idealized other), it is also effective in addressing the different phenotypic presentations, forms of expression, and/or fluctuating mental states from grandiose to vulnerable, from arrogant/entitled to depressed/depleted that may characterize narcissistic personality disturbances (Cain et al. 2011, PDM Task Force 2006).
Based on our clinical experience with and research data on patients with narcissistic personality disorders, we have developed modifications of Transference-Focused Psychotherapy (TFP) to treat patients with different levels of severity of narcissistic pathology (Diamond et al, 2011; Diamond et al. in press). These modifications focus around the centrality of the grandiose self, its central defensive role in psychological structure of the patient with NPD, and how best to address this rigid defensive system. Modifications to standard TFP technique at all stages of TFP include the following: 1) Modifications to the assessment and treatment contracting phase of TFP including a more prolonged and flexible phase of contract setting; 2) A more prolonged phase of inquiry-based interpretive efforts, i.e., those aspects of the interpretive process that focus on requesting clarification from the patient about his or her mental life rather than the more traditional delivery of interpretations by the therapist; and 3) the enumeration of several technical strategies that support the patient’s ability to tolerate the necessarily painful and threatening feelings (e.g., anxiety, rage, a sense of disorientation and/or annihilation) that accompany the more challenging aspects of interpretive work in a psychoanalytic psychotherapy with narcissistic patients. Our clinical formulations have been informed by our research on patients with co-morbid borderline and narcissistic disorders (NPD/BPD) from three international samples of BPD patients in Transference-Focused Psychotherapy. In brief our findings suggest that the NPD/BPD patients may be distinguished from BPD patients without NPD on a variety of clinical dimensions including: 1) a particular pattern of co-morbidity with other AXIS II disorders (histrionic, anti-social, schizoptypal and paranoid) and 2) distinctive internal working models of attachment (Diamond et al. in press). In brief, individuals with NPD/BPD are characterized by attachment representions including dismissing devaluation of attachment relationships, preoccupation with unresolved anger about early attachment experiences, often oscillating between these two contradictory states of mind with respect to attachment—which helps us to understand the fluctuations in narcissistic resistances and transferences that make these patients so challenging to treat. Our research and clinical findings have been presented in a number of publications and presentations that are available on our website. In addition, our faculty have been involved in training and teaching TFP for NPD internationally.
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Dhawan N, Kunik ME, Oldham J, Coverdale J (2010). Prevalence and treatment of narcissistic personality disorder in the community: a systematic review. Compr Psychiatry 51(4):333-339.
Diamond D, Yeomans F, Stern B, Levy K, Hörz S, Fisher-Kern M, Delaney J, Clarkin J (in press). Transference Focused Psychotherapy For Patients With Co-Morbid Narcissistic And Borderline Personality Disorder. Psychoanalytic Inquiry.
Diamond D, Yeomans FE, Levy K (2011). Psychodynamic Psychotherapy for Narcissistic Personality Disorder. In:
Campbell K, Miller J (eds.). The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatment. New York: Wiley, 423-433.
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Ronningstam E (2011). Narcissistic personality disorder in DSM V—In support of retaining a significant diagnosis. JPersonal Disord 25(2):248-259.
Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, Grant BF (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from theWave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 69(7):1033-1045.
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New York, USA
Diana Diamond, Ph.D., Barry Stern, Ph.D., Frank Yeomans, Ph.D., Weil Medical College of Cornell University, ddiamonda (at) gmail.com, bs2137 (at) columbia.edu, Fyeomans (at) nyc.rr.com