New Insights into Treating Narcissistic Personality Disorder

Research on narcissistic personality disorder (NPD) and the formulation of treatment techniques and treatments for NPD have markedly increased in recent years. Previously regarded as a somewhat “mystified” character disease, periodically deemed untreatable and mostly recognized for causing significant suffering in therapists attempting to treat affected people, we are now entering a more optimistic age. Motivated by a conference on Narcissistic Personality Disorder (NPD) held two years prior by the Borderline Personality Disorder Training Institute, now the Gunderson Personality Disorder Training Institute, led by Dr. Lois Choi-Kain at McLean Hospital and Harvard Medical School, I resolved to launch this Special Issue of the Journal of Personality Disorders, focused on pathological narcissism (PN) and NPD. The symposium was particularly beneficial as it sought to disseminate information on advancements in our comprehension and management of patients with PN or NPD. This is a significant advancement, since this spectrum of illnesses has often been generalized and briefly examined. Various factors have facilitated the progression of research and therapy for NPD. Narcissistic Personality Disorder (NPD) was retained in the 2013 revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) under Section II for personality disorders and was also incorporated in the Alternative Model for Personality Disorders (AMPD) in Section III (American Psychiatric Association, 2013). The amalgamation of dimensional and trait conceptualizations of Narcissistic Personality Disorder (NPD) has facilitated novel integrated diagnostic approaches, including both internal and interpersonal functioning. The AMPD includes variations in self-esteem, the interplay between self-esteem and emotion regulation, and diminished empathic capacity (rather than an absence of it) as key features in the diagnostic criteria for NPD. This methodology for identifying PN and NPD facilitates a more dynamic, participatory, and incremental comprehension of these individuals. It encourages more research into the developmental and neuropsychological foundations of PN and NPD, and primarily, it is enlightening and relevant to a wider and more personalized selection of therapy approaches. Secondly, evidence of pathological narcissism (PN) and narcissistic personality disorder (NPD) from research studies is increasingly derived from investigations including persons clinically diagnosed with NPD. This has led to a consolidation of Narcissistic Personality Disorder (NPD) characterized in psychiatric rather than social or personality psychology terms. Narcissism, an integral aspect of overall personality functioning, varies from healthy and exaggerated to pathological, including both high and low functioning Narcissistic Personality Disorder (NPD), along with extreme manifestations characterized by malignant or psychopathic traits. Furthermore, pathological disorders may also be influenced by other comorbidities. Thus, there is a growing ethical, scientific, and professional need to delineate the domain of PN and NPD as a mental disease in individuals who really contend with this condition and its potentially severe repercussions, and who also want or require therapy and transformation. Third, the increasing volume of neuroscientific research on Narcissistic Personality Disorder (NPD) and associated diseases might provide significant insights into the foundations of narcissistic pathology, particularly influencing patients’ interpersonal sensitivity, emotional regulation, and empathic functioning. Traditionally, the salient interpersonal characteristics of Narcissistic Personality Disorder (NPD) have led to judgments on these patients’ personality functioning that often overlook significant underlying variables such as deficiencies, emotional intolerance, hyper-vigilance, and control issues. All characteristics contribute to variable functioning in persons with PN or NPD, characterized by notable reactivity, insecurity, fragility, or avoidance under a facade of competence or continual self-aggrandizement. Likewise, these patients’ articulate cognitive and linguistic communication may starkly contrast with their internal, sometimes overpowering or incessant subjective sensations, which they may be reluctant or unable of expressing. All of these characteristics significantly impact the selection and formulation of therapeutic strategies. Fourth, several therapeutic modalities are now accessible for individuals with Narcissistic Personality Disorder (NPD), including modifications of evidence-based psychotherapies such as transference-focused psychotherapy and mentalization-based treatment, both originally designed for borderline personality disorder. Modifying the concepts of classic psychodynamic or psychoanalytically oriented psychotherapy to address the particular functioning and problems in the treatment of Narcissistic Personality Disorder (NPD) has proven very important. Moreover, there are notable initiatives to incorporate Narcissistic Personality Disorder (NPD) into treatment modalities for personality disorders, such as schema-focused therapy (Behary & Dieckmann, 2011), metacognitive therapy (Dimaggio & Attina, 2012), and clarification-oriented psychotherapy (Sachse, 2019); each encompasses strategies specifically designed for NPD. This finding is highly promising, particularly as it offers chances to examine and comprehend both long-term and profound interpersonal and internal subjective patterns in patients with substantial PN or NPD throughout therapy. This also allows for the inclusion of developmental factors such as attachment styles, temperament, psychological trauma, impaired emotional regulation, and role assignments, all of which can influence the functioning of narcissistic personality, characterized by distinct interpersonal and self-regulatory patterns. They together provide the basis for assessing and modifying treatment techniques and treatments that concentrate on the distinct characteristics of narcissistic personality functioning. The authors of the ten papers in this Special Issue have each, in diverse ways, examined and discussed one or more of the four significant advancements in the study and treatment of PN and NPD. Specifically, it is essential to reconcile these patients’ internal processing with their interpersonal relational functioning to enhance our comprehension and formulate treatment strategies that can tackle the impediments and foster conditions conducive to change in narcissistic personality functioning. The first publication, authored by Lee and associates, delivers a pertinent and significant investigation into oxidative stress, revealing an increase in the oxidized variant of guanine, 8-OH-DG, in NPD, a biomarker indicative of oxidative stress load associated with interpersonal hypersensitivity. This finding in borderline personality disorder (BPD) indicates a physiological connection between narcissistic personality disorder (NPD) and BPD. These results need more investigation and comprehension of the effects of medical health issues, particularly life-related stresses that pose distinct challenges for NPD. The second paper, authored by Fjermestad-Noll and associates, corroborates the simultaneous presence of self-oriented and socially dictated perfectionism, shame, and violence in individuals diagnosed with Narcissistic Personality Disorder and associated depression. The findings challenge some prior hypotheses and observations on the mediation and moderation of this trajectory, namely the interactive co-occurrence of shame-based violence in Narcissistic Personality Disorder (NPD). Thus, the research emphasizes the distinction between using trait-focused assessments alone and evaluating characteristics with the participants’ engagement in demanding task-oriented scenarios. The following three articles examine particular challenges in the identification and treatment of individuals with NPD. Tanzilli and Gualco examined therapists’ reactions, namely countertransference, and its effect on the therapeutic alliance in the treatment of three subgroups of teenage Narcissistic Personality Disorder patients: grandiose, fragile, and high-functioning/exhibitionistic. This research highlights the spectrum of interpersonal dynamics between patients and their physicians, together with the concurrent quality of the therapeutic alliance at that time. The findings underscore the significance of addressing the alliance and connection between patient and therapist, as well as customizing therapies according to the particular patient’s distinct NPD subtypes and narcissistic behaviors. Maillard and colleagues elucidated the transformative process in clarification-oriented psychotherapy (COP) for narcissistic personality disorder (NPD), a pertinent subject considering the need for evidence-based techniques and targeted therapies that also include the therapist’s evaluation and comprehension. Modifications in content, procedure, and relationships among patients were assessed. Patients exhibited enhancements in the importance of content and the quality of interactions, and a decrease in avoidance behaviors. Furthermore, the therapists’ focus on the patients’ internalized representations and associated emotions shown in interpersonal relationships facilitated symptom alleviation. The early comprehension of patients’ issues by therapists may facilitate the selection of solutions. Ronningstam’s paper examines the cognitive, emotional, and relational internal processing of individuals with Narcissistic Personality Disorder (NPD), which affects narcissistic functioning, including self-regulation, reactivity, and awareness of oneself and others. Factors such as temperament, attachment, internalized object connections, and neuropsychological elements of emotional and interpersonal processing strongly influence the exterior manifestations of PN and NPD, particularly evident in interpersonal interactions and relationships. Empirical study findings are reviewed, integrating the relationship between internal processing components, external aspects, and dimensions with therapeutic treatments and techniques. Caligor and Stern examine the diagnostic assessment of Narcissistic Personality Disorder (NPD), integrating the clinical characteristics delineated in the Object Relations Theory (ORT) model with the diagnostic dimensional criteria for NPD presented in the DSM-5 Section III Alternative Model for Personality Disorders (AMPD). They delineate a categorization model for personality organization including fundamental structural characteristics. This initiative is both urgent and significant, addressing the need for a comprehensive diagnostic methodology for Narcissistic Personality Disorder (NPD) rather than a trait-centric paradigm. It involves assessing the pathological grandiose self-structure and levels of personality functioning across varying degrees of severity. The following articles concentrate on the treatment of Narcissistic Personality Disorder (NPD). Weinberg and Ronningstam propose a pragmatic, change-oriented treatment strategy for Narcissistic Personality Disorder (NPD), based on research and clinical experience, which delineates many successful ways to enhance the patient’s feeling of agency and drive for change. The recommendations delineate certain prevalent poor strategies and therapies for Narcissistic Personality Disorder (NPD) that often lead to impasses, ruptures in alliances, and conflicts resulting in abrupt cessation of treatment. Strategies are delineated for facilitating patient transformation, the Dos, and for mitigating barriers and prevalent errors, the Don’ts, in the management of NPD. Crisp and Gabbard examine psychodynamic therapies tailored to the distinct characterological traits and functioning in Narcissistic Personality Disorder (NPD). The authors emphatically support the need to customize psychotherapy for patients with NPD, rather than conforming to broad psychodynamic concepts or standardized approaches. They advocate for a positive strategy towards patients’ resistance, emphasizing the importance of their delicate self-esteem and integrated symptoms, while maintaining flexibility and sensitivity to patients’ self-centeredness and aversion to transference interpretations. The following two articles outline modifications to the NPD of evidence-based and empirically proven psychotherapies first designed for BPD. Diamond and Hersh delineate the adaptation of transference-focused psychotherapy (TFP) for individuals exhibiting narcissistic personality disorder (NPD) or narcissistic features (TFP-N). This modified modality emphasizes transference by examining the interpersonal dynamics between therapist and patient in the present moment to uncover internalized and dissociated object-relation dyads, particularly with grandiosity and vulnerability. Following an initial contracting phase, the predominant self-object-affect dyads, together with their variations and protective roles, are discerned. The subsequent phase examines the developmental roots of these patterns and their role in pathological narcissistic functioning. In the paper by Drozek and Unruh, mentalization-based therapy (MBT), first designed for borderline personality disorder (BPD), has been modified to address pathological narcissism, referred to as MBT for PN. Research on parenting methods and corresponding attachment patterns in children has shown limited mentalization in parental figures, particularly for affective aspects. The authors delineate MBT tactics particularly relevant for PN, namely, empathetic validation, elucidation of tough living circumstances, and examination of emotions, including both the patient’s own feelings and their views of others. Interventions and tactics specifically tailored to distinct PN patterns are delineated. Comprehending the mental states of oneself and others has been shown to provide functional enhancements. Three commenters, influenced by these publications, have each offered distinct interpretations. Pincus emphasizes the intricate character of narcissistic disorder and the need of acknowledging the many dynamics and manifestations in self and interpersonal functioning. Huprich emphasizes critical differences between susceptible narcissistic and depressed personality disorders, which may be easily neglected in diagnosis and therapy. Choi-Kain employs general psychiatric management (GPM) for Narcissistic Personality Disorder (NPD), a method first designed for Borderline Personality Disorder (BPD), and emphasizes the need for a pragmatic strategy for NPD applicable by clinicians across various treatment environments. This Special Issue’s collection of papers highlights recent substantial advancements in the research and treatment of PN and NPD, alongside continued attempts to recognize and include the inherent complexity and diversity of opinions about this pathological character functioning. This is an ongoing endeavor aimed at establishing more robust criteria for the identification, comprehension, and treatment of persons afflicted by this disorder.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Behary, W. T., & Dieckman, E. (2011). Schema therapy for narcissism: The art of empathic confrontation, limit-setting, and leverage. In W. K. Campbell & J. D. Miller (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments (pp. 445–456). Hoboken, NJ: John Wiley & Sons.

Dimaggio, G., & Attina, G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of Clinical Psychology: In Session, 68(8), 922–934.

Sachse, R. (2019). Personality disorders: A clarification-oriented psychotherapy treatment model. Gottingen, Germany: Hogrefe.