Personality Disorders: Theory, Research, and Treatment 2014, Vol. 5, No. 4, 419 – 421
© 2014 American Psychological Association 1949-2715/14/$12.00 http://dx.doi.org/10.1037/per0000093
INTRODUCTION
Introduction to the Special Series on “Narcissistic Personality Disorder—New Perspectives on Diagnosis and Treatment” This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Elsa Ronningstam, Guest Editor Harvard Medical School
The recent debate on the narcissistic personal disorder (NPD) diagnosis and its format in DSM-5 has spurred increased interest in improving our conceptualization and understanding of this most complex personality disorder. The dual diagnostic approach for personality disorders in DSM-5, the trait model in Section II and the proposed hybrid model combining dimensions and traits in Section III, opens a most valuable intersect for furthering studies and discussions about pathological narcissism and NPD. A move toward more clinically useful ways to identify and diagnose patients with NPD is now both timely and much needed. The applicability of the trait focused NPD diagnosis in clinical practice has been problematic. One of the prime difficulties involves identifying and communicating NPD traits and diagnosis in ways that bypass narcissistic patients’ combined guarded inflexibility, vulnerability, and hyper-reactivity. In addition, the strong judgmental social and societal preconceptions regarding narcissism and NPD tend to preclude more constructive and informative patient-clinician discussions. Another difficulty relates to the fact that narcissism ranges from healthy to pathological, including psychopathic and malignant features in its most severe forms. Sorting out the healthy, self-preserving aspects of narcissism from its pervasive or temporary pathological aspects can move the diagnostic process toward a more balanced understanding of self-regulation and functioning. Clinical strategies and conceptualizations are needed that can more accurately and meaningfully connect the narcissistic patients’ subjective experiences and descriptions of their problems with approved diagnostic features and formulations, as well as with treatment goals and techniques. Relating narcissism to such central aspects as reflective function/mentalization and attachment has indeed broadened our conceptualization of narcissistic personality functioning. Similarly, identifying empathy as a multifactorial capability instead of a trait that can be present or absent incorporates recent psychological and neuroscientific research and invites further explorations in diagnosis and treatment. Inclusion of self-agency as a foundation for self-regulation can help incorporate such important personality factors as goal setting, motivation, self-assessment, and direction, which also represents a major step forward. The proposed model for personality disorders, including NPD, outlined in DSM-5 Section III identifies problems in self and interpersonal functioning. Features for NPD include fluctuations in self-esteem regulation, with apparent difficulties in identity, self-direction, empathy and intimacy, as well as in traits describing antagonism (i.e., grandiosity and attention seeking; Skodol, Bender, Morey, 2014, pp. 422– 427). The first aim for this Special Series is to further the dimensional self-regulatory diagnostic approach for identifying NPD by integrating range of functioning, co-occurring grandiosity and vulnerability, compromised empathic ability, self-enhancing interpersonal strategies and relatedness, and overt and covert expressions of pathological narcissism. A second aim is to broaden the conceptualization of pathological narcissism by identifying it in terms of attachment and mentalization/reflective function. Such connection can provide a much needed link between narcissism and other more integrated theoretical models and frames of reference for personality functioning, especially those applied to borderline personality disorder (BPD). A comparison of co-occurring NPD with BPD to BPD only indicates that the combined NPD/BPD group displays dismissing and unclassifiable attachment style with deficits in reflective function (Diamond et al., 2014, pp. 428 – 433). This research can begin to explain the obvious resistance to alliance building and tendencies to drop out of patients with NPD, and guide the development of more effective treatment approaches for NPD.
Correspondence concerning this article should be addressed to Elsa Ronningstam, Harvard Medical School, McLean Hospital, AOPC Mailstop 109, 115 Mill Street, Belmont, MA 02478. E-mail: [email protected] 419
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
420
RONNINGSTAM
The third aim is to apply the combined dimensional and trait diagnostic approach to clinical practice, both diagnostic evaluation and treatment. To this end, Ronningstam (2014, pp. 434 – 438) outlines an exploratory collaborative diagnostic process that identifies both pathological and healthy features of narcissism, and attends to subjective experiences as well as to interpersonal functioning as indicators of narcissistic selfregulation and sense of agency. Linking the diagnostic process and case formulation closer to treatment objectives is essential. It is not uncommon that the NPD diagnosis can’t adequately address the essential or urgent issues of the patient seeking treatment. Sometimes the NPD diagnosis may even become an obstacle for alliance building, evoking the patient’s defensive or blaming attitudes. Treatment strategies that specifically focus on the complex phenotypic presentations can open new ways for building an alliance with the usually quite guarded and treatment reluctant patient with NPD. Attending to concomitant grandiose and vulnerable features, both of which can be either more or less obvious (sometimes provocatively obtrusive) or, alternatively, effectively concealed, can promote a more integrated approach to the treatment of pathological narcissism (Pincus, Cain, & Wright, 2014, pp. 439 – 443). A necessary focus for future studies is also to identify the factors and processes in treatment that can contribute to change in pathological narcissism and narcissistic personality functioning (see Kealy, Hadjipavlou, & Ogrodniczuk, 2014, pp. 444 – 445; Perry, 2014, pp. 446 – 447). The intercorrelation between internal/experiential and external/behavioral change and its interaction in narcissistic personality functioning remains a major area for further exploration and understanding. The phenotypic presentation of patients with NPD is often influenced by the co-occurrence of other mental conditions such as mood, substance use, or eating disorders that can contribute to underlying and not always obvious characterological manifestations and accompanying treatment resistance. Alternatively, narcissistic traits and self-regulation can be the sole predominant condition with persistent or intermittent overt expressions in specific contexts in which self-enhancement is enforced or self-esteem threatened. Whereas some people with NPD can be very high functioning or well contained for periods of time in certain life contexts, others may struggle with functional impairment and extreme self-esteem fluctuations (see Pincus et al., 2014, pp. 439 – 443). People with more prevailing and consistent self-enhancement/grandiosity, controlled substance use, or even co-occurring antisocial or psychopathic tendencies may function within the societal frame (i.e., outside treatment, substance focused, or forensic settings) for long periods of time. These circumstances have made studies of pathological narcissism and NPD particularly challenging, contributing to questions regarding the validity of fragility and vulnerability in narcissistic personality functioning and self-regulation (Hopwood, 2014, pp. 448 – 449; Miller, Widiger, & Campbell, 2014, pp. 450 – 451). An important question concerns which presentation (i.e., enhanced/grandiose or vulnerable/inferior) should be considered most representative of the phenotypic and functional range of pathological narcissism and NPD. People with NPD who seek treatment do present with self-regulatory ranges and fluctuations, including both self-enhancement/grandiosity and vulnerabilities/inferiority. Indeed, facing and admitting inferiority/vulnerability, usually perceived by the patient as evidence of personal weakness or failure, can nevertheless serve as a major motivator to seek treatment. However, people in other life contexts may not experience such fluctuations, or at least not until they are confronted with very specific challenging or threatening life events. An overarching question is whether the developmental conditions for characterological self-enhancement and grandiosity indeed co-occur with and/or are necessitated by experiences of vulnerability and inferiority, and whether such conditions for long periods of time can be counterbalanced or effectively encapsulated through supportive resources and skillful narcissistic strategies. Continuing studies of developmental underpinnings to pathological narcissism and NPD, and the role of attachment, losses, narcissistic trauma, and self-regulatory/ esteem challenges are much needed. Similarly, finding common denominators for pathological narcissism and NPD identified by personality structure and self-regulation, rather than by mainly manifest features or descriptions of functional ability and interpersonal patterns, is an important topic for future studies. Hopefully directions and questions addressed in this Special Series on NPD will encourage and guide further studies of NPD that can improve our understanding and treatment of the individual patient suffering from pathological narcissism and NPD.
References Diamond, D., Levy, K. N., Clarkin, J. F., Fischer-Kern, M., Cain, N. M., Doering, S., . . . Buchheim, A. (2014). Attachment and mentalization in female patients with comorbid narcissistic and borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 428 – 433. doi:10.1037/per0000065 Hopwood, C. J. (2014). The maturation of narcissism: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 448 – 449. doi:10.1037/per0000081
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
INTRODUCTION TO THE SPECIAL SERIES Kealy, D., Hadjipavlou, G. A., & Ogrodniczuk, J. S. (2014). Moving the field forward: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 444 – 445. doi:10.1037/per0000084 Miller, J. D., Widiger, T. A., & Campbell, W. K. (2014). Vulnerable narcissism: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 450 – 451. doi:10.1037/per0000083 Perry, J. C. (2014). Phenomenology in need of treatment: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 446 – 447. doi:10.1037/per0000082 Pincus, A. L., Cain, N. M., & Wright, A. G. C. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disorders: Theory, Research, and Treatment, 5, 439 – 443. doi:10.1037/per0000031 Ronningstam, E. (2014). Beyond the diagnostic traits: A collaborative exploratory diagnostic process for dimensions and underpinnings of narcissistic personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 434 – 438. doi:10.1037/per0000034 Skodol, A. E., Bender, D. S., & Morey, L. C. (2014). Narcissistic personality disorder in DSM-5. Personality Disorders: Theory, Research, and Treatment, 5, 422– 427. doi:10.1037/per0000023
421
© 2014 American Psychological Association 1949-2715/14/$12.00 http://dx.doi.org/10.1037/per0000093
INTRODUCTION
Introduction to the Special Series on “Narcissistic Personality Disorder—New Perspectives on Diagnosis and Treatment” This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Elsa Ronningstam, Guest Editor Harvard Medical School
The recent debate on the narcissistic personal disorder (NPD) diagnosis and its format in DSM-5 has spurred increased interest in improving our conceptualization and understanding of this most complex personality disorder. The dual diagnostic approach for personality disorders in DSM-5, the trait model in Section II and the proposed hybrid model combining dimensions and traits in Section III, opens a most valuable intersect for furthering studies and discussions about pathological narcissism and NPD. A move toward more clinically useful ways to identify and diagnose patients with NPD is now both timely and much needed. The applicability of the trait focused NPD diagnosis in clinical practice has been problematic. One of the prime difficulties involves identifying and communicating NPD traits and diagnosis in ways that bypass narcissistic patients’ combined guarded inflexibility, vulnerability, and hyper-reactivity. In addition, the strong judgmental social and societal preconceptions regarding narcissism and NPD tend to preclude more constructive and informative patient-clinician discussions. Another difficulty relates to the fact that narcissism ranges from healthy to pathological, including psychopathic and malignant features in its most severe forms. Sorting out the healthy, self-preserving aspects of narcissism from its pervasive or temporary pathological aspects can move the diagnostic process toward a more balanced understanding of self-regulation and functioning. Clinical strategies and conceptualizations are needed that can more accurately and meaningfully connect the narcissistic patients’ subjective experiences and descriptions of their problems with approved diagnostic features and formulations, as well as with treatment goals and techniques. Relating narcissism to such central aspects as reflective function/mentalization and attachment has indeed broadened our conceptualization of narcissistic personality functioning. Similarly, identifying empathy as a multifactorial capability instead of a trait that can be present or absent incorporates recent psychological and neuroscientific research and invites further explorations in diagnosis and treatment. Inclusion of self-agency as a foundation for self-regulation can help incorporate such important personality factors as goal setting, motivation, self-assessment, and direction, which also represents a major step forward. The proposed model for personality disorders, including NPD, outlined in DSM-5 Section III identifies problems in self and interpersonal functioning. Features for NPD include fluctuations in self-esteem regulation, with apparent difficulties in identity, self-direction, empathy and intimacy, as well as in traits describing antagonism (i.e., grandiosity and attention seeking; Skodol, Bender, Morey, 2014, pp. 422– 427). The first aim for this Special Series is to further the dimensional self-regulatory diagnostic approach for identifying NPD by integrating range of functioning, co-occurring grandiosity and vulnerability, compromised empathic ability, self-enhancing interpersonal strategies and relatedness, and overt and covert expressions of pathological narcissism. A second aim is to broaden the conceptualization of pathological narcissism by identifying it in terms of attachment and mentalization/reflective function. Such connection can provide a much needed link between narcissism and other more integrated theoretical models and frames of reference for personality functioning, especially those applied to borderline personality disorder (BPD). A comparison of co-occurring NPD with BPD to BPD only indicates that the combined NPD/BPD group displays dismissing and unclassifiable attachment style with deficits in reflective function (Diamond et al., 2014, pp. 428 – 433). This research can begin to explain the obvious resistance to alliance building and tendencies to drop out of patients with NPD, and guide the development of more effective treatment approaches for NPD.
Correspondence concerning this article should be addressed to Elsa Ronningstam, Harvard Medical School, McLean Hospital, AOPC Mailstop 109, 115 Mill Street, Belmont, MA 02478. E-mail: [email protected] 419
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
420
RONNINGSTAM
The third aim is to apply the combined dimensional and trait diagnostic approach to clinical practice, both diagnostic evaluation and treatment. To this end, Ronningstam (2014, pp. 434 – 438) outlines an exploratory collaborative diagnostic process that identifies both pathological and healthy features of narcissism, and attends to subjective experiences as well as to interpersonal functioning as indicators of narcissistic selfregulation and sense of agency. Linking the diagnostic process and case formulation closer to treatment objectives is essential. It is not uncommon that the NPD diagnosis can’t adequately address the essential or urgent issues of the patient seeking treatment. Sometimes the NPD diagnosis may even become an obstacle for alliance building, evoking the patient’s defensive or blaming attitudes. Treatment strategies that specifically focus on the complex phenotypic presentations can open new ways for building an alliance with the usually quite guarded and treatment reluctant patient with NPD. Attending to concomitant grandiose and vulnerable features, both of which can be either more or less obvious (sometimes provocatively obtrusive) or, alternatively, effectively concealed, can promote a more integrated approach to the treatment of pathological narcissism (Pincus, Cain, & Wright, 2014, pp. 439 – 443). A necessary focus for future studies is also to identify the factors and processes in treatment that can contribute to change in pathological narcissism and narcissistic personality functioning (see Kealy, Hadjipavlou, & Ogrodniczuk, 2014, pp. 444 – 445; Perry, 2014, pp. 446 – 447). The intercorrelation between internal/experiential and external/behavioral change and its interaction in narcissistic personality functioning remains a major area for further exploration and understanding. The phenotypic presentation of patients with NPD is often influenced by the co-occurrence of other mental conditions such as mood, substance use, or eating disorders that can contribute to underlying and not always obvious characterological manifestations and accompanying treatment resistance. Alternatively, narcissistic traits and self-regulation can be the sole predominant condition with persistent or intermittent overt expressions in specific contexts in which self-enhancement is enforced or self-esteem threatened. Whereas some people with NPD can be very high functioning or well contained for periods of time in certain life contexts, others may struggle with functional impairment and extreme self-esteem fluctuations (see Pincus et al., 2014, pp. 439 – 443). People with more prevailing and consistent self-enhancement/grandiosity, controlled substance use, or even co-occurring antisocial or psychopathic tendencies may function within the societal frame (i.e., outside treatment, substance focused, or forensic settings) for long periods of time. These circumstances have made studies of pathological narcissism and NPD particularly challenging, contributing to questions regarding the validity of fragility and vulnerability in narcissistic personality functioning and self-regulation (Hopwood, 2014, pp. 448 – 449; Miller, Widiger, & Campbell, 2014, pp. 450 – 451). An important question concerns which presentation (i.e., enhanced/grandiose or vulnerable/inferior) should be considered most representative of the phenotypic and functional range of pathological narcissism and NPD. People with NPD who seek treatment do present with self-regulatory ranges and fluctuations, including both self-enhancement/grandiosity and vulnerabilities/inferiority. Indeed, facing and admitting inferiority/vulnerability, usually perceived by the patient as evidence of personal weakness or failure, can nevertheless serve as a major motivator to seek treatment. However, people in other life contexts may not experience such fluctuations, or at least not until they are confronted with very specific challenging or threatening life events. An overarching question is whether the developmental conditions for characterological self-enhancement and grandiosity indeed co-occur with and/or are necessitated by experiences of vulnerability and inferiority, and whether such conditions for long periods of time can be counterbalanced or effectively encapsulated through supportive resources and skillful narcissistic strategies. Continuing studies of developmental underpinnings to pathological narcissism and NPD, and the role of attachment, losses, narcissistic trauma, and self-regulatory/ esteem challenges are much needed. Similarly, finding common denominators for pathological narcissism and NPD identified by personality structure and self-regulation, rather than by mainly manifest features or descriptions of functional ability and interpersonal patterns, is an important topic for future studies. Hopefully directions and questions addressed in this Special Series on NPD will encourage and guide further studies of NPD that can improve our understanding and treatment of the individual patient suffering from pathological narcissism and NPD.
References Diamond, D., Levy, K. N., Clarkin, J. F., Fischer-Kern, M., Cain, N. M., Doering, S., . . . Buchheim, A. (2014). Attachment and mentalization in female patients with comorbid narcissistic and borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 428 – 433. doi:10.1037/per0000065 Hopwood, C. J. (2014). The maturation of narcissism: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 448 – 449. doi:10.1037/per0000081
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
INTRODUCTION TO THE SPECIAL SERIES Kealy, D., Hadjipavlou, G. A., & Ogrodniczuk, J. S. (2014). Moving the field forward: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 444 – 445. doi:10.1037/per0000084 Miller, J. D., Widiger, T. A., & Campbell, W. K. (2014). Vulnerable narcissism: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 450 – 451. doi:10.1037/per0000083 Perry, J. C. (2014). Phenomenology in need of treatment: Commentary for the special series “Narcissistic personality disorder—New perspectives on diagnosis and treatment.” Personality Disorders: Theory, Research, and Treatment, 5, 446 – 447. doi:10.1037/per0000082 Pincus, A. L., Cain, N. M., & Wright, A. G. C. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disorders: Theory, Research, and Treatment, 5, 439 – 443. doi:10.1037/per0000031 Ronningstam, E. (2014). Beyond the diagnostic traits: A collaborative exploratory diagnostic process for dimensions and underpinnings of narcissistic personality disorder. Personality Disorders: Theory, Research, and Treatment, 5, 434 – 438. doi:10.1037/per0000034 Skodol, A. E., Bender, D. S., & Morey, L. C. (2014). Narcissistic personality disorder in DSM-5. Personality Disorders: Theory, Research, and Treatment, 5, 422– 427. doi:10.1037/per0000023
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