Personality Disorders: Theory, Research, and Treatment 2014, Vol. 5, No. 4, 444 – 445
© 2014 American Psychological Association 1949-2715/14/$12.00 http://dx.doi.org/10.1037/per0000084
COMMENTARY
Moving the Field Forward: Commentary for the Special Series “Narcissistic Personality Disorder—New Perspectives on Diagnosis and Treatment” David Kealy, George A. Hadjipavlou, and John S. Ogrodniczuk 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.
University of British Columbia
covert presentations. Ultimately, the lack of change to personality disorder categories in the main text of DSM-5 has failed to realize these intentions, compromising clinical exploration of the complex nature of narcissism. Skodol and colleagues thus encourage clinicians and researchers to utilize the DSM-5 Section III criteria when working with NPD.
Literature on narcissistic personality disorder (NPD) is rife with contention and contradiction. Pathological narcissism is commonly encountered in clinical settings, but NPD has been rare in most epidemiological studies. It is widely recognized that the official nosology of the Diagnostic and Statistical Manual of Mental Disorders (DSM), with its stark emphasis on overt grandiosity, obscures clinically salient dimensions of vulnerability that often lie at the core of narcissistic pathology. This disparity has led to a situation in which the term “narcissism” is inconsistently applied and understood in clinical contexts. The NPD diagnosis has a pejorative connotation and is renowned as a “difficult-totreat” condition, yet there is little empirical evidence regarding its clinical course and management. Consequently, the field continues to grapple with questions about defining, identifying, understanding, and treating pathological narcissism. This special issue on NPD addresses such challenges.
Identifying NPD In her article on the diagnostic process, Ronningstam (2014, pp. 434 – 438) highlights clinical features that should alert clinicians to a diagnosis of NPD, beyond the identification of arrogant and entitled attitudes and behaviors. Ronningstam illustrates the complex intertwining of compromised self-esteem, emotion dysregulation, and interpersonal problems in pathological narcissism. Aspects of each of these areas may be obscured in the patient’s self-narrative or may operate surreptitiously, requiring the clinician’s patient exploration of self-representational and affective themes throughout the diagnostic process. Ronningstam emphasizes the role of affect regulation associated with self-representation. Impaired modulation of shame is a core NPD feature, activating defensive indulgence in grandiose fantasy and antagonistic behaviors. The need to urgently restore a positive self-representation also impedes empathic functioning and selfagency. As Ronningstam notes, distorted expectations of one’s own capacities, achievements, and possibilities can either propel the individual forward—albeit impulsively or antagonistically— or derail ambition and self-direction. Consequently, many patients with NPD function at levels below their actual abilities. For some individuals, impaired self-agency may be linked with an unfounded sense of entitlement, whereas others may adopt avoidant strategies in a struggle against unbearable experiences of shame rooted in exacting perfectionism and associated self-criticism.
Defining NPD Skodol, Bender, and Morey (2014, pp. 422– 427) describe the process of revising the DSM personality disorders section, including the controversial initial move to delete NPD from DSM-5 (questioning whether pathological narcissism is better understood as an underlying common element of personality dysfunction) and its reintroduction. They thoughtfully review the shortcomings of the DSM–IV NPD diagnostic criteria, highlighting the notable omission of narcissistic vulnerability—widely regarded as a nearuniversal component of pathological narcissism. The current NPD criteria continue to depict an overtly grandiose and interpersonally exploitative presentation of narcissism that is only partially representative of the phenomena encountered by clinicians. Indeed, grandiosity is increasingly regarded as simply one expression of maladaptive self-esteem regulation, which lies at the core of NPD. As Skodol and colleagues describe, the revised NPD criteria for DSM-5 were intended to better capture the dimensional nature of narcissism, its grandiose and vulnerable aspects, and overt and
Understanding NPD Attachment theory has developed links between self- and affectregulation and the manner in which early attachment bonds (and their disruption) are psychologically encoded as representational models. Diamond and colleagues (2014, pp. 428 – 433) report on the attachment profiles of 22 women diagnosed with co-occurring narcissistic and borderline personality disorders, compared with 129 women who experience borderline personality disorder (BPD) without NPD. This is one of the few investigations into attachment
David Kealy, George A. Hadjipavlou, and John S. Ogrodniczuk, Department of Psychiatry, University of British Columbia. Correspondence concerning this article should be addressed to John S. Ogrodniczuk, #420-5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada. E-mail: [email protected] 444
MOVING THE FIELD FORWARD
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.
and pathological narcissism. Although both groups scored low on mentalization (i.e., the ability to reflect on mental states of oneself and others), patients with BPD and NPD (vs. those with BPD alone) were more likely to have dismissive attachment, or were too inconsistent to be classified as they oscillated between different attachment strategies. This suggests that patients with NPD tend to devalue intimate bonds and divert attention from relationship difficulties. Whereas a dismissing stance might help shore up a fragile self, interpersonal relations invariably suffer. These findings will ring true for clinicians who have grappled with narcissistic patients’ tenacious disavowal of the personal significance of the therapeutic relationship.
Treating NPD Pincus, Cain, and Wright (2014, pp. 439 – 443) illustrate some of the challenges encountered in the psychotherapy of patients with pathological narcissism. First, clinicians must recognize narcissistic pathology. This is a difficult task if one’s inquiry is constrained by DSM NPD criteria, because most patients with NPD present for treatment during states of overt narcissistic vulnerability. These states of depletion may be misunderstood as major depressive episodes; their role within a core narcissistic pathology may be obscured in the absence of overt grandiose features. Beyond identification and diagnosis, grandiose and vulnerable narcissistic expressions each bring their own challenges in psychotherapeutic treatment. Because grandiosity is associated with domineering and vindictive interpersonal behaviors, it may be tempting to regard grandiosity as the more problematic expression of pathological narcissism in the treatment domain. However, narcissistic vulnerability can be pernicious and constricting, often involving profound shame and self-criticism. Associated depressive states tend to consist of empty, agitated, and envious feelings, rather than sadness related to the loss of a person or a role adjustment.
445
Narcissistic loss tends to revolve around loss of self-esteem, admiration, or fortification of self-image. The oscillation between vulnerability and grandiosity adds another layer of complexity for the clinician, who must attempt to anticipate fluctuating self-states and manage challenging countertransference reactions associated with them. The articles in this special issue provide useful guidance for all clinicians working with patients with narcissistic pathology, particularly those who may not have considered narcissism as an underlying cause of a patient’s presenting difficulties or as a contributor to therapeutic impasse. Taken together, they offer a more conceptually sophisticated approach to NPD than the constraining criteria of the DSM, and make a compelling case that it is time for NPD and pathological narcissism to receive greater clinical and research attention. Hopefully such efforts will help reduce the stigma and pessimism surrounding this disorder.
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 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
© 2014 American Psychological Association 1949-2715/14/$12.00 http://dx.doi.org/10.1037/per0000084
COMMENTARY
Moving the Field Forward: Commentary for the Special Series “Narcissistic Personality Disorder—New Perspectives on Diagnosis and Treatment” David Kealy, George A. Hadjipavlou, and John S. Ogrodniczuk 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.
University of British Columbia
covert presentations. Ultimately, the lack of change to personality disorder categories in the main text of DSM-5 has failed to realize these intentions, compromising clinical exploration of the complex nature of narcissism. Skodol and colleagues thus encourage clinicians and researchers to utilize the DSM-5 Section III criteria when working with NPD.
Literature on narcissistic personality disorder (NPD) is rife with contention and contradiction. Pathological narcissism is commonly encountered in clinical settings, but NPD has been rare in most epidemiological studies. It is widely recognized that the official nosology of the Diagnostic and Statistical Manual of Mental Disorders (DSM), with its stark emphasis on overt grandiosity, obscures clinically salient dimensions of vulnerability that often lie at the core of narcissistic pathology. This disparity has led to a situation in which the term “narcissism” is inconsistently applied and understood in clinical contexts. The NPD diagnosis has a pejorative connotation and is renowned as a “difficult-totreat” condition, yet there is little empirical evidence regarding its clinical course and management. Consequently, the field continues to grapple with questions about defining, identifying, understanding, and treating pathological narcissism. This special issue on NPD addresses such challenges.
Identifying NPD In her article on the diagnostic process, Ronningstam (2014, pp. 434 – 438) highlights clinical features that should alert clinicians to a diagnosis of NPD, beyond the identification of arrogant and entitled attitudes and behaviors. Ronningstam illustrates the complex intertwining of compromised self-esteem, emotion dysregulation, and interpersonal problems in pathological narcissism. Aspects of each of these areas may be obscured in the patient’s self-narrative or may operate surreptitiously, requiring the clinician’s patient exploration of self-representational and affective themes throughout the diagnostic process. Ronningstam emphasizes the role of affect regulation associated with self-representation. Impaired modulation of shame is a core NPD feature, activating defensive indulgence in grandiose fantasy and antagonistic behaviors. The need to urgently restore a positive self-representation also impedes empathic functioning and selfagency. As Ronningstam notes, distorted expectations of one’s own capacities, achievements, and possibilities can either propel the individual forward—albeit impulsively or antagonistically— or derail ambition and self-direction. Consequently, many patients with NPD function at levels below their actual abilities. For some individuals, impaired self-agency may be linked with an unfounded sense of entitlement, whereas others may adopt avoidant strategies in a struggle against unbearable experiences of shame rooted in exacting perfectionism and associated self-criticism.
Defining NPD Skodol, Bender, and Morey (2014, pp. 422– 427) describe the process of revising the DSM personality disorders section, including the controversial initial move to delete NPD from DSM-5 (questioning whether pathological narcissism is better understood as an underlying common element of personality dysfunction) and its reintroduction. They thoughtfully review the shortcomings of the DSM–IV NPD diagnostic criteria, highlighting the notable omission of narcissistic vulnerability—widely regarded as a nearuniversal component of pathological narcissism. The current NPD criteria continue to depict an overtly grandiose and interpersonally exploitative presentation of narcissism that is only partially representative of the phenomena encountered by clinicians. Indeed, grandiosity is increasingly regarded as simply one expression of maladaptive self-esteem regulation, which lies at the core of NPD. As Skodol and colleagues describe, the revised NPD criteria for DSM-5 were intended to better capture the dimensional nature of narcissism, its grandiose and vulnerable aspects, and overt and
Understanding NPD Attachment theory has developed links between self- and affectregulation and the manner in which early attachment bonds (and their disruption) are psychologically encoded as representational models. Diamond and colleagues (2014, pp. 428 – 433) report on the attachment profiles of 22 women diagnosed with co-occurring narcissistic and borderline personality disorders, compared with 129 women who experience borderline personality disorder (BPD) without NPD. This is one of the few investigations into attachment
David Kealy, George A. Hadjipavlou, and John S. Ogrodniczuk, Department of Psychiatry, University of British Columbia. Correspondence concerning this article should be addressed to John S. Ogrodniczuk, #420-5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada. E-mail: [email protected] 444
MOVING THE FIELD FORWARD
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.
and pathological narcissism. Although both groups scored low on mentalization (i.e., the ability to reflect on mental states of oneself and others), patients with BPD and NPD (vs. those with BPD alone) were more likely to have dismissive attachment, or were too inconsistent to be classified as they oscillated between different attachment strategies. This suggests that patients with NPD tend to devalue intimate bonds and divert attention from relationship difficulties. Whereas a dismissing stance might help shore up a fragile self, interpersonal relations invariably suffer. These findings will ring true for clinicians who have grappled with narcissistic patients’ tenacious disavowal of the personal significance of the therapeutic relationship.
Treating NPD Pincus, Cain, and Wright (2014, pp. 439 – 443) illustrate some of the challenges encountered in the psychotherapy of patients with pathological narcissism. First, clinicians must recognize narcissistic pathology. This is a difficult task if one’s inquiry is constrained by DSM NPD criteria, because most patients with NPD present for treatment during states of overt narcissistic vulnerability. These states of depletion may be misunderstood as major depressive episodes; their role within a core narcissistic pathology may be obscured in the absence of overt grandiose features. Beyond identification and diagnosis, grandiose and vulnerable narcissistic expressions each bring their own challenges in psychotherapeutic treatment. Because grandiosity is associated with domineering and vindictive interpersonal behaviors, it may be tempting to regard grandiosity as the more problematic expression of pathological narcissism in the treatment domain. However, narcissistic vulnerability can be pernicious and constricting, often involving profound shame and self-criticism. Associated depressive states tend to consist of empty, agitated, and envious feelings, rather than sadness related to the loss of a person or a role adjustment.
445
Narcissistic loss tends to revolve around loss of self-esteem, admiration, or fortification of self-image. The oscillation between vulnerability and grandiosity adds another layer of complexity for the clinician, who must attempt to anticipate fluctuating self-states and manage challenging countertransference reactions associated with them. The articles in this special issue provide useful guidance for all clinicians working with patients with narcissistic pathology, particularly those who may not have considered narcissism as an underlying cause of a patient’s presenting difficulties or as a contributor to therapeutic impasse. Taken together, they offer a more conceptually sophisticated approach to NPD than the constraining criteria of the DSM, and make a compelling case that it is time for NPD and pathological narcissism to receive greater clinical and research attention. Hopefully such efforts will help reduce the stigma and pessimism surrounding this disorder.
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 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
