Personality Disorders: Theory, Research, and Treatment 2014, Vol. 5, No. 4, 446 – 447
© 2014 American Psychological Association 1949-2715/14/$12.00 http://dx.doi.org/10.1037/per0000082
COMMENTARY
Phenomenology in Need of Treatment: Commentary for the Special Series “Narcissistic Personality Disorder—New Perspectives on Diagnosis and Treatment” J. Christopher Perry 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.
McGill University
tiness, nihilism, and perhaps suicidality. Although initially covert, grandiosity, entitlement, and fantasies of success gradually emerge. Defensive image-distorting attempts to shore up the vulnerable self are then reflected in the helplessness experienced by therapists in their countertransference reactions. The authors essentially focus on the phenomenology of NPD, yet conclude with a wish that this can “lead to promising new treatment approaches.” The vehicle for this is left unsaid. Skodol, Bender, and Morey (2014, pp. 422– 427) reviewed the rationale guiding their development of a mixed categorical and dimensional diagnostic model for DSM-5. NPD has received only 10% of the number of research papers compared with borderline personality disorder (BPD), and NPD nearly faced official banishment before an outcry from clinicians brought NPD back into the family. The authors reviewed some trait-oriented research suggesting that the current DSM–IV criteria are inadequate, underrepresenting the covert and vulnerable aspects of narcissistic pathology. Whatever one thinks of their proposal for NPD in Section III of DSM-5, one can only admire the amount of thought and work they brought to bear to the development of their proposal. Key criteria for deciding which traits were to be required for diagnosing NPD were internal consistency and the prevalence and overlap with other PD diagnoses—none of which strike me as core validators. Grandiosity and attention-seeking made the cut, whereas antagonism and negative affectivity did not. The diagnostician can still describe additional traits (Specifiers) for a given patient from the list of 25 trait facets. The authors conclude by encouraging research on the new diagnostic method. Diamond et al. (2014, pp. 428 – 433) went beyond phenomenology to examine theoretically informed aspects of underlying pathology. Combining two treatment studies of BPD, they examined attachment styles and reflective functioning in those with and without co-occurring NPD. As predicted, the Preoccupied and Unresolved styles were twice as common in pure BPD as in NPD/BPD, whereas the Dismissive and Cannot Classify styles were more common in NPD/BPD. Both groups were low in Reflective Functioning. These are theoretically consistent findings. BPD is characterized by heightened sensitivity to attachment issues, in which intimacy leads to entanglement and anxiety. Conversely, NPD is characterized by failures in relating to others, leading to aloofness, dismissiveness, and failures in empathy, rather than separation anxiety. The lack of an NPD group without BPD limits generalizability somewhat, as does the exclusion in one
In 1980, when the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM–III) first published explicit diagnostic criteria, the then 12 personality disorders (PDs) were considered the step-children of mental disorders for want of professional attention, research, and respect. With the publication of DSM-5, perhaps a better metaphor for some PD types would be orphans: they receive scant attention, compared with borderline or antisocial PDs. This includes attention from advocacy and funding organizations, financial support for research, and research articles. The four contributions in this Special Issue challenge this trend. Dr. Ronningstam has built her career on understanding pathological narcissism. Her article on the process of diagnosing narcissistic personality disorder (NPD; Ronningstam, 2014, pp. 434 – 438) posits that individuals with NPD vacillate between states of mind, from which the outward traits emerge. One state outwardly reflects apparent self-agency, competence, and even healthy narcissism, whereas other states reflect distressing vulnerability in selfand affect-regulation with concomitant defensive self-protection. However, the diagnostic process is more informative if the clinician does not focus solely on outward traits of NPD (such as grandiosity), but interacts with the patient to allow distressing subjective states to emerge (i.e., those evidenced by self-doubt, self-criticism, shame, and the like). Structured diagnostic interviews probably miss this. Dr. Ronningstam identifies three underlying characteristics of narcissistic personality functioning: emotion regulation, dysfunctional interpersonal relating, and narcissistic traumas or events that threaten self-regulation. Whereas the reported case exemplifies these, Ronningstam only alludes to how the clinician can facilitate the process. This is why books showing the therapeutic dialogue are still valuable. Pincus, Cain, and Wright (2014, pp. 439 – 443) take on related phenomenological issues in diagnosis, contrasting the overt grandiose and arrogant patient, exemplified in the DSM criteria, with the vulnerable form of narcissism. These latter patients may not score five or more criteria for NPD. They describe two cases that demonstrate how the vulnerable features of narcissism unfold during treatment, preceded by the harbingers of dysphoria, emp-
Correspondence concerning this article should be addressed to J. Christopher Perry, McGill University, Department of Psychiatry at Jewish General Hospital, 4333 Chemin de la Cote Ste-Catherine, Montreal, QC, H3T 1E4, Canada. E-mail: [email protected] 446
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.
PHENOMENOLOGY IN NEED OF TREATMENT
cohort of those with antisocial PD, which is known to co-occur with NPD. Also, I would be curious about the possibility of interaction or moderating effects of one disorder on the other’s attachment system. Nonetheless, this study confirms the importance of attachment issues in both disorders, opening the way for examining potential etiological factors leading to both the attachment styles and disorders in question. Finally, these data suggest that, compared with BPD, treatment experience with the NPD/ BPD patient might yield meaningful differences in transferential and other relationship issues. Good delineation of the phenomenology of NPD is necessary but insufficient for informing us on what to do clinically. I suspect that we will see reams of publications comparing Section III and II diagnoses with various external measures and possibly experimental procedures. We will learn some important things, along with many facts without actionable consequences. However, because NPD does not show many differential relationships to particular functional measures, I believe that treatment studies will likely be the most informative. As with the original description of BPD (Stern, 1938), those first describing narcissistic psychopathology did so in the service of understanding the patients’ particular responses to treatment. Now we need systematic studies that link psychopathology and etiological factors to psychotherapy process and outcome. Improving treatment outcome
447
may be the ultimate validator. After all, relieving suffering is the aim of all of this, right?
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. http://dx.doi.org/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. http://dx.doi .org/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. http://dx.doi.org/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. http://dx.doi.org/10.1037/per0000023 Stern, A. (1938). Psychoanalytic investigation of and therapy in the borderline group of neuroses. The Psychoanalytic Quarterly, 7, 467– 489.
© 2014 American Psychological Association 1949-2715/14/$12.00 http://dx.doi.org/10.1037/per0000082
COMMENTARY
Phenomenology in Need of Treatment: Commentary for the Special Series “Narcissistic Personality Disorder—New Perspectives on Diagnosis and Treatment” J. Christopher Perry 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.
McGill University
tiness, nihilism, and perhaps suicidality. Although initially covert, grandiosity, entitlement, and fantasies of success gradually emerge. Defensive image-distorting attempts to shore up the vulnerable self are then reflected in the helplessness experienced by therapists in their countertransference reactions. The authors essentially focus on the phenomenology of NPD, yet conclude with a wish that this can “lead to promising new treatment approaches.” The vehicle for this is left unsaid. Skodol, Bender, and Morey (2014, pp. 422– 427) reviewed the rationale guiding their development of a mixed categorical and dimensional diagnostic model for DSM-5. NPD has received only 10% of the number of research papers compared with borderline personality disorder (BPD), and NPD nearly faced official banishment before an outcry from clinicians brought NPD back into the family. The authors reviewed some trait-oriented research suggesting that the current DSM–IV criteria are inadequate, underrepresenting the covert and vulnerable aspects of narcissistic pathology. Whatever one thinks of their proposal for NPD in Section III of DSM-5, one can only admire the amount of thought and work they brought to bear to the development of their proposal. Key criteria for deciding which traits were to be required for diagnosing NPD were internal consistency and the prevalence and overlap with other PD diagnoses—none of which strike me as core validators. Grandiosity and attention-seeking made the cut, whereas antagonism and negative affectivity did not. The diagnostician can still describe additional traits (Specifiers) for a given patient from the list of 25 trait facets. The authors conclude by encouraging research on the new diagnostic method. Diamond et al. (2014, pp. 428 – 433) went beyond phenomenology to examine theoretically informed aspects of underlying pathology. Combining two treatment studies of BPD, they examined attachment styles and reflective functioning in those with and without co-occurring NPD. As predicted, the Preoccupied and Unresolved styles were twice as common in pure BPD as in NPD/BPD, whereas the Dismissive and Cannot Classify styles were more common in NPD/BPD. Both groups were low in Reflective Functioning. These are theoretically consistent findings. BPD is characterized by heightened sensitivity to attachment issues, in which intimacy leads to entanglement and anxiety. Conversely, NPD is characterized by failures in relating to others, leading to aloofness, dismissiveness, and failures in empathy, rather than separation anxiety. The lack of an NPD group without BPD limits generalizability somewhat, as does the exclusion in one
In 1980, when the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM–III) first published explicit diagnostic criteria, the then 12 personality disorders (PDs) were considered the step-children of mental disorders for want of professional attention, research, and respect. With the publication of DSM-5, perhaps a better metaphor for some PD types would be orphans: they receive scant attention, compared with borderline or antisocial PDs. This includes attention from advocacy and funding organizations, financial support for research, and research articles. The four contributions in this Special Issue challenge this trend. Dr. Ronningstam has built her career on understanding pathological narcissism. Her article on the process of diagnosing narcissistic personality disorder (NPD; Ronningstam, 2014, pp. 434 – 438) posits that individuals with NPD vacillate between states of mind, from which the outward traits emerge. One state outwardly reflects apparent self-agency, competence, and even healthy narcissism, whereas other states reflect distressing vulnerability in selfand affect-regulation with concomitant defensive self-protection. However, the diagnostic process is more informative if the clinician does not focus solely on outward traits of NPD (such as grandiosity), but interacts with the patient to allow distressing subjective states to emerge (i.e., those evidenced by self-doubt, self-criticism, shame, and the like). Structured diagnostic interviews probably miss this. Dr. Ronningstam identifies three underlying characteristics of narcissistic personality functioning: emotion regulation, dysfunctional interpersonal relating, and narcissistic traumas or events that threaten self-regulation. Whereas the reported case exemplifies these, Ronningstam only alludes to how the clinician can facilitate the process. This is why books showing the therapeutic dialogue are still valuable. Pincus, Cain, and Wright (2014, pp. 439 – 443) take on related phenomenological issues in diagnosis, contrasting the overt grandiose and arrogant patient, exemplified in the DSM criteria, with the vulnerable form of narcissism. These latter patients may not score five or more criteria for NPD. They describe two cases that demonstrate how the vulnerable features of narcissism unfold during treatment, preceded by the harbingers of dysphoria, emp-
Correspondence concerning this article should be addressed to J. Christopher Perry, McGill University, Department of Psychiatry at Jewish General Hospital, 4333 Chemin de la Cote Ste-Catherine, Montreal, QC, H3T 1E4, Canada. E-mail: [email protected] 446
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.
PHENOMENOLOGY IN NEED OF TREATMENT
cohort of those with antisocial PD, which is known to co-occur with NPD. Also, I would be curious about the possibility of interaction or moderating effects of one disorder on the other’s attachment system. Nonetheless, this study confirms the importance of attachment issues in both disorders, opening the way for examining potential etiological factors leading to both the attachment styles and disorders in question. Finally, these data suggest that, compared with BPD, treatment experience with the NPD/ BPD patient might yield meaningful differences in transferential and other relationship issues. Good delineation of the phenomenology of NPD is necessary but insufficient for informing us on what to do clinically. I suspect that we will see reams of publications comparing Section III and II diagnoses with various external measures and possibly experimental procedures. We will learn some important things, along with many facts without actionable consequences. However, because NPD does not show many differential relationships to particular functional measures, I believe that treatment studies will likely be the most informative. As with the original description of BPD (Stern, 1938), those first describing narcissistic psychopathology did so in the service of understanding the patients’ particular responses to treatment. Now we need systematic studies that link psychopathology and etiological factors to psychotherapy process and outcome. Improving treatment outcome
447
may be the ultimate validator. After all, relieving suffering is the aim of all of this, right?
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. http://dx.doi.org/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. http://dx.doi .org/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. http://dx.doi.org/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. http://dx.doi.org/10.1037/per0000023 Stern, A. (1938). Psychoanalytic investigation of and therapy in the borderline group of neuroses. The Psychoanalytic Quarterly, 7, 467– 489.
