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Narcissistic Personality Disorder: Patterns, Processes, and Indicators of Change in Long-Term Psychotherapy

Published Online:June 2023https://doi.org/10.1521/pedi.2023.37.3.337

Abstract

Change in treatment of narcissistic personality disorder (NPD) has been considered difficult to attain. Aspects of narcissistic pathology, including interpersonal enhancement, avoidance, aggressivity, and control, have contributed to challenges in forming a therapeutic alliance and pursuing treatment towards attainable goals for change and remission. This study, based on a qualitative review of therapists’ case reports of individual psychotherapy with eight patients diagnosed with NPD, is the first to identify and explore patterns, processes, and indicators of change in pathological narcissism. All patients showed significant improvement in personality and life functioning, including engagement in work or education and long-term close relationships, with remission of the NPD diagnosis. The process of change was gradual, with some noticeable changes occurring in specific life contexts. Additional factors indicating and contributing to change included patients’ motivation and commitment to psychotherapy, reflective ability, emotion regulation, sense of agency, and interpersonal and social engagement.

REFERENCES

  • Aafjes-van Doorn K., , & Barber J. (2018). Mechanisms of change in treatment of personality disorders. Commentary on the special issue. Journal of Personality Disorders, 32(Suppl), 143–151. https://doi.org/10.1521/pedi.2018.32.supp.143 Link, Google Scholar
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing. Crossref, Google Scholar
  • Baskin-Sommers A., , Krusemark E., , & Ronningstam E. (2014). Empathy in narcissistic personality disorder: From clinical and empirical perspectives. Personality Disorders: Theory, Research and Treatment, 5(3), 323–333. Crossref, Google Scholar
  • Behary W. T., , & Dieckmann E. (2011). Schema therapy for narcissism: The art of empathic confrontation, limit-setting, and leverage. In Campbell K. W., & Miller J. D. (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments (pp 445–456). John Wiley & Sons. https://doi.org/10.1002/9781118093108.ch40 Crossref, Google Scholar
  • Caligor E., , Levy K. N., , & Yeomans F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415–422. Crossref Medline, Google Scholar
  • Castonguay L. G., , & Hill C. E. (Eds.). (2012). Transformation in psychotherapy: Corrective experiences across cognitive behavioral, humanistic, and psychodynamic approaches. American Psychological Association. Google Scholar
  • Choi-Kain L.W., , Simonsen S., , & Euler S. (2022). A mentalization approach to narcissistic personality disorder: Moving from “me-mode” to “we-mode.” American Journal of Psychotherapy, 75(1), 38–43. Crossref Medline, Google Scholar
  • Cramer P. (2011). Narcissism through the ages: What happens when narcissists grow older? Journal of Research in Personality, 45(5), 479–492. https://doi.org/10.1016/j.jrp.2011.06.003 Crossref, Google Scholar
  • Di Pierro R., , & Fanti E. (2021). Self-concept in narcissism: Profile comparisons of narcissistic manifestations on facets of the self. Clinical Neuropsychiatry, 18(4), 211–222. https://doi.org/10.36131/cnfioritieditore20210404 Medline, Google Scholar
  • Diamond D., , & Hersh R. G. (2020). Transference-focused psychotherapy for narcissistic personality disorder: An object relations approach. Journal of Personality Disorders 34(Suppl), 159–176. https://doi.org/10.1521/pedi.2020.34.supp.159 Link, Google Scholar
  • Diamond D., , & Mehan K. B. (2013). Attachment and object relations in patients with narcissistic personality disorder: Implications for therapeutic process and outcome. Journal of Clinical Psychology, 69(11), 1148–1159. https://doi.org/10.1002/jclp.22042 Crossref Medline, Google Scholar
  • Dimaggio G. (2022). Treatment principles for pathological narcissism and narcissistic personality disorder. Journal of Psychotherapy Integration, 32(4), 408–225. Crossref, Google Scholar
  • Dimaggio G., , & Attinà G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of Clinical Psychology, 68(8), 922–934. https://doi.org/10.1002/jclp.21896 Crossref Medline, Google Scholar
  • Dimaggio G., , MacBeth A., , Popolo R., , Salvatore G., , Perrini F., , Raouna A., , Osam C. S., , Buonocore L., , Bandiera A., , & Montano A. (2018). The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders. Comprehensive Psychiatry, 83, 71–78. https://doi.org/10.1016/j.comppsych.2018.03.005 Crossref Medline, Google Scholar
  • Dowgwillo E. A., , Pincus A. L., , & Lenzenweger M. L. (2019). A parallel process latent growth model of narcissistic personality disorder symptoms and normal personality traits. Personality Disorders: Theory, Research and Treatment, 10(3), 257–266. Crossref, Google Scholar
  • Drozek R. P., , & Unruh B. T. (2020). Mentalization-based treatment for pathological narcissism. Journal of Personality Disorders, 34(Suppl), 177–203. https://doi.org/10.1521/pedi.2020.34.supp.177 Link, Google Scholar
  • Drozek R. P., , Unruh B., , & Bateman A. (2023). Mentalization-based treatment for pathological narcissism: A handbook. Oxford University Press. Google Scholar
  • Ellison W. D., , Levy K. N., , Cain N. M., , Ansell E. B., , & Pincus A. L. (2013). The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: A naturalistic investigation. Journal of Personality Assessment, 95(3), 291–300. https://doi.org/10.1080/00223891.2012.742904 Crossref Medline, Google Scholar
  • Fjermestad-Noll J., , Ronningstam E., , Bach B. S., , Rosenbaum B., , & Simonsen E. (2020). Perfectionism, shame and aggression in depressive patients with narcissistic personality disorder. Journal of Personality Disorders, 34(Suppl), 25–41. https://doi.org/10.1521/pedi.2020.34.supp.25 Link, Google Scholar
  • Fonagy P., , Gergely G., , Jurist E. J., , & Target M. (2002). The development of an understanding of self and agency. In Affect regulation, mentalization and the development of the self (pp. 203–252). Routledge. Google Scholar
  • Friedlander M. L., , Sutherland O., , Sandler S., , Kortz L., , Bernardi S., , Lee H.-H., , & Drozd A. (2011). Exploring corrective experiences in a successful case of short-term dynamic psychotherapy. Psychotherapy, 49(3), 349–363. Crossref Medline, Google Scholar
  • Gabbard G., , & Crisp-Han H. (2016). The many faces of narcissism. World Psychiatry, 15(2), 115–116. https://doi.org/10.1002/wps.20323 Crossref Medline, Google Scholar
  • Gabbard G., , & Crisp H. (2018). Narcissism and its discontents: Diagnostic dilemmas and treatment strategies with narcissistic patients. American Psychiatric Association Publishing. Crossref, Google Scholar
  • Gamache D., , Savard C., , Lemelin S., , Côté A., , & Villeneuve E. (2018). Premature psychotherapy termination in an outpatient treatment program for personality disorders: A survival analysis. Comprehensive Psychiatry, 80(1), 14–23. Crossref Medline, Google Scholar
  • Gunderson J. (2018). Mechanisms of change in treatment of personality disorders: Commentary on the special issue. Journal of Personality Disorders, 32(Suppl), 129–133. Link, Google Scholar
  • Gunderson J., , Bender D., , Sanislow C., , Yen S., , Rettew J. B., , Dolan-Sewell R., , Dyck I., , Morey L. C., , McGlashan T. H., , Shea M. T., , & Skodol A. E. (2003). Plausibility and possible determinant of sudden “remission” in borderline patients. Psychiatry: Interpersonal and Biological Processes, 66(2), 111–119. https://doi.org/10.1521/psyc.66.2.111.20614 Link, Google Scholar
  • Gunderson J., , Waldinger R., , Sabo A. N., , & Najavits L. M. (1993). Stages of changes in dynamic psychotherapy with borderline patients. Journal of Psychotherapy Practice and Research, 2(1), 64–72. Medline, Google Scholar
  • Hersh R. G., , McCommon B., , & Golkin E. (2019). Sharing a diagnosis of narcissistic personality: A challenging decision with associated risks and benefits. Current Behavioral Neuroscience Reports, 6, 133–140. https://doi.org/10.1007/s40473-019-00193-2 Crossref, Google Scholar
  • Hilsenroth M. J., , Holdwick D. J., , Castlebury F. D., , & Blais M. A. (1998). The effects of DSM-IV cluster B personality disorder symptoms on the termination and continuation of psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 35(2), 163–176. https://doi.org/10.1037/h0087845 Crossref, Google Scholar
  • Huprich S. K. (2014). Malignant self-regard. A self-structure enhancing the understanding of masochistic, depressive, and vulnerably narcissistic personalities. Harvard Review of Psychiatry, 22(5), 295–305. https://doi.org/10.1097/HRP.0000000000000019 Crossref Medline, Google Scholar
  • Jauk E., , & Kanske P. (2021). Can neuroscience help to understand narcissism? A systematic review of an emerging field. Personality Neuroscience, 4(3), 1–29. https://doi.org/10.1017/pen.2021.1 Google Scholar
  • Kazdin A. F. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27. Crossref Medline, Google Scholar
  • Kealy D., , Goodman G., , Rasmussen B., , Weideman R., , & Ogrodniczuk J. S. (2017). Therapists’ perspectives on optimal treatment for pathological narcissism. Personality Disorders: Theory, Research and Treatment, 8(1), 35–45. https://doi.org/10.1037/per0000164 Crossref, Google Scholar
  • Kealy D., , & Ogrodniczuk J. S. (2018). Mechanisms of change in treatments of personality disorders: Commentary on the special section. Journal of Personality Disorders, 32(Suppl), 134–142. https://doi.org/10.1521/pedi.2018.32.supp.134 Link, Google Scholar
  • Kernberg O. F. (1992). Aggression in personality disorders and perversions. Yale University Press. Crossref, Google Scholar
  • Kernberg O. F. (1995). Love relations: Normality and pathology. Yale University Press. Google Scholar
  • Kernberg O. F. (2007). The almost untreatable narcissistic patient. Journal of the American Psychoanalytic Association, 55, 503–539. Crossref Medline, Google Scholar
  • Kramer U. (2018). Mechanisms of change in treatments of personality disorders: Introduction to the special section. Journal of Personality Disorders, 32(Suppl), 1–11. Link, Google Scholar
  • Kramer U., , Pascual-Leone A., , Rohde K. B., , & Sachse R. (2016). Emotional processing, autointeraction process, and outcome in clarification-oriented psychotherapy for personality disorders: A process-outcome analysis. Journal of Personality Disorders, 30, 373–394. Link, Google Scholar
  • Kramer U., , Pascual-Leone A., , Rohde K. B., , & Sachse R. (2018). The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: An exploratory study. Clinical Psychology and Psychotherapy, 25(2), 272–282. https://doi.org/10.1002/cpp.2160. Crossref Medline, Google Scholar
  • Krebs P., , Norcross J. C., , Nicholson J. M., , & Prochaska O. (2018). Stages in change and psychotherapy outcomes. A review and meta-analysis. Journal of Clinical Psychology, 74(11), 1964–1979. Crossref Medline, Google Scholar
  • Lingiardi V., , & McWilliams N. (Eds). (2017). Psychodynamic Diagnostic Manual: PDM-2 (2nd ed.) Guilford Press. Google Scholar
  • Maillard P., , Berthoud L., , Kolly S., , Sachse R., , & Kramer U. (2020). Processes of change in psychotherapy for narcissistic personality disorder. Journal of Personality Disorders, 32(Suppl), 63–79. https://doi.org/10.1521/pedi.2020.34.supp.63 Link, Google Scholar
  • Moldovan R., , & Pintea S. (2015). Mechanisms of change in psychotherapy: Methodological and statistical considerations. Cognition, Brain, Behavior, 29(4), 299–311. Google Scholar
  • Nook E. C., , Jaroszewski A. C., , Finch E. F., , & Choi-Kain L. W. (2022). A cognitive-behavioral formulation of narcissistic self-esteem dysregulation. Focus, 20(4), 378–388. https://doi.org/10.1176/appi.focus.20220055 Crossref Medline, Google Scholar
  • 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(4), 439–443. https://doi.org/10.1037/per000003 Crossref, Google Scholar
  • Reed-Knight B., , & Fischer S. (2011). Treatment of narcissistic personality disorder symptoms in a dialectical behavior therapy framework: A discussion and case example. In Campbell K. W., & Miller J. D. (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings, and treatments (pp. 466–475). John Wiley. https://doi.org/10.1002/9781118093108.ch42 Crossref, Google Scholar
  • Ritter K., , Vater A., , Rüsch N., , Schröder-Abé M., , Schütz A., , Fydrich T., , Lammers C. H., , & Roepke S. (2014). Shame in patients with narcissistic personality disorder. Psychiatry Research, 215(2), 429–437. Crossref Medline, Google Scholar
  • Ronningstam E. (2005). Identifying and understanding narcissistic personality disorder. Oxford University Press. Google Scholar
  • Ronningstam E. (2012). Alliance building and the diagnosis of narcissistic personality disorder. Journal of Clinical Psychology, 68(8), 943–953. Crossref Medline, Google Scholar
  • Ronningstam E. (2017). Intersect between self-esteem and emotion regulation in narcissistic personality disorder—Implications for alliance building and treatment. Borderline Personality Disorder and Emotion Dysregulation, 4(3), 1–13. https://doi.org/10.1186/s40479-017-0054-8 Medline, Google Scholar
  • Ronningstam E. (2020). Internal processing in narcissistic personality disorder: Implications for assessment and treatment. Journal of Personality Disorders, 34(Suppl), 80–103. https://doi.org/10.1521/pedi.2020.34.supp.80 Link, Google Scholar
  • Ronningstam E. (2021). Narcissistic personality disorder: A basic guide for providers (4th ed.). www.mcleanhospital.org/npd-provider-guide Google Scholar
  • Ronningstam E., , & Baskin-Sommers A. (2013). Fear and decision-making in narcissistic personality disorder—A link between psychoanalysis and neuroscience. Dialogues in Clinical NeuroScience, 15(2), 191–201. https://doi.org/10.31887/DCNS.2013.15.2/eronningstam Crossref Medline, Google Scholar
  • Ronningstam E., , Gunderson J., , & Lyons M. (1995). Changes in pathological narcissism. American Journal of Psychiatry, 152, 253–257. Crossref Medline, Google Scholar
  • Ronningstam E., , & Weinberg I. (2013). Narcissistic personality disorder: Progress in recognition and treatment. Focus, 11(2), 167–177. https://doi.org/10.1176/appi.focus.11.2.167 Crossref, Google Scholar
  • Sachse R. (2019). Personality disorders: A clarification-oriented psychotherapy treatment model. Hogrefe Publishing. Crossref, Google Scholar
  • Schalkwijk F., , Luyten P., , Ingenhoven T., , & Dekker J. (2021). Narcissistic personality disorder: Are psychodynamic and the alternative DSM-5 model for personality disorders finally going to meet? Frontiers in Psychology, 12, 676733. https://doi.org/10.3389/fpsyg.2021.676733 Crossref Medline, Google Scholar
  • Simon R. I. (2002). Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder: A diagnostic challenge. Harvard Review of Psychiatry, 10(1), 28–36. https://doi.org/10.1080/10673220216206 Crossref Medline, Google Scholar
  • Smith M., , Sherry S. B., , Chen S., , Saklofske D. H., , Flett G. L., , & Hewitt P. L. (2016). Perfectionism and narcissism: A meta-analytic review. Journal of Research in Personality, 64, 90–101. https://doi.org/10.1016/j.jrp.2016.07.012 Crossref, Google Scholar
  • Stinson F. S., , Dawson D. A., , Goldstein R. B., , Chou S. P., , Huang B., , Smith S. M., , Ruan W. J., , Pulay A. J., , Saha T. D., , Pickering R. P., , & Grant B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(7), 1033–1045. https://doi.org/10.4088/jcp.v69n0701. Crossref Medline, Google Scholar
  • Stone M. (2006). Personality disordered patients: Treatable or untreatable. American Psychiatric Publishing. Google Scholar
  • Ucar S. (2017). Reluctance and resistance: Challenges in change in psychotherapy. Journal of Psychology and Clinical Psychiatry, 7(6), 00464. https://doi.org/10.15406/jpcpy.2017.07.00464 Crossref, Google Scholar
  • Vater A., , Ritter K., , Strunz S., , Ronningstam E., , Renneberg B., , & Röpke S. (2014). Stability of narcissistic personality disorder: Tracking categorical and dimensional rating systems over a two-year period. Personality Disorders: Theory, Research and Treatment, 5(3), 305–313. Crossref, Google Scholar
  • Watson P. J., , Little T., , Sawrie S. M., , & Biderman M. D. (1992). Measures of the narcissistic personality: Complexity of relationships with self-esteem and empathy. Journal of Personality Disorders, 6(4), 434–449. https://doi.org/10.1521/pedi.1992.6.4.434 Link, Google Scholar
  • Weinberg I., , & Ronningstam E. (2020). Dos and don'ts in treatment of NPD. Journal of Personality Disorders, 34(Suppl), 122–141. Link, Google Scholar
  • Weinberg I., , & Ronningstam E. (2022). Narcissistic personality disorder: Progress in understanding and treatment. Focus, 20(4), 368–377. https://doi.org/10.1176/appi.focus.20220052 Crossref Medline, Google Scholar
  • Weinberg I., , Ronningstam E., , & Gunderson J. (2023). Can patients with narcissistic personality disorder change? A case series [Unpublished manuscript]. Google Scholar
  • Weinberg I., , Finch E. F., , & Choi-Kain L. W. (2019). Implementation of good psychiatric management for narcissistic personality disorder: Good enough or not good enough? In Choi-Kain L. W., & Gunderson J. G. (Eds.), Applications of good psychiatric management for borderline personality disorder: A practical guide (pp. 253–279). American Psychiatric Association Publishing. Google Scholar
  • World Health Organization. (2019). International classification of diseases and related health problems (11th ed.). Author. https://icd.who.int/ Google Scholar
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