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Quaderni di Psicoterapia Cognitiva - Open Access

Studies and researches

No. 52 (2023)

Narcissistic personality disorder. Conceptualization of the construct, empirical review on the effectiveness of treatments, principles and suggestions for good clinical practice

DOI
https://doi.org/10.3280/qpc52-2023oa16174
Submitted
luglio 6, 2023
Published
2023-07-17

Abstract

This work reviews historical contributions to the conceptualization of narcissism and Narcissistic Personality Disorder (NPD), including its evolution as a clinical diagnosis within the DSM classification of mental disorders. It focuses on the complexity of Narcissistic Personality Disorder and the importance of defining it as a continuum ranging from normal to abnormal personality expression. In this continuum, the authors identify two typical features, overt or grandiose and covert or vulnerable narcissism. Then, authors consider a wide variety of challenges that contribute to worse outcomes in therapies with NPD patients. Only few theoretical approaches have advanced treatments targeting NPD and hardly any of these treatments were tested in randomized controlled trials. Treating persons with PN, or with NPD is a challenge to clinicians as sound empirical evidence on how to treat them is lacking. The lack of empirically supported treatments has highlighted the need to provide some principles of “good clinical practice”, in line with the idea of a more integrated approach to the treatment of personality disorders.

References

  1. American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) (DSM-III). Washington, DC: American Psychiatric Publishing.
  2. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Washington, DC: American Psychiatric Publishing.
  3. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5). Washington, DC: American Psychiatric Publishing.
  4. Ball, S.A. (2007). Comparing individual therapies for personality disordered opioid dependent patients. Journal of Personality Disorders, 21: 305-321. DOI: 10.1521/pedi.2007.21.3.305.
  5. Ball, S.A., Cobb-Richardson, P., Connolly, A.J., Bujosa, C.T. & O’Neall, T.W. (2005). Substance abuse and personality disorders in homeless drop-in center clients: Symptom severity and psychotherapy retention in a randomized clinical trial. Comprehensive Psychiatry, 46: 371-379. DOI: 10.1016/j.comppsych.2004.11.003.
  6. Ball, S.A., Maccarelli, L.M., LaPaglia, D.M. & Ostrowski, M.J. (2011). Randomized trial of dual-focused vs. single-focused individual therapy for personality disorders and substance dependence. Journal of Nervous and Mental Disease, 199: 319-328. DOI: 10.1097/NMD.0b013e3182174e6f.
  7. Bamelis, L.L., Evers, S.M., Spinhoven, P. & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171: 305-322. DOI: 10.1176/appi.ajp.2013.12040518.
  8. Bateman, A. & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization based treatment. Oxford: Oxford University Press. DOI: 10.1093/med:psych/9780198527664.001.0001.
  9. Beck, A.T., Davis, D.D. & Freeman, A. (2015). Cognitive therapy of personality disorders, 3rd edition. New York: Guilford Press.
  10. Bleske-Rechek, A., Remiker, M.W. & Baker, J.P. (2008). Narcissistic men and women think they are so hot… but they are not. Personality and Individual Differences, 45: 420-424. DOI: 10.1016/j.paid.2008.05.018.
  11. Britton, R. (2004). Subjectivity, objectivity, and triangular space. Psychoanalytic Quarterly, 73: 47-61. DOI: 10.1002/j.2167-4086.2004.tb00152.
  12. Brown, D.P. & Elliott, D.S. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. W.W. Norton. DOI: 10.1080/00029157.2018.1544438.
  13. Brunell, A.B., Gentry, W.A., Campbell, W., Hoffman, B.J., Kuhnert, K.W. & DeMarree, K.G. (2008). Leader emergence: The case of the narcissistic leader. Personalityand Social Psychology Bulletin, 34: 1663-1676. DOI: 10.1177/0146167208324101.
  14. Buffardi, L.E. & Campbell, W.K. (2008). Narcissism and social networking web sites. Personality and Social Psychology Bulletin, 34: 1303-1314. DOI: 10.1177/0146167208320061.
  15. Cain, N.M., Pincus, A.L. & Ansell, E.B. (2008). Narcissism at the crossroads: phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clinical Psychology Review, 28: 638-656. DOI: 10.1016/j.cpr.2007.09.006.
  16. Caligor, E. & Stern, B.L. (2020). Diagnosis, Classification, and Assessment of Narcissistic Personality Disorder Within the Framework of Object Relations Theory. Journal of Personality Disorders, 34, Supplement: 104-121. DOI: 10.1521/pedi.2020.34.supp.104.
  17. Carcione, A., Nicolò, G. & Semerari, A. (2016). Curare i Casi Complessi. La Terapia Metacognitiva Interpersonale dei Disturbi di Personalità. Roma-Bari: Laterza.
  18. Carcione, A. & Semerari, A. (a cura di) (2017). Il narcisismo e i suoi disturbi: la terapia metacognitiva interpersonale. Firenze: Eclipsi.
  19. Clarkin, J.F., Levy, J.N., Lenzenweger, M.F. & Kernberg, O.F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164: 922-928. DOI: 10.1176/ajp.2007.164.6.922.
  20. Cooper, A. (1998). Nuovi sviluppi nella diagnosi clinica del Disturbo Narcisistico di Personalità In: Ronningstam, E.F. (a cura di). I disturbi del narcisimo. Diagnosi, clinica, ricerca. Milano: Raffaello Cortina.
  21. Crisp, H. & Gabbard, G.O. (2020). Principles of Psychodynamic Treatment for Patients With Narcissistic Personality Disorder. Journal of Personality Disorders, 34: Supplement: 143-158. DOI: 10.1521/pedi.2020.34.supp.143.
  22. De Panfilis, C., Antonucci, C., Meehan, K.B., Cain, N.M., Soliani, A., Marchesi, C., Clarkin, J.F. & Sambataro, F. (2019). Facial Emotion Recognition and Social-Cognitive Correlates of Narcissistic Features. Journal of Personality Disorders, 33: 433-449. DOI: 10.1521/pedi_2018_32_350.
  23. Dhawan, N., Kunik, M.E., Oldham, J. et al. (2010). Prevalence and treatment of narcissistic personality disorder in the community: a systematic review. Comprehensive Psychiatry, 51: 333-339. DOI: 10.1016/j.comppsych.2009.09.003.
  24. Diamond, D., Clarkin, J.F., Levy, K.N., Meehan, K.B., Cain, N.M., Yeomans, F.E. & Kernberg, O.F. (2014). Change in attachment and reflective function in borderline patients with or without narcissistic personality disorder in transference focused psychotherapy. Contemporary Psychoanalysis, 50: 175-201. DOI:10.1037/2Fper0000065.
  25. Dickinson, K.A. & Pincus, A.L. (2003). Interpersonal analysis of grandiose and vulnerable narcissism. Journal of Personality Disorders, 17: 188-207. DOI: 10.1521/pedi.17.3.188.22146.
  26. Dimaggio, G. & Semerari, A. (2003). I disturbi di personalità. Modelli e trattamento. Roma-Bari: Laterza.
  27. Dimaggio, G. & Attinà, G. (2012). Metacognitive Interpersonal Therapy for Narcissistic Personality Disorders with perfectionistic features: The case of Leonardo. Journal of Clinical Psychology, 68: 922-934. DOI: 10.1002/jclp.21896.
  28. Dimaggio, G. (2022). Treatment principles for pathological narcissism and narcissistic personality disorder. Journal of Psychotherapy Integration, 32(4): 408-425. DOI: 10.1037/int0000263.
  29. Dimaggio, G., Fiore, D., Lysaker, P.H., Petrilli, D., Salvatore, G., Semerari, A. et al. (2006). Early narcissistic transference patterns: An exploratory single case study from the perspective of dialogical self theory. Psychology and Psychotherapy: Theory, Research and Practice, 79(4): 495-516. DOI: 10.1348/147608305X 63089.
  30. Dimaggio, G., Carcione, A., Conti, M.L., Nicolò, G., Fiore, D., Pedone, R., Popolo, R., Procacci, M. & Semerari, A. (2009). Impaired decentration in Personality Disorder: An analysis with the Metacognition Assessment Scale. Clinical Psychology e Psychotherapy, 16: 450-462. DOI: 10.1002/cpp.619.
  31. 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 and emotional inhibition as predictors of personality disorder. Comprehensive Psychiatry, 83: 71-78. DOI: 10.1016/j.comppsych.2018.03.005.
  32. Dimaggio, G., Nicolò, G., Fiore, R., Pedone, R., Popolo, R., Centenero, E., Semerari, A. & Carcione, A. (2008). States of minds in narcissistic personality disorder. Three psychotherapy patients analysed through the Grid of Problematic States. Psychotherapy Research, 18: 466-480. DOI: 10.1080/10503300701881877.
  33. Dimaggio, G., Petrilli, D., Fiore, D. & Mancioppi, S. (2003). Il Disturbo Narcisistico di Personalità: la malattia della grande vita (pp. 161-200). In: Dimaggio, G. & Semerari, A. (a cura di), I Disturbi di personalità. Modelli e trattamento. Roma-Bari: Laterza.
  34. Dimaggio, G., Procacci, M. & Semerari, A. (1999). Deficit di condivisone e di appartenenza (pp. 231-279). In: Semerari, A. (a cura di), Psicoterapia cognitiva del paziente grave. Milano: Raffaello Cortina.
  35. Dimaggio, G., Salvatore, G., Lysaker, P.H., Ottavi, P., & Popolo, R. (2015). Behavioral activation revised as a common mechanism of change for personality disorders psychotherapy. Journal of Psychotherapy Integration, 25: 30-38. DOI: 10.1037/a0038769.
  36. Dimaggio, G., Semerari, A., Carcione, A., Nicolò, G. & Procacci, M. (2007). Psychotherapy of Personality Disorders: Metacognition, States of Mind and Interpersonal Cycles. New York: Routledge.
  37. Dimaggio, G., Semerari, A., Falcone, M., Nicolò, G., Carcione, A. & Procacci, M. (2002). Metacognition, states of mind, cognitive biases and interpersonal cycles. Proposal for an integrated model of Narcissism. Journal of Psychotherapy Integration, 12: 421-451. DOI: 10.1037/1053-0479.12.4.421.
  38. Dimaggio, G., Ottavi, P., Popolo, R. & Salvatore, G. (2019). Corpo, immaginazione e cambiamento. Terapia Metacognitiva Interpersonale. Milano: Raffaello Cortina.
  39. Drozek, R.P. & Unruh, B.T. (2020). Mentalization-Based Treatment for Pathological Narcissism. Journal of Personality Disorders, 34: 177-203. DOI: 10.1521/pedi.2020.34.supp.177.
  40. Edershile, E.A. & Wright, A.G.C. (2021). Fluctuations in grandiose and vulnerable narcissistic states: A momentary perspective. Journal of Personality and Social Psychology, 120(5): 1386-1414. DOI: 10.1037/pspp0000370.
  41. Etchegoyen, R.H. (2005). The fundamentals of psychoanalytic technique. London: Karnac.
  42. Farwell, L. & Wohlwend-Lloyd, R. (1998). Narcissistic processes: Optimistic expectations, favorable self-evaluations, and self-enhancing attributions. Journal of Personality, 66: 65-83. DOI:10.1111/1467-6494.00003.
  43. 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, Supplement: 24-41. DOI: 10.1521/pedi.2020.34.supp.25.
  44. Fossati, A., Somma, A., Borroni, S., Pincus, A.L., Markon, K.E. & Krueger, R.F. (2017). Profiling pathological narcissism according to DSM-5 domains and traits: Astudy on consecutively admitted Italian psychotherapy patients. Psychological Assessment, 29(11): 1400-1411. DOI: 10.1037/pas0000348.
  45. Gordon, K.H. & Dombeck, J.J. (2010). The associations between two facets of narcissism and eating disorder symptoms. Eating Behaviors, 11: 288-292. DOI: 10.1016/j.eatbeh.2010.08.004.
  46. Hart, W., Adams, J., Burton, K.A. & Tortoriello, G.K. (2017). Narcissism and self-presentation: Profiling grandiose and vulnerable narcissists’ self-presentation tacticuse. Personality and Individual Differences, 1044: 8-57. DOI: 10.1016/j.paid.2016.06.062.
  47. Hasin, D.S. & Grant, B.F. (2015). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Social Psychiatry and Psychiatric Epidemiology, 50: 1609-1640. DOI: 10.1007/s00127-015-1088-0.
  48. Hepper, E.G., Hart, C.M. & Sedikides, C. (2014). Moving Narcissus: Can narcissists beempathic? Personality and Social Psychology Bulletin, 40: 1079-1091. DOI: 10.1177/0146167214535812.
  49. Horton, R.S. & Sedikides, C. (2009). Narcissistic responding to ego threat: When thestatus of the evaluator matters. Journal of Personality, 77: 1493-1525. DOI: 10.1111/j.1467-6494.2009.00590.x.
  50. John, O.P. & Robins, R.W. (1994). Accuracy and Bias in Self-perception: Individual Differences in Self-Enhancement and the role of Narcissism. Journal of personality and social psychology, 66: 206-219. DOI: 10.1037/0022-3514.66.1.206.
  51. Kealy, D., Ogrodniczuk, J.S., Joyce, A.S., Steinberg, P.I. & Piper, W.E. (2015). Narcissism and Relational Representations Among Psychiatric Outpatients. Journal of Personality Disorders, 29: 393-407. DOI: 10.1521/pedi_2013_27_084.
  52. Kealy, D., Ogrodniczuk, J.S., Rice, S.M. & Oliffe, J.L. (2017). Pathological narcissism and maladaptive self-regulatory behaviours in a nationally representative sample of Canadian men. Psychiatry Research, 256: 156-161. DOI:10.1016/j.psychres.2017.06.009.
  53. Kernberg, O.F. (1992) Aggression in Personality Disorders and Perversions. Yale: University Press.
  54. Kernberg, O.F. (1970). A psychoanalytic classification of character pathology. Journal of the American Psychoanalytic Association, 18(4): 800-822. DOI: 10.1177/000306517001800403.
  55. Kernberg, O.F. (2007). The almost untreatable narcissistic patient. Journal of the American Psychoanalytic Association, 55: 503-539. DOI: 10.1177/00030651070550020701.
  56. Kohut, H. (1977). The Restoration of the Self. New York: International Universities Press.
  57. Krizan, Z. & Johar, O. (2015). Narcissistic rage revisited. Journal of Personality and Social Psychology, 108(5): 784-801. DOI: 10.1037/pspp0000013.
  58. Leder, J., Foster, J.D. & Schütz, A. (2020). Willing to do what others won’t: Narcissism, risktaking, and social approval. Personality and Individual Differences, 153: article 109672. DOI: 10.1016/j.paid.2019.109672.
  59. Lenzenweger, M.F., Lane, M.C., Loranger, A.W. & Kessler, R.C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replica. Biol Psychiatry, 62(6): 553-564. DOI: 10.1016/j.biopsych.2006.09.019.
  60. Livesley, W.J. (2012). Integrated treatment: a conceptual framework for an evidence-based approach to the treatment of personality disorder. Journal of Personality Disorders, 26: 17-42. DOI: 10.1521/pedi.2012.26.1.17.
  61. Miller, J.D., Dir, A., Gentile, B. et al (2010). Searching for a vulnerable dark triad: comparing factor 2 psychopathy, vulnerable narcissism, and borderline personality disorder. Journal of Personality, 78: 1529-1564. DOI: 10.1111/j.1467-6494.2010.00660.x.
  62. Miller, J.D., Price, J., Gentile, B., Lynam, D.R. & Campbell, W.K. (2012). Grandiose and vulnerable narcissism from the perspective of the interpersonal circumplex. Personality and Individual Differences, 53: 507-512. DOI: 10.1016/j.paid.2012.04.026.
  63. Modell, A.H. (1984). Psychoanalysis in a New Context. International Universities Press.
  64. Moeller, S.J., Crocker, J. & Bushman, B.J. (2009). Creating hostility and conflict: Effects of entitlement and self-image goals. Journal of Experimental Social Psychology, 45: 448-452. DOI: 10.1016/j.jesp.2008.11.005.
  65. Pincus, A.L. & Lukowitsky, M.R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 68: 943-953. DOI: 10.1146/annurev.clinpsy.121208.131215.
  66. Pincus, A.L., Cain, N.M. & Wright, A.G. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disorders: Theory, Research and Treatment, 5: 439-443. DOI: 10.1037/per0000031.
  67. Reed-Knight, B. & Fischer, S. (2011). Treatment of narcissistic personality disorder symptoms in a dialectical behaviour therapy framework: a discussion and case example. In: Campbell, W.K. & Miller, J.D. (a cura di), The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments. John Wiley & Sons. DOI: 10.1002/9781118093108.ch42.
  68. 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: 429-437. DOI: 10.1016/j.psychres.2013.11.019.
  69. Ronningstam, E. (1996). Pathological narcissism and narcissistic personality disorder in Axis I disorders. Harvard Review of Psyhciatry, 3: 326-340. DOI: 10.3109/10673229609017201.
  70. Ronningstam, E. (2005). Identifying and understanding the narcissistic personality. New York: Oxford University Press.
  71. Ronningstam, E. (2009). Narcissistic personality disorder: Facing DSM-5. Psychiatric Annals, 39: 111-121. DOI: 10.3928/00485713-20090301-09.
  72. Ronningstam, E. (2017). Intersect between selfesteem and emotion regulation in narcissistic personality disorder. Implications for alliance building and treatment. Borderline Personality Disorder and Emotion Dysregulation, 4(3): 1-13. DOI: 10.1186/s40479-017-0054-8.
  73. Ronningstam, E. (2020). Internal processing in patients with pathological narcissism or narcissistic personality disorder: Implications for alliance building and therapeutic strategies. Journal of Personality Disorders, 34, Supplement: 80-103. DOI: 10.1521/pedi.2020.34.supp.80.
  74. 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: 191-201. DOI: 10.31887/DCNS.2013.15.2/eronningstam.
  75. Ronningstam, E. & Weinberg, I. (2013). Narcissistic personality disorder: Progress in recognition and treatment. Focus: The Journal of Lifelong Learning in Psychiatry, 11: 167-177. DOI: 10.1176/appi.focus.11.2.167.
  76. Ronningstam, E. & Weinberg, I. (2023). Narcissistic Personality Disorder: Patterns, processes, and Indicators of Change in Long-term Psychotherapy. Journal of Personality Disorders. In press.
  77. Safran, J.D. & Muran, J.C. (2000). Negotiating the therapeutic alliance. A relational treatment guide. New York: Guilford Press.
  78. Scopelliti, I., Loewenstein, G. & Vosgerau, J. (2015). You call it “self-exuberance”, I callit “bragging”: Miscalibrated predictions of emotional responses to self-promotion. Psychological Science, 26: 903-914. DOI: 10.1177/0956797615573516.
  79. Silverman, B.C., Asby, A., Brendel, D.H., Choras, P., Chu, J.A., Holman, J. & Bodkin, J.A. (2012). Psychiatric treatment of the VIP: Some paradoxical risks. Journal of Nervous and Mental Disease, 200: 545-548. DOI: 10.1097/NMD.0b013e318257c805.
  80. 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. The Journal of clinical psychiatry, 69(7): 1033-1045. DOI: 10.4088/jcp.v69n0701.
  81. Torgersen, S. (2012). Epidemiology. In: Widiger, T.A. (a cura di), The Oxford handbook of personality disorders. Oxford: Oxford University Press.
  82. Thomaes, S., Brummelman, E. & Sedikides, C. (2018). Narcissism: A social-developmental perspective. In: Zeigler-Hill, V. & Shackelford, T.K. (a cura di), The SAGE handbook of personality and individual differences: Applications of personality and individual differences. SAGE Publications. DOI: 10.4135/9781526451248.n16.
  83. Urbonaviciute, G. & Hepper, E.G. (2020). When is narcissism associated with low empathy? A meta-analytic review. Journal of Research in Personality, 89: 104036. DOI: 10.1016/j.jrp.2020.104036.
  84. Vinnars, B., Barber, J.P., Norén, K., Gallop, R. & Weinryb, R.M. (2005). Manualized supportive-expressive psychotherapy versus non manualized community-delivered psychodynamic therapy for patients with personality disorders: Bridging efficacy and effectiveness. American Journal of Psychiatry, 162: 1933-1940. DOI: 10.1176/appi.ajp.162.10.1933.
  85. Weinberg, I. & Ronningstam, E. (2020). Dos and Don’ts in Treatments of Patients With Narcissistic Personality Disorder. Journal of Personality Disorders, 34: Supplement, 122-142. DOI: 10.1521/pedi.2020.34.supp.122.
  86. Westen, D. (1990). The relations among narcissism, egocentrism, self-concept, and self-esteem: Experimental, clinical, and theoretical considerations. Psychoanalysis and Contemporary Thought, 13, 183-239.
  87. Yakeley, J. (2018). Current understanding of narcissism and narcissistic personality disorder. The British Journal of Psychiatry, 24: 305-315. DOI: 10.1192/bja.2018.20.
  88. Young, J.E., Klosko, J.S. & Weishaar, M.E. (2003). Schema Therapy: A Practitioner’s Guide. New York: Guilford Press. DOI: 10.1007/s11630-003-0064-2.
  89. Zimmerman, M., Chelminski, I. & Young, D. (2008). The frequency of personality disorders in psychiatric patients. Psychiatric Clinics of North America, 31: 405-420. DOI: 10.1016/j.psc.2008.03.015.

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