Can Patients With Narcissistic Personality Disorder Change? A Case Series.

ABSTRACT: The study was set out to establish the potential for psychotherapy to effect improvements in patients with narcissistic personality disorder (NPD). Eight patients with NPD who improved in treatment were identified. Consensus clinician/investigator diagnostic scores from before and after the psychotherapies were retroactively established on the Diagnostic Interview for Narcissism (DIN) and the Diagnostic Statistic Manual for Psychiatric Disorders, 5th Edition (DSM-5) Personality Disorder Section II criteria. Psychosocial functioning (work or school, romantic relationships) before and after the psychotherapies was retroactively evaluated as well. At the completion of the therapies after 2.5 to 5 years, all patients had improved, no longer met DIN or DSM-5 criteria for NPD, and showed better psychosocial functioning. Symptomatic improvements were associated with large effect sizes. In conclusion, changes in NPD can occur in treatment after 2.5 to 5 years. Future research should identify patient characteristics, interventions, and common processes in such improved cases that could help with development of treatments.

What do we need in order to successfully treat persons with pathological narcissism? How does change happen? Treatment principles and mechanisms of change emerging from single cases treated by experts: A commentary.

Persons with pathological narcissism (PN) or narcissistic personality disorder present with a wide array of symptoms and social problems. They need effective psychotherapies but empirical evidence for what works with them is mostly lacking. In this issue of the Journal and Clinical Psychology: In Session four authors from different orientations described single cases of patients suffering from different manifestations of PN. In this commentary we reviewed in detail the four cases and tried to distill (a) the treatment principles adopted; (b) the actual mechanisms of therapeutic change. We hope that the list of principles and mechanisms and change we identified here can help both clinicians and researchers develop and test effective options for persons with PN who are difficult to treat but do have chances to change in a meaningful way in treatment.

Treatment of Alec: "History does not have to repeat itself".

Treatment of patients with pathological narcissism presents several challenges and there is paucity of published case reports that document meaningful and durable change in patients suffering from this condition. Using descriptive and atheoretical language, this paper presents a treatment of a young man in his transition from young adulthood to middle adulthood while he was negotiating complex residues of his experiences of growing up along with developmental challenges related to work and love. Against the backdrop of these transitions, the patient was working through various aspects of functioning related to pathological narcissism. Initially, given academic pressures and past romantic disappointments, he was confronting issues related to perfectionism, self-criticism, and avoidance. While he was able to move past some of these dynamics and function academically, later challenges related to becoming an independent adult led to a retreat into an avoidant state of futility and pessimism. Working through painful family dynamics related to not being seen and controlled, along with a deepening attachment in therapy as well as confrontation with realities of his life, led him to take steps toward greater independence. Thereafter, his treatment focused on learning from life experiences such as a newly developed career and romantic life, accepting the complexity of self and others, and tolerating disillusionments.

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

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.

Narcissistic Personality Disorder: Progress in Understanding and Treatment.

This review summarizes current knowledge about narcissistic personality disorder (NPD). Each section brings the reader up to date on advances in our knowledge during the last decade. In terms of NPD diagnosis, this review describes the addition of the dimensional model to the categorical model. The accumulating knowledge has led to the description of grandiose and vulnerable narcissism as well as their complex interrelationship. Strong support exists for co-occurrence of these presentations among people with high levels of grandiose narcissism. Studies have identified mechanisms, in domains such as self-esteem dysregulation, emotion dysregulation, cognitive style, interpersonal relations, and empathy, and possible developmental and temperamental antecedents of the disorder. Thus, it appears that NPD has a multifactorial etiology and pathogenesis, with numerous mechanisms associated with each area of dysfunction. Longitudinal studies support the view that these patients can improve, but such improvement is gradual and slow. Several treatments have been developed for the disorder, and a majority share commonalities, including clear goals, attention to treatment frame, attention to relationships and self-esteem, alliance building, and monitoring of countertransference.

Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder.

This article identifies guiding principles in effective psychotherapies of patients with narcissistic personality disorder (NPD) and cautions against some common pitfalls. Individual psychotherapies of NPD patients were examined by both authors, who tested whether or not some principles, recommended in the literature, effectively promote these therapies and help these patients in moving forward with their lives and with effective therapy use. The authors identify a number of principles that were associated with more positive therapy development: helping patients identify goals and direction of their therapies, promoting a sense of agency, promoting a shift of focus to sense of vulnerability, and anticipating difficulty in developing and maintaining the treatment alliance. Common mistakes in these treatments are engaging in a power struggle with the patient, overindulging the grandiosity of the patient, directly challenging the grandiosity of the patient, and ignoring treatment-interfering behaviors. Identification of principles of effective therapies with NPD patients can help with the development of more effective treatment approaches for NPD.

Suicide attempts in major depressed patients with personality disorder.

Suicide attempters who met criteria for borderline personality disorder (BPD) comorbid with major depressive disorder (MDD) were compared to both suicide attempters suffering from MDD alone and to attempters with comorbid MDD and other personality disorders (PD). Participants were 239 (158 patients with comorbid PD and 81 patients with MDD without comorbidity) inpatients consecutively admitted after a suicide attempt made in the last 24 hours. Suicide attempters with comorbid MDD and BPD had more frequent previous suicide attempts and were more likely to have a history of aggressive behaviors and alcohol and drug use disorders compared with patients suffering from MDD without Axis II comorbidity.

Traumatic subjective experiences invite suicide.

The overwhelming events that lead to posttraumatic stress disorders and similar states are commonly understood to arise from noxious external events. It is however the unmasterable subjective experiences such events provoke that injure the mind and ultimately the brain. Further, traumatic over-arousal may arise from inner affective deluge with minimal external stimulation. Affects that promote suicide when sufficiently intense are reviewed; we propose that suicidal crises are often marked by repetitions (flashbacks) of these affects as they were originally endured in past traumatic experiences. Further, recurrent overwhelming suicidal states may retraumatize patients (patients who survive suicide attempts survive attempted murders, albeit at their own hands). We propose that repeated affective traumatization by unendurable crises corrodes the capacity for hope and erodes the ability to make and maintain loving attachments.

Common factors in empirically supported treatments of borderline personality disorder.

In this article, we examine the manuals of empirically supported psychotherapies for borderline personality disorder (BPD) by comparing their common and specific treatment strategies. We compare these treatments using a previously constructed scale of treatment interventions. Individual psychotherapies for BPD have several common strategies: clear treatment framework, attention to affect, focus on treatment relationship, an active therapist, and exploratory and change-oriented interventions. Use of interpretations, supportive interventions, designating treatment targets, attention to patient functioning, multimodal treatment, and support for therapies varied across the psychotherapies. We discuss these findings in the context of clusters of BPD symptoms, reports regarding overlap in treatment interventions used by various psychotherapies, and the effectiveness of specific treatment strategies.

Suicide fantasy as a life-sustaining recourse.

The suicide literature tends to lump all suicidal ideation together, thereby implying that it is all functionally equivalent. However obvious the claim that suicidal ideation is usually a prelude to suicidal action, some suicidal daydreaming tends to inhibit suicidal action. How are we to distinguish between those daydreams that augur an impending attempt from those that help patients calm down?

Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals.

OBJECTIVE: Many reports of treatments for suicidal patients claim effectiveness in reducing suicidal behavior but fail to demonstrate which treatment interventions, or combinations thereof, diminish suicidality. In this study, treatment manuals for empirically supported psychological treatments for suicidal patients were examined to identify which interventions they had in common and which interventions were treatment-specific. METHOD: Empirically supported treatments for suicidality were identified through a literature search of PsychLit and MEDLINE for the years 1970-2007, employing the following search strategy: [suicide OR parasuicide] AND [therapy OR psychotherapy OR treatment] AND [random OR randomized]. After identifying the reports on randomized controlled studies that tested effectiveness of different treatments, the reference list of each report was searched for further studies. Only reports published in English were included. To ensure that rated manuals actually correspond to the delivered and tested treatments, we included only treatment interventions with explicit adherence rating and scoring and with adequate adherence ratings in the published studies. Five manualized treatments demonstrating efficacy in reducing suicide risk were identified and were independently evaluated by raters using a list of treatment interventions. RESULTS: The common interventions included a clear treatment framework; a defined strategy for managing suicide crises; close attention to affect; an active, participatory therapist style; and use of exploratory and change-oriented interventions. Some treatments encouraged a multimodal approach and identification of suicidality as an explicit target behavior, and some concentrated on the patient-therapist relationship. Emphasis on interpretation and supportive interventions varied. Not all methods encouraged systematic support for therapists. CONCLUSION: This study identified candidate interventions for possible effectiveness in reducing suicidality. These interventions seem to address central characteristics of suicidal patients. Further studies are needed to confirm which interventions and which combinations thereof are most effective.

Eleven deaths of Mr. K.: contributing factors to suicide in narcissistic personalities.

The objective of this paper is to discuss and illuminate the problem of abrupt suicide in relatively well-functioning individuals without a major DSM-IV mental illness. A case of a man diagnosed with narcissistic personality, who first allegedly staged a suicide attempt and later, without overt warning, killed himself in the context of financial losses and divorce, will be discussed. The paper addresses how and why a life event can generate an internal subjective experience that evokes a sudden deadly self-attack. Discussion of eleven explanatory hypotheses serves to further the understanding of these seemingly inexplicable events. We conclude that additional studies are necessary, especially of the interconnected interaction between life event, psychological functioning, and neurobiological correlates to expand understanding and develop proactive treatment strategies.

The interface between borderline personality disorder and bipolar spectrum disorders.

OBJECTIVE: This review examines whether borderline personality disorder (BPD) should be considered part of the bipolar spectrum. METHODS: A literature review examined studies of co-occurrence, phenomenology, family prevalence, medication response, longitudinal course, and etiology. RESULTS: Borderline personality disorder and bipolar disorder co-occur, but their relationship is not consistent or specific. There are overlaps but important differences in phenomenology and in medication response. Family studies suggest clear distinctions, and it is unusual for BPD to evolve into bipolar disorder. Research is insufficient to establish whether these disorders have a common etiology. CONCLUSIONS: Existing data fail to support the conclusion that BPD and bipolar disorders exist on a spectrum but allows for the possibility of partially overlapping etiologies.

Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients.

This study examines the efficacy of a short-term individual therapy, Manual Assisted Cognitive Treatment (MACT), which was developed to treat parasuicidal (suicidal or self-harming) patients. In this trial, MACT was modified to focus on deliberate self-harm (DSH) in patients with borderline personality disorder (BPD). Thirty BPD patients who were engaged in DSH while in ongoing treatments, i.e., treatment-as-usual (TAU), were randomly assigned to receive MACT (N = 15) or not. DSH and level of suicide ideation were assessed at the baseline, at completion of the MACT intervention, and six months later. Results indicated that MACT was associated with significantly less frequent DSH upon completion of the intervention and with significantly decreased DSH frequency and severity at the six months follow-up. Moreover, MACT's contribution to reducing DSH frequency and severity was greater than the contribution by the amount of concurrent treatments. In contrast, MACT did not affect the level of suicide ideation and time-to-repeat of DSH. In conclusion, MACT seems to be a promising intervention for DSH in patients with BPD. More definitive studies are needed.

Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder.

OBJECTIVE: The purpose of this study was to test whether borderline personality disorder is a variant of bipolar disorder by examining the rates of co-occurrence in both disorders, the effects of co-occurrence on a longitudinal course, and whether the presence of either disorder confers the risk for new onsets of the other. METHOD: A prospective repeated-measures design with reliable independent diagnostic measures and 4 years of follow-up was used to assess 196 patients with borderline personality disorder and 433 patients with other personality disorders. RESULTS: Patients with borderline personality disorder had a significantly higher co-occurrence of bipolar disorder (19.4%) than did patients with other personality disorders. However, this co-occurrence did not appear to affect the subsequent course of borderline personality disorder. Although only 8.2% of the borderline personality disorder patients developed new onsets of bipolar disorder, this rate was higher than in patients with other personality disorders. Patients with other personality disorders with co-occurring bipolar disorder generally had more new onsets of borderline personality disorder (25%) than did patients with other personality disorders without co-occurring bipolar disorder (10%). CONCLUSIONS: A modest association between borderline personality disorder and bipolar disorder is reported.

Psychoanalytic perspectives on the treatment of an acute suicidal crisis.

The psychoanalytic understanding of suicide has greatly expanded in the past 30 years, and the older therapeutic approach has been modified. Although the turning of murder on the self inferred by Freud 90 years ago remains a cornerstone, current practice concentrates on the identification of a precipitating event, the escalation of intolerable painful affect that the patient cannot moderate, the self-perception of helplessness, the evolution of hopelessness as a secondary affect, increasing fantasies of suicide as a means of escape, and ego regression (self-deconstruction), leading progressively to suicide. Recent clinical research, advances in the study of cognition, and neurobiological studies have contributed to the reorientation and enrichment of the psychoanalytic perspective on suicide. The treatment of a university student who had fallen into a suicide crisis is discussed from the psychoanalytic point of view, and evidence for the efficacy of this treatment is reviewed.

Elevated suicide rates on the first workday: a replication in Israel.

This study verified variations in suicide rates throughout the days of the week among Israel Defense Force soldiers during 1974 - 2001. Results confirmed the findings of most previous studies. The first workday was associated with a 60% increase in suicide rate among young men. This increase was not observed among female reserve or professional soldiers. This finding might indicate a particular susceptibility of men to contextual and situational factors. The explanation of the increased suicide risk on the first workday stresses such processes as the broken-promise effect as well as difficulty in facing the demands of service and transitions from the weekend to the workweek.