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Narcissistic Personality Disorder:
Facing DSM-V
P
sychoanalytic theories and clini- cal case studies of patients with narcissistic character pathology were most influential in outlining the conceptualization and description of the narcissistic personality disorder (NPD) when it was first included as a diagnostic category in the Diagnostic and Statistic Manual of Mental Disorders , third edi- tion, (DSM-III) in 1980. This was elo- quently summarized by Salman Akhtar.^1 Influences from other disciplines, (ie, psychiatric and psychosocial research on epidemiology and prototypical features), as well as academic social psychological inventory and laboratory studies of hu- man behavior, have contributed additional perspectives on pathological narcissism and NPD. More recently, cognitive neu- ropsychology and studies of infant and child development have also added valu- able information to our understanding of the origins of pathological narcissism and specific areas of narcissistic personality functioning. Three recent reviews2-4^ have
Elsa Ronningstam, PhD
© Medusa Lemieux / Pennsylvania College of Art & Design Elsa Ronningstam, PhD, is Associate Clinical Professor, Harvard Medical School, and Psychol- ogist, McLean Hospital. Address correspondence to: Elsa Ron- ningstam, PhD, McLean Hospital, 115 Mill Street, Belmont MA 02478; or e-mail ron- ningstam@email.com. Dr. Ronningstam has disclosed no relevant financial relationships.
112 | PsychiatricAnnalsOnline.com PSYCHIATRIC ANNALS 39:3 | MARCH 2009 summarized available knowledge and suggested new avenues toward improve- ment in diagnosis and clinical conceptu- alization of NPD. Clinical accounts of the narcissistic personality indicate a range of charac- teristics and behaviors among these pa- tients. Some match the typical expecta- tion of a narcissistic personality (ie, being boastful, assertive, and arrogant). Others can initially appear friendly and tuned in, but gradually become strikingly distant and aloof. Some can be modest and unas- suming with an air of grace. Still others present as perpetual failures, while con- stantly driven by unattainable, grandiose aims. One can be shy and quiet, another charming and talkative, yet another dom- ineering, aggressive, and manipulative. Absence of symptoms and experiences of suffering can be a paradoxical blessing for some people with NPD while others are prone to depression, substance use, mood swings, or eating disorder. Some people effectively hide their narcissistic aims, while others openly and bluntly ex- hibit their most extreme narcissistic char- acteristics. Nevertheless, the underlying commonality is that they all struggle with grandiosity, self-esteem fluctuations, limitations in their interpersonal relation- ships, and intense emotional reactions to threats to their self-experience. Empirical studies have supported the clinical observations that pathological narcissism can be expressed in temporary traits or in a stable, enduring personality disorder. It can be identified as symp- toms that to various degrees influence and limit interpersonal and/or vocation- al functioning, or as context-determined narcissistic reactions.5,6^ Independently of level of severity, pathological narcis- sism can either show as overt, striking and obtrusive symptoms and function- ing, or it can be internally concealed and unnoticeable.1,7^ Narcissism can also take malignant forms and co-occur with anti- social behavior or psychopathy.8, Currently, there is evidence within four areas of relevance for NPD that can fur- ther guide the discussion about the diag- nosis of NPD and its delineating criteria. Regulatory patterns in pathological nar- cissism can be identified within a range of narcissistic features. The range of function, phenotype, changeability, and empathy in NPD will be discussed and integrated into reformulations of charac- teristics that can represent, describe, and help understand people with disordered narcissism and NPD. THE FUNCTIONAL RANGE The variable prevalence rates of NPD in different settings imply a functional range in people given this diagnosis (see Table 1). Several studies have indicated functional impairment and mental dis- ability, especially when co-occurring with major Axis I disorders such as sub- stance use and mood and anxiety disor- ders.10-12^ A recent study, Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC),^13 found a lifetime prevalence rate of 6% (7.7% for men and 4.8% for women) in the general population, with considerable psycho- social disability, especially among men, and co-occurring mood disorders (de- pression, bipolar I disorder), anxiety disorder, personality disorders, and sub- stance use disorder. On the other hand, the NPD diagno- sis has more often been reported in out- patient private practice and small clinics as compared with the general population and larger psychiatric settings. NPD has also been diagnosed in non-psychiatric professional settings such as the mili- tary and medical school, indicating that NPD does not necessarily cause nor is it necessarily accompanied by impairment in ability to work, or in social or daily functioning. In other words, people with NPD, contrary to most other personality disorders, include both those who are high-functioning who can be profession- ally and socially successful, as well as those with functional impairment, with severely disabling narcissistic traits and character functioning or accompanying Axis I disorders. There are several possible explana- tions to the high functional ability in people with NPD. One suggests that they can appear stable stoic, rigorous, and organized despite internal dysregu- lation, hyperreactivity, and fluctuations. Their surface functioning and absence of symptomatology, combined with in- terpersonal distance and difficulties with self-disclosure, may support their internal control and allow their internal suffering to remain bypassed or hidden. Another suggests that people with NPD cause dis- tress, pain, and suffering in others while they themselves are oblivious and do not experience their own suffering. Those without accompanying Axis I disorder who also can avoid professional or per- sonal failure may not experience psycho- logical stress at all.^10 A third explanation relates to the range of narcissism from healthy and extraordinary to pathological and malignant.^14 Co-exis- TABLE 1.
Prevalence of NPD
General population 0%-5.3%86- Wave 2, NESARC lifetime prevalence 4.8%-7.7%^13 Clinical population 1.3%-17%53,91- Forensic population (^) 6%^95 Outpatient private practice 8.5%-20%67,96, Military setting (NPD and NP traits) 20%98, 99 Medical school, first-year students 17%^100
114 | PsychiatricAnnalsOnline.com PSYCHIATRIC ANNALS 39:3 | MARCH 2009 trait and the most distinguishing and dif- ferentiating characteristic for NPD, is re- active and state-dependent. For instance, it can be influenced by brief depressive reactions or depressive disorder causing a more self-critical and humble attitude, or by moving from late adolescence to adult- hood with experiences of more realistic achievements and interpersonal experi- ences that stabilize self-esteem. Sudden threats to self-esteem or to more favor- able self-images can temporarily increase defensive grandiose behavior, such as an- ger and hostility.31,32^ Alternatively, such threats can cause a loss of self-esteem with shame and detachment.^33 A continu- ous search for others’ affirmation of the grandiose but vulnerable self is typical, as is the use of interpersonal self-regulatory strategies such as self-enhancing behav- ior and blaming others for failures. On the other hand, corrective life events, such as achievements, relationships, and manage- able disillusionments, can contribute to a more realistic alignment of the self-es- teem and of the evaluation of the person’s own capacity and potential.^5 In addition, life events such as losses and narcissistic injuries can also promote disengagement from inhibitions and can lead to meaning- ful engagements and self-representational change in the context of achieving more realistically anchored ego-ideals.^34 Depression and anxiety, not endem- ic to NPD but resulting from problems, failures, or realizations of their own limitations, may also cause changes in narcissistic individuals’ general functioning.^10 Stress associated with external experiences can escalate nar- cissistic symptoms and functioning, overwhelm the self, and trigger symp- toms such as shame, humiliation, and rage. Although underlying vulnerabil- ity to such stress can stem from the presence of pathological narcissism or NPD, even relatively healthy people can develop narcissistic symptoms af- ter experiencing more or less severe narcissistic threats or humiliation.^6
THE RANGE OF EMPATHIC
FUNCTIONING
Empathy, usually considered an inborn and naturally occurring ability, is also a complex, multidimensional regulatory process that requires skills, tact, and ex- perience. Empathy is an essential aspect of self-esteem regulation, and it is crucial for the ability to master interpersonal re- lationships and social interactions. Com- promised or fluctuating empathic process- ing is basic to pathological narcissism and NPD. Recent studies on empathic func- tioning have implications for identify- ing, understanding, and treating empathic deficits in narcissistic patients. Social psychological research has identified empathic regulation in terms of cognitive empathy (perceiving the ex- pression in others and theory of mind) and emotional empathy (affective recog- nition of the emotions perceived in oth- ers). Both empathic accuracy and em- pathic concern are involved in empathic regulation and both can vary indepen- dently^35 (ie, an individual can present with empathic accuracy in the absence of em- pathic concern, and vice versa). Netzlek and colleagues^36 suggested that people have dispositional ability to be empathic (ie, to perceive and experience the emo- tions of others), but situational factors can influence, or even overwhelm the expres- sions of such abilities. They concluded: “… the capacity to experience empathy in the right contexts can be viewed as a skill or ability rather than an automatic, dispositionally driven process … Such an ability is likely related to people’s ability to regulate their emotions.”^35 Empathy refers to the ability to perceive the inner psychological state of others and to identify and feel the feelings and needs of other people. Decety and colleagues^37 identified four neuropsychological com- ponents involved in empathic capability: affect sharing is based on the ability to mimic and the development of shared rep- resentations between self and others; self- other awareness requires a sense of self- agency and separateness from the other; mental flexibility includes the ability for perspective-taking and adopting the oth- er’s subjective perspective; and emotional regulation holds emotional resonance and reappraisal. Self-awareness and self- regulation are also central components in empathic functioning. Those require sev- eral abilities (ie, to identify and feel one’s own emotions and separate oneself from one’s own feelings); to recognize the other person as similar to one’s self but at the same time as separate and different from one’s self; and the ability to regulate and inhibit one’s own emotional expressions. Fonagy^38 suggested empathy dysfunction can stem from impaired capacity to un- derstand own feelings and disconnected interpersonal affective interpretative func- tion, which are essential in emotional reso- nance. Low affect tolerance, or strong re- actions to the perception of the feelings of others, especially helplessness and shame, tend to impair capacity for empathic con- cern.^39 On the other hand, self-serving and self-enhancing strivings also interfere with empathic capability.^40 In addition, empa- thy is modulated by cultural values and personal, developmental experiences. Empathic Variations in Psychiatric Samples Studies of empathic functioning in psychiatric samples can provide some information relevant to understanding the narcissistic individual’s empathic abilities and limitations. People with autism have difficulties with “cognitive empathy” (ie, perceiving the expression in another person’s face). They also have problems with empathic accuracy, (ie, to accurately infer or even recognize the ex- istence of others’ thoughts and feelings). However, variations in empathic ability, especially empathic accuracy, have been found along the autism spectrum.^41 Pa- tients with schizophrenia have a general empathic deficit manifest across all do- mains of empathy-related processes.^42 However, notable variations are related
PSYCHIATRIC ANNALS 39:3 | MARCH 2009 PsychiatricAnnalsOnline.com | 115 to the symptoms and source that cause a specifi c deficit. For instance, patients with schizophrenia with paranoid symp- toms are hypersensitive to threats and therefore likely to misinterpret others’ facial intentions and expressions. On the other hand, an inability to feel what the others feel (affective blunting) can also lead to a misidentification of others’ fa- cial expressions. Blair and colleagues^43 found a high degree of selectivity in empathic func- tioning in people with psychopathy. They concluded that while these people have an impaired ability to process selective emotional expressions (fear, sadness, dis- gust), there is no evidence that they have a cognitive or “theory of mind”-related empathic impairment. Similarly, studies of empathic functioning in people with antisocial personality disorder (ASPD) also show that they do not have basic “cognitive or “theory of mind” deficits, or difficulties reading basic or complex emotions from facial expressions. In- stead, their problems refer to their ability to make empathic inference about how others feel.^44 Patients with borderline per- sonality disorder (BPD) have been con- sidered above average in their ability to infer others’ thoughts and feelings. How- ever, Flury and Ickes^45 challenged this as- sumption in a study of paired BPD–non- BPD dyads whose ability to accurately read thoughts and feelings of each other were measured. They concluded that people with BPD do not have empathic impairment (ie, they are capable of pro- cessing the complex borderline-related dysregulatory emotional experiences in themselves and others, but they do not have exceptional or above-average em- pathic capability). Conditions related to pathological narcissism have been associated with low levels of cognitive empathy (preoccupa- tion with other things). Gilgun^46 identi- fied a high degree of self-centeredness in perpetrators of child abuse (ie, “a focus on the self so intense that it precludes consideration of the feelings and choices of others and which at times causes di- rect emotional and/or physical harm to others”).^46 Similarly, Wiehe^47 found an inverse correlation between empathy and need for power, control, and dominance in child abuse perpetrators. Implications for Empathic Functioning in Narcissistic Individuals Compromised empathic functioning causing recurrent interpersonal failures or conflicts can be a source of fluctuating or low self-esteem and underlying inse- curity. The narcissistic individual, ready to blame others, may or may not be aware of such a deficit. Several possible factors may impact the narcissistic individual’s empathic capability and functional pat- tern. Those include: a) High degree of self-centeredness and focus on self-enhancing and self- serving interpersonal strivings; b) Emotional dysregulation (ie, in- sensitivity or impaired ability to appraise certain emotions in others, such as de- spair, sadness, grief, joy, happiness; or difficulties in tolerating, modulating, and processing certain of one’s own emotions triggered by the perception of others’ experiences or emotions, such as strong negative feelings of contempt, shame, rage or envy); c) Self-esteem dysregulation, where the perception of others’ experiences evoke self- promoting or self-enhancing strivings, or alternatively, feelings of in- feriority, powerlessness; and d) Superego dysregulation, with com- promised ability for care and concern, exploitative efforts, disregard for the pos- sessions, and well-being of other people, or deceitfulness. Narcissistic people may be able to ap- propriately empathize when feeling in control or when their self-esteem is un- challenged or promoted. Some can em- pathize more with others’ positive feel- ings and success-related experiences than with others’ negative feelings or defeats and vice versa. Those influenced by envy can be unable to tolerate others’ positive events and feelings, while those who tend to mirror themselves in the light of others may perceive others’ success as an opportunity for self-enhancement. Simi- larly, those who readily feel contempt can find others’ defeats and losses despi- cable and secure their own superiority or perfectionism in the comparison between self and the other. Others are able to em- pathize under certain circumstances (ie, when asked for advice by a friend who has marital problems, but unable to relate to their own marital problems as pointed out by the spouse). A guide for evalua- tion of the narcissistic patient’s specific individual empathic deficits and func- tional patterns is outlined in the Sidebar (see page 116). Empathic dysfunction and compro- mised ability for empathic processing can disable the narcissistic patient from accurately perceiving and experiencing empathy from another person. This has Sudden threats to self- esteem or to more favorable self-images can temporarily increase defensive grandiose behavior, such as anger and hostility.
PSYCHIATRIC ANNALS 39:3 | MARCH 2009 PsychiatricAnnalsOnline.com | 117 logical narcissism that range beyond the DSM-IV-text revision^69 criteria set, or people who have less severe or less overt narcissistic pathology and for various reasons do not meet any combination of five required criteria, will consequently not be correctly identified. The current NPD criterion set has re- peatedly been criticized for its low speci- ficity with high diagnostic overlap and comorbidity. The fact that the diagnosis is heavily relying on overt and one-sided determinants of grandiosity and on con- text-dependent external symptoms or pat- terns of reactions and interpersonal inter- actions has contributed to this problem. In addition, the narcissistic individual’s experiences of the complex interplay be- tween self-esteem fluctuations and emo- tional dysregulation within the interper- sonal context are not adequately captured. Consequently, there is reluctance among clinicians to use the diagnosis, and pa- tients tend to strongly oppose to being “labeled” NPD, conceiving it as more prejudicial than informative and helpful. An integrative diagnostic approach for pathological narcissism and NPD with al- ternative formulations is much called for, one that focuses more on basic indicators for the range of narcissistic personality functioning and less on symptomatic fea- tures or phenotypic categories (see Table 2, page 118). Such a diagnostic approach should evaluate basic characteristics of nar- cissistic functioning, and differentiate tem- porary fluctuating or externally triggered shifts in narcissistic functioning from en- during indications of pathological narcis- sism. Regulation of self-esteem, a central part of self-regulation, is identified as the motivating force in narcissistic function- ing, and its vulnerability and fluctuations are indicated by reactions to threats and challenges to the self-esteem (ie, the most significant trait of NPD; compare vulner- ability and reactions with abandonment as a central marker for borderline personality disorder). A broader definition of grandios- ity captures not only a sense of superiority and success fantasies, but is also expressed in terms of perfectionism and high ideals and is sustained through self-enhancing and self-serving interpersonal behavior. These reformulations serve to expand the spectrum of grandiosity-promoting striv- ings and activities, capture its fluctuations, and attend to the narcissistic individual’s internal experiences and motivation. Independently of whether the future DSM will remain categorical or move toward a dimensional perspective, the conceptualization of NPD in terms of a range of narcissistic dysregulatory func- tioning aims at improving clinical utility, promoting awareness, and understanding, and motivating and guiding treatment for both clinicians and patients. ALTERNATIVE FORMULATIONS
1. Grandiosity Grandiosity is by now an evidence- based criterion, and the most distinguish- ing and discriminating for NPD.25,70, However, it is also limited by the few external features assigned to it. The dif- ferentiation between enhanced compared with unrealistic sense of superiority, and the inclusion of value, capability, and fan- tasies of unfulfilled achievements serve to capture a broader functional range of narcissism and to make the diagnosis applicable to both those with NPD who are vocationally higher functioning and those who are disabled. For the purpose of clinical utility, it is useful to evaluate grandiosity not only in terms of its sur- face expressions but also in the context of its functional base (ie, to differentiate unrealistic and defensive aspects of gran- diosity and grandiose fantasies), from po- tentially realistic competence and hidden or potential capability for factual or even successful abilities. 2. Vulnerable and Fluctuating Self-esteem Vulnerable and fluctuating self-es- teem relate to changeability in grandios- ity. Several accounts support the shifts in self-esteem-related internal experiences and overt expressions of grandiosity.5, Vulnerability and insecurity have usu- ally been assigned to the range of NPD that includes the shy, covert, shame-rid- den phenotype. However, such shifts in the arrogant aggressive phenotypic range may be easily bypassed or covered up, and only overtly occur in the context of ultimatums or when feeling trapped with no way out, and then expressed in rage at- tacks, retaliation, or suicidal behavior. 3. Strong Reactions to Perceived Challenges or Threats to Self-esteem Strong reactions in response to criti- cism from others was included in DSM- III^72 and DSM III-revision but excluded in DSM IV^73 because of its low discrimina- tory power and overlap with other person- ality disorders. Morey^53 has convincingly argued for its reinstatement. This alterna- tive formulation, strong reactions to per- ceived challenges,or threats to self-esteem attest to the narcissistic individual’s spe- cific self-esteem vulnerability and to the threats or challenges that are perceived as especially narcissistically threatening. It also captures a pattern of emotional dysregulation. Mood variations as a sign of narcissistic vulnerability and reactiv- ity reflect shifting levels in self-esteem^18 and are important in differentiating Axis I mood disorders. The concept “threatened egotism”^32 suggests that such vulnerabil- ity and reactivity could make narcissistic individuals prone to more distress, such as depression, substance use, self-defeating or violent behavior, or suicidality. 4. Self-enhancing Interpersonal Behavior The alternative formulation self-en- hancing interpersonal behavior integrates 3.5 of the DSM-IV-TR criteria. It aims at diminishing the previously heavy focus on grandiosity-related features by highlight- ing its self-esteem regulatory and motiva-
118 | PsychiatricAnnalsOnline.com PSYCHIATRIC ANNALS 39:3 | MARCH 2009 TABLE 2.
Diagnostic Criteria for NPD: DSM-IV-TR^69 and Alternative Formulations
DSM-IV-TR NPD: Construct and Criteria Alternative Formulations: Construct and Criteria A pervasive pattern of grandiosity (in fantasy and behavior), need for admira- tion, and lack of empathy, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: A pervasive pattern of fluctuating and vulnerable self-esteem ranging from grandiosity and assertiveness to inferiority or insecurity, with self- enhancing and self-serving interpersonal behavior, and intense reac- tions to perceived threats, beginning in early adulthood and present in a variety of contexts as indicated by five (or more) of the following: DSM 1. Has a grandiose sense of self-importance (eg, exaggerates achieve- ment and talents, expects to be recognized as superior without commen- surate achievements). DSM 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. DSM 3. Believes that he or she is “special” and unique and can only be understood by, or should be associ- ated with, other special or high-status people (or institutions).
1. Grandiosity: enhanced or unrealistic sense of superiority, uniqueness, value or capability, expressed either overtly in unwar- ranted expectations, exceptionally high aspirations, and self-centered- ness, or covertly in inner convictions, fantasies of unfulfilled ambitions or unlimited success, power, brilliance, beauty, or ideal relationships. 2. Fluctuating and vulnerable self esteem, alternating between feel- ing overly confident or assured, and feeling inferior or insecure. DSM 8. Is often envious of others or believes that others are envious of them. 3. Strong reactions to perceived challenges or threats to self-es- teem (humiliation, defeats, criticism, or envy from others), including overtly expressed or covertly hidden intense feelings (aggression, envy or shame) or mood variations (irritability, depression or elation). DSM 3. Believes that he or she is “special” and unique and can only be understood by, or should be associated with, other special or high-status people (or institutions). DSM 4. Requires excessive admiration. 4. Self-enhancing interpersonal behavior (ie, admiring attention seeking, self-promoting, boastful, or competitive behavior). DSM 5. Has a sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). DSM 6. Is interpersonally exploitive (ie, takes advantage of others to achieve his or her own ends). 5. Self-serving interpersonal behavior (ie, expecting unreasonable and unwarranted rights and services and unreciprocated favors from others, or taking emotional, intellectual and social advantage of others). DSM 9. Shows arrogant, haughty behaviors or attitudes. 6. Interpersonally aggressive (ie, arrogant, critically argumentative, resentful, hostile, or passive-aggressive). 7. Interpersonally controlling (ie, domineering, distant or uncommit- ted interpersonal behavior that serves to avoid intolerable affects or threats to self-esteem). DSM 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8. Fluctuating or impaired empathic ability , compromised by self-centeredness, self-serving interests, or emotional dysregulation (low affect tolerance or intense reactions, ie, shame, envy, inferiority, powerlessness, anger). 9. Exceptionally high or perfectionist (although inconsistent) personal ideals and standards, with strong reactions, including aggression, harsh self-criticism, shame, or deceitfulness when failing to measure up.
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- Ronningstam E. Narcissistic personality disor- der: a review. In: M Maj, H Akiskal, J Mezzich, A Okasha, eds. The World Psychiatric Series , vol. 8: Evidence and Experiences in Psychiatry — Personality Disorders. Chichester, UK: John Wiley and Sons; 2005:277-327.
- Ronningstam E, Gunderson J, Lyons M. Chang- es in pathological narcissism. Am J Psychiatry. 1995;152(2):253-257.
- Simon RI. Distinguishing trauma-associated narcissistic symptoms from posttraumatic stress disorder: A diagnostic challenge. Harv Rev Psy- chiatry. 2001;10(1):28-36.
- Akhtar S. The shy narcissist. In: Akhtar S. New Clinical Realms. Pushing the Envelope of Theo- ry and Technique. Northvale, NJ: Jason Aronson Inc.; 2003:47-58.
- Kernberg OF. The psychotherapeutic manage- ment of psychopathic, narcissistic and para- noid transference. In: T Millon, E Simonsen, M Birket-Smith, RD Davis, eds. Psychopathy. Antisocial, Violent and Criminal Behavior. New York, Guilford Press; 1998:372-392.
- Hart SD, Hare RD. The association between psychopathy and narcissism: Theoretical views and empirical evidence. In: E. Ron- ningstam, ed. Disorders of Narcissism: Diag- nostic, Clinical, and Empirical Implications. Washington, DC: American Psychiatric Pub- lishing; 1998:415-436.
- Miller JD, Campbell WK, Pilkonis PA. Narcis- sistic personality disorder: relations with distress and functional impairment. Compr Psychiatry. 2007;48(2):170-177.
- Plakun EM. Narcissistic personality disorder: A validity study and comparison to borderline personality disorder. Psychiatr Clin North Am. 1989;12(3):653-671.
- Ronningstam E. Pathological narcissism and narcissistic personality disorder in Axis I disor- ders. Harv Rev Psychiatry. 1996;3(6):326-340.
- Stinson FS, Dawson DA, Goldstein RB, et al. Prevalence, correlates, disability, and comorbid- ity of DSM-IV narcissistic personality disorder: Results from the Wave 2 National Epidemiologic Survey of Alcohol and Related Conditions. J Clin Psychiatry. 2008;69(7):1033-1045.
- Ronningstam E. Identifying and Understanding the Narcissistic Personality. Oxford University Press; 2005.
- Akhtar S, Thomson JA. Overview: Narcis- sistic personality disorder. Am J Psychiatry. 1982;139(1):12-20.
- Rosenfeld H. Impasses and Interpretations. Lon- don, UK: Tavistock Publications; 1987.
- Gabbard GO. Two subtypes of narcissistic personality disorder. Bull Menninger Clin. 1989;53(6):527-532.
- Cooper A, Ronningstam E. Narcissistic person- ality disorder. In: Tasman A, Riba M, eds. Ameri- can Psychiatric Association, Annual Review, vol. 11. Washington DC: American Psychiatric Pub- lishing; 1992:80-97.
- Masterson J. The Emerging Self — A Develop- mental, Self, and Object Relations Approach to the Treatment of the Closet Narcissistic Disorder of the Self. New York: Brunner Mazel; 1993.
- Cooper AM. Further developments of the di- agnosis of narcissistic personality disorder. In: Ronningstam E, ed. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implica- tions. Washington, DC: American Psychiatric Publishing; 1998:53-74.
- Wink P. Two faces of narcissism. J Pers Soc Psychol. 1991;61(4):590-597.
- Rathvon N, Holmstrom RW. An MMPI- portrait of narcissism. J Pers Assessment. 1996;66(1):1-19.
- Rose P. The happy and unhappy faces of nar- cissism. Personality and Individual Differ- ences. 2002;33:379-391.
- Dickinson KA, Pincus AL. Interpersonal analysis of grandiose and vulnerable narcis- sism. J Pers Disorders. 2003;17(3):188-207.
- Perry JD, Perry JC. Conflicts, defenses and the stability of narcissistic personality fea- tures. Psychiatry. 2004;67(4):310-330.
- Fossati A, Beauchaine TP, Grazioli F, Carretta I, Cortinovis F, Maffei C. A latent structure analysis of Diagnostic and Statistical Manual of Mental Disorders, fourth edition, narcissis- tic personality disorder criteria. Compr Psy- chiatry. 2005;46(5):361-367.
- Tangney JP, Wagner P, Fletcher C, Gramzow R. Shamed into anger? The relation of shame and guilt to anger and self-reported aggression. J Pers Soc Psychol. 1992 ;62(4):669-675.
- PDM Task Force. Psychodynamic Diagnostic Manual PDM. Silver Spring, MD: Alliance of Psychoanalytic Organizations; 2006
- Green A. Life Narcissism Death Narcissism. New York, NY: Free Association Books; 2001.
- Kernberg OF. Aggression in Personality Dis- orders and Perversions. New Haven, CT: Yale University Press; 1992.
- Rhodewalt F, Morf CC. On self-aggran- dizement and anger: A temporal analysis of narcissism and affective reactions to success and failure. J Pers Soc Psychol. 1998;74(3):672-685.
- Baumeister RF, Smart L, Boden JM. Relation of threatened egotism to violence and aggression: The dark side of high self-esteem. Psychol Rev. 1996;103(1):5-33.
- Schore A. Affect Regulation and the Origin of the Self. Hillsdale, NJ: Lawrence Erlbaum As- sociates; 1994.
- Viderman M. Personality change through life experience: The role of ego ideal, personality, and events. In: Cooper A, Kernberg OF, Spec- tor Person E, eds. Psychoanalysis — Towards the Second Century. New Haven: Yale Univer- sity Press; 1989:111-132.
- Klein KJK, Hodge SD. Gender differences, mo- tivation and empathic accuracy: when it pays to understand. Personality and Social Psychology Bulletin. 2001;27:720-730.
- Netzlek JB, Schutz A, Lopes P, Smith CV. Naturally occurring variability in state em- pathy. In: Farroe T, Woodruff P. Empathy in Mental Illness. Cambridge, UK: Cambridge University Press:187-200.
- Decety J, Jackson PL. The functional architec- ture of human empathy. Behav Cogn Neurosci Rev. 2004;3(2):71-100.
- Fonagy P, Gergely G, Jurist EL, Target M. Affect Regulation, Mentalization, and the Development of the Self. New York, NY: Other Press; 2003.
- Tangney JP. Shame and guilt in interpersonal relations. In: Tangney JP, Fischer KW, eds. Self - conscious Emotions. The Psychology of Shame, Guilt, Embarrassment and Pride. New York, NY: Guilford Press; 1995:114-139.
- Campbell WK, Reeder GD, Sedikides C, Elliot AJ. Narcissism and comparative self-enhance- ment strategies. Journal of Research in Person- ality. 2000;34:329-347.
- Baron-Cohen S. Mindblindness: An Essay on Autism and Theory of Mind. Cambridge, MA: MIT Press; 1995.
- Fear CR, Sharp H, Healy D. Cognitive pro- cesses in delusional disorders. Br J Psychiatry. 1996;168(1):61-67.
- Blair RJ, Sellars C, Strickland I, et al. Theory of mind in the psychopath. Journal of Forensic Psy- chiatry. 1996;7:15-25.
- Dolan M, Fullam R. Theory of mind and mental- ization ability in antisocial personality disorder with and without psychopathy. Psychol Med. 2004;34(6):1093-1102.
- Flury J, Ickes W. Emotional intelligence and em- pathc accuracy. In: Ciarrochi J, Forgar J, Mayer J, eds. Emotional Intelligence in everyday Life: A Scientific Inquiry. 2 nd^ ed. New York, NY: Psy- chology Press; 2006:140-165.
- Gilgun J. Self-centerness and the adult male perpetrator of child sexual abuse. Contemporary Family Therapy. 1988;10:216-234.
- Wiehe VR. Empathy and narcissism in a sam- ple of child abuse perpetrators and comparison sample of foster parents. Child Abuse Negl. 2003;27(5):541-555.
- Glasser M. Problems in the psychoanalysis of certain narcissistic disorders_. Int J Psychoanal._ 1992;73(Pt 3):493-503.
- Kernberg OF. Severe Personality Disorders. New Haven, CT: Yale University Press; 1984.
- Kohut H. The Analysis of the Self. New York, NY: International Universities Press; 1971.
- Kohut H. The Restoration of the Self. New York, NY: International University Press; 1977.
- Gabbard G. Transference and countertransfer- ence in treatment of narcissistic patients. In: Ronningstam E, ed_. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implica- tions._ Washington, DC: American Psychiatric Publishing; 1998:125-146. 53. Morey LC, Jones JK. Empirical studies of the construct validity of narcissistic personality disorder. In: Ronningstam E, ed. Disorders of Narcissism: Diagnostic, Clinical and Empirical Implica- tions. Washington, DC: American Psychiatric Publishing; 1998.
- Westen D, Shedler J. Revising and assessing Axis II: Part I. Developing a clinically meaning-
PSYCHIATRIC ANNALS 39:3 | MARCH 2009 PsychiatricAnnalsOnline.com | 121 ful empirically valid assessment method. Am J Psychiatry. 1999;156(2):258-272.
- Maldonado JL. Narcissistic resistance in the ana- lytic experience. Int J Psychoanal. 1999;80(Pt 6):1131-1146.
- Maldonado JL. Obstacles facing the psychoana- lyst when interpreting narcissistic pathologies: characteristics of the authoritarian patient. Int J Psychoanal. 2003;84(Pt 2):347-366.
- Almond R. “I can do it (all) myself” clinical tech- nique with defensive narcissistic self-sufficiency. Psychoanalytic Psychology. 2004;21(3):371-384.
- Apter A, Bleich A, King R, et al. Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psy- chiatry. 1993;50(2):138-142.
- King RA, Apter A. Psychoanalytic perspectives on adolescent suicide. Psychoanal Study Child. 1997;51:491-511.
- Arie M, Haruvi-Catalan L, Apter A. Personality and suicidal behavior in adolescence. Clinical Neuropsychiatry: Journal of Treatment Evalua- tion. 2005;2(1):37-47.
- Ronningstam E, Weinberg I, Maltsberger JT. Eleven deaths of Mr. K — contributing factors to suicide in narcissistic personalities. Psychiatry. 2008;71(2):169-182.
- Ronningstam EF, Maltsberger JT. Pathological narcissism and sudden suicidal collapse. Suicide Life Threat Behav. 1998;28(3):261-271.
- Krystal H. Affect regulation and narcissism: trauma, alexithymia and psychosomatic illness in narcissistic patients. In: Ronningstam E, ed. Disorders of Narcissism: Diagnostic, Clinical and Empirical Implications. Washington, DC: American Psychiatric Publishing; 1998.
- Gabbard GO. Miscarriages of psychoanalytic treatment with suicidal patients. Int J Psycho- anal. 2003;84(Pt 2):249-261.
- Hendin H, Maltsberger JT, Pollinger Haas A, Szanto K, Rabinowicz H. Desperation and other affective states in suicidal patients. Suicide Life Threat Behav. 2004;34(4):386-394.
- Kernberg OF. The suicidal risk in severe person- ality disorders: Differential diagnosis and treat- ment. J Pers Disord. 2001;15(3):195-208.
- Westen D, Arkowitz-Westen L. Limitations of Axis II in diagnosing personality pathol- ogy in clinical practice. Am J Psychiatry. 1998;155(12):258-272.
- Gunderson J, Ronningstam E, Smith L. Nar- cissistic personality disorder: A review of data on DSM-III-R Descriptions. J Pers Disord. 1991;5:167-177.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed, Washington, DC: American Psychiatric Publishing; 2000.
- Blais MA, Hilsenroth MJ, Castlebury FD. Con- tent validity of the DSM-IV borderline and nar- cissistic personality disorder criteria sets. Compr Psychiatry. 1997;38(1):31-37.
- Ronningstam E, Gunderson J. Discriminating criteria for identifying narcissistic personality disorder. Am J Psychiatry. 1990;147:918-922.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Pub- lishing: 1980.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Pub- lishing; 1994.
- Kriegman G. Entitlement attitudes: Psychosocial and therapeutic implications. J Am Acad Psycho- anal. 1983;11(2):265-281.
- Gunderson JG. Ronningstam E. Differentiating antisocial and narcissistic personality disorder. J Pers Disord. 2001;15(2):103-109.
- Holdwick DJ, Hilsenroth MJ, Castlebury FD, Blais MA. Identifying the unique and common characteristics among the DSM-IV antisocial, borderline and narcissistic personality disorder. Compr Psychiatry. 1998;39(5):277-286.
- Ronningstam E, Gunderson J. Differentiat- ing borderline personality disorder from nar- cissistic personality disorder. J Pers Disord. 1991;5:225-232.
- Raskin R, Novacek J, Hogan R. Narcissism, self- esteem, and defensive self-enhancement. J Pers. 1991;59(1):19-38.
- Dejong CAJ, van den Brink W, Jansen JAM, et al. Interpersonal aspects of DSM-III Axis II: theoretical hypothesis and empirical findings. J Pers Disor. 1989;3:135-146.
- Wiggins JS, Pincus AL. Conceptions of person- ality disorders and dimensions of personality. Psychological Assessment. 1989;1:305-316.
- Blatt SJ. The destructiveness of perfectionism. Am Psychol. 1995;50(12):1003-1020.
- Hewitt PL, Flett GL. Perfectionism in the self and social contexts: Conceptualization, assess- ment, and association with psychopathology. J Pers Soc Psychol. 1991;60(3):456-470.
- Rothstein A. The narcissistic pursuit for perfec- tion. New York, NY: International Universities Press; 1980.
- Morrison AP. Working with shame in psycho- analytic treatment. J Am Psychoanal Assoc. 1984;32(3):479-505.
- Kris A. Helping patients by analyzing self criti- cism. J Am Psychoanal Assoc. 1990;38(3):605-
- Mattia JI, Zimmerman M. Epidemiology. In: Livesley WJ, ed. Handbook of Personality Dis- orders. New York, NY: The Guilford Press. 2001;107-123.
- Torgersen S, Kringlen E, Cramer V. The preva- lence of Personality Disorders in a Community sample. Arch Gen Psych. 2001;58(6):590-596.
- Ekselius L, Tillfors M, Furmark T, Fredrikson M. Personality disorders in the general popula- tion: DSM-IV and ICD-10 defined prevalence as related to sociodemographic profile. Personality and Individual Differences. 2001;30:311-320.
- Klein DN, Riso LP, Donaldson SK, et al. Fam- ily study of early-onset dysthymia: mood and personality disorders in relatives of outpatients with dysthymia and episodic major depres- sive and normal controls. Arch Gen Psych. 1995;52(6):487-496.
- Reich J, Yates W, Ndvaguba M. Prevalence of DSM-III personality disorders in the com- munity. Soc Psychiatry Psychiatr Epidemiol. 1989;24(1):12-16.
- Zimmerman M, Rotschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162(10):1911-1918.
- Hilsenroth MJ, Castelbury FD, Holdwick DJ, Blais MA. The effects of DSM-IV cluster B personality disorder symptoms on the termina- tion and continuation of psychotherapy. Psycho- therapy. 1998;35(2):163-176.
- Grilo CM, McGlashan TH, Quinlan DM, Walker ML, Greenfeld D, Edell WS. Frequen- cy of personality disorders in two age cohorts of psychiatric inpatients. Am J Psychiatry. 1998;155(1):140-142.
- Bodlund O, Ekselius L, Lindström E. Personal- ity traits and disorders among psychiatric out- patients and normal subjects on the basis of the SCID screen questionnaire. Nordisk Psychiatrisk Tidskrift. 1993;47:425-433.
- de Ruiter C, Greeven PG. Personality disorders in a Dutch forensic psychiatric sample: Conver- gence of interview and self-report measures. J Pers Disord. 2000;14(2):162-170.
- Doidge N, Simon B, Brauer L, et al. Psychoana- lytic patients in the US, Canada, and Australia: I. DSM-III-R, previous treatment, medications, and length of treatment. J Am Psychoanal Assoc. 2002;50(2):575-614.
- DiGiuseppe R, Robin M, Szeszko PR, Primav- era L. Cluster analysis of narcissistic personal- ity disorder on the MCMI-II. J Pers Disord. 1995;17:188-207.
- Crosby RM, Hall MJ. Psychiatric evalua- tion of self-referred and non-self-referred active duty military members. Mil Med. 1992;157(5):224-229.
- Bourgeois JJ, Hall MJ, Crosby RM, Dexler KG. An examination of narcissistic personality traits as seen in a military population. Mil Med. 1993;158(3):170-174.
- Maffei C, Fossati A, Lingiardi V, Madeddu F, Borellini C, Petrachi M. Personality maladjust- ment, defenses and psychopathological symp- toms in non-clinical subjects. J Pers Disord. 1995;9(4):330-345.
