Narcissistic Personality Disorder: Diagnosticand Clinical ChallengesEve Caligor, M.D., Kenneth N. Levy, Ph.D., Frank E. Yeomans, M.D., Ph.D.

FOUR DIFFERENT FACES OF NARCISSISTIC PERSONALITY DISORDER

“Mr. A” is a 42-year-old married man presenting to aprivate-practice psychotherapist complaining of prob-lemswithhiswife.He is a successful entrepreneur, highlycompetitive, who describes enjoying social gatherings,where he tends to be the center of attention, as well aschallengesatwork,wherehebelieves thathehasa superiorability to solveproblems.Hecomesto treatmentbecauseheis wondering whether or not to stay in his marriage. Mr. Adescribed having lost all sexual interest in his wife duringtheir early years together. Throughout themarriage, he hasmaintained a series of lovers whom he has housed, sup-ported, and then cut off and replaced. He feels that thisarrangementhashadno impact onhis relationshipwithhiswife but wonders if he would do better with someone else.

“Mr. B” is a 34-year-old single man with a history ofcocaine and alcohol abuse, currently unemployed. Hepresented to the emergency department complaining ofpain following a dental procedure and requesting Per-cocet (acetaminophen and oxycodone). Although he wasinitially ingratiating with the attending physician whotook his history, when she explained that she would haveto speak with his oral surgeon before writing a pre-scription for anarcotic,Mr.Bbegan to insult andbullyher.The attending spoke with Mr. B’s “girlfriend,” whosecontact information he had provided. The girlfriend ex-plained that she had recently broken things off withMr. Bbecause he had been exploiting herfinancially; since beingfired 1 year earlier from a high-paying financial job, he hadbeen unable to find employment that met his lofty ex-pectations for himself, preferring instead to live off moneyfrom his father and his girlfriend.

“Mr. C” is a 29-year-old single man with a history ofinsulin-dependentdiabeteswhopresents toanoutpatientclinic for treatment of dysthymia and social phobia. He

has held a series of low-level jobs that “have not workedout,” and he currently works part-time doing data entry.Mr. C described his mood as chronically “miserable.”Socially isolated and easily slighted, he has no interests,takespleasure innothing, androutinelywonders “whetherlife isworth living.”When feeling down, he often “forgets”to administer his insulin, resulting in multiple hospitaliza-tions for hyperglycemia. He constantly compares himselfwith others, feeling envious and resentful, and describeshimself as deficient and defective. At the same time, heresents that others fail to recognize all he has to offer. Attimes he engages in fantasies of his employer publiclyacknowledging his special talents and promoting him; atother times, he has fantasies of humiliating his boss witha display of superior knowledge.

“Ms. D” is a 44-year-old single woman referred toa group specializing in severe personality disorders. Shecomplained of “refractory depression” for which shewason medical disability. She had been treated for 10 yearswith every modality her local hospital could offer, in-cluding ECT. She portrayed her previous therapists inscathingly derogatory terms, seeming tofind gratificationin their failed attempts to help her. Her group therapistdiagnosed her with narcissistic personality disorder basedon the gap between her self-image as an extremely giftedbut unrecognized author and the reality that she hadwritten almost nothing. Antisocial features consisted ofchronic lying, a history of prostitution in her 20s, and“working the system” to obtain disability payments ratherthan taking onwork that shewas able to do. Therewere noneurovegetative symptoms of depression. When her newtherapist raised the possibility of working toward em-ployment,Ms. D coolly declared that shewould kill herself,orhim, ifhe interferedwithherabilitytoobtainherbenefits.

Narcissistic personality disorder is prevalent, highly com-orbid with other disorders, and associated with significantfunctional impairment and psychosocial disability (1, 2).

However, it has been one of the least studied personality dis-orders. As a result, there is a fair amount of confusion regardingthe reliability, validity, specificity, and sensitivity of diagnostic

See related features: Clinical Guidance (Table of Contents) and AJP Audio (online).

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criteria, as well as the prevalence of the disorder, and to datethere have been no randomized clinical trials examining theefficacy of any treatment for the disorder (3). In fact, becauseofthe limited research literature, narcissistic personality disorderwas initially slated to be omitted from DSM-5. However, inresponse to feedback fromtheclinical andresearchcommunity(e.g., 4–8) this decision was reversed, and narcissistic per-sonality disorder was included in Section II of DSM-5 (Di-agnostic Criteria and Codes) and also reconstructed in SectionIII (Emerging Measures and Models).

DEFINITION AND DIAGNOSTIC CHALLENGES

Diagnostic confusion surrounding narcissistic personalitydisorder reflects the disorder’s highly variable presentationand the wide range of severity that can characterize nar-cissistic pathology. Individuals with narcissistic personalitydisorder may be grandiose or self-loathing, extraverted orsocially isolated, captains of industry or unable to maintainsteady employment, model citizens or prone to antisocialactivities. Given this heterogeneity, it is far from self-evidentwhat such individuals could have in common to justify ashared diagnosis. The DSM-5 criteria (Table 1) to some de-gree sidestep this question by providing a rather narrow andhomogeneous definition of narcissistic personality disordercharacterizedbyapervasivepatternof grandiosity (in fantasyor behavior), need for admiration, entitlement, and lack ofempathy. However, while these criteria capture importantaspects of narcissistic pathology, they provide inadequatecoverage of the broad population of individuals who receivethe diagnosis in clinical practice (9–11), and they fail to covercorepsychological featuresof thedisorder, includingvulnerableself-esteem; feelings of inferiority, emptiness, and boredom;and affective reactivity and distress (11). Furthermore, becauseDSM-5 criteria are, a priori, limited to observable features ofpsychopathology, the description of narcissistic personality dis-order in Section II of DSM-5 does not address underlying psy-chological structures or dynamic constellations that can be seento organize and unify the various presentations of the disorder.

SUBTYPES AND CORE PSYCHOLOGICAL FEATURES

Although DSM-5 describes a single, relatively homogeneoussyndrome, there is a rich literature supporting the existenceofdifferentsubtypesofnarcissisticpersonalitydisorder (12–22).The clinical vignettes we provide here of four patients di-agnosedwithnarcissisticpersonalitydisorder illustrateboththevariable presentation of the disorder with regard to descriptivefeatures (“subtypes”) and the broad spectrum of severity ofpathology associated with the disorder. Typical presentationsof narcissistic personality disorder are the grandiose, “overt,”subtype, corresponding closely to the DSM-5 criteria and il-lustrated in the vignettes by Mr. B; the vulnerable, “covert,”subtype, less well covered in current diagnostic criteria,illustrated by Mr. C; and the healthier, “high-functioning”subtype illustrated by Mr. A.

The grandiose, thick-skinned, overt subtype is charac-terized by overt grandiosity, attention seeking, entitlement,arrogance, and little observable anxiety. These individualscan be socially charming, despite being oblivious to the needsof others, and are interpersonally exploitative. In contrast,the vulnerable, “fragile” or thin-skinned, covert subtype is in-hibited,manifestly distressed, hypersensitive to the evaluationsof others while chronically envious and evaluating themselvesin relation to others. Interpersonally these individuals are oftenshy,outwardly self-effacing, andhypersensitive toslights,whileharboring secretgrandiosity.Both typesareextraordinarily self-absorbed.Manyindividualswithnarcissisticpersonalitydisorderfluctuate between grandiose and depleted states, depending onlife circumstances,whileothersmaypresentwithmixed features(11, 15, 17, 22). In addition to the grandiose and vulnerable subtypes,there is a healthier group of individuals with narcissisticpersonality disorder, described as “high-functioning,” “exhibi-tionistic,” or “autonomous.” These individuals, illustrated byMr. A, are grandiose, competitive, attention seeking, and sex-ually provocative, while demonstrating adaptive functioningandusing their narcissistic traits to succeed.Becauseof theirhighlevel of functioning, at first glance individuals in this groupmay not appear to have a personality disorder, and the nar-cissistic personality disorder diagnosis can be overlooked ondiagnostic assessment.

An appreciation of the various subtypes of narcissisticpersonality disorder leads to thequestionofwhat are the corepsychological features that define narcissistic personalitydisorder and that can in turn be relied upon to inform clinicalassessment and treatmentplanning.This issue is addressed tosome degree in the alternative model for conceptualizingpersonality disorders developed by the DSM-5 Work Groupand included in Section III of DSM-5. This model goes be-yond the familiar focuson thedescriptive features ofdifferentpersonality disorders to emphasize additionally the role ofimpairment of self and interpersonal functioning in personalitypathology. For narcissistic personality disorder, Section IIIidentifies deficits in self-definition, self-esteem and affect reg-ulation, andconsolidationof internalgoalsandstandardsascorefeaturesof thedisorder; interpersonal relationsare “functional,”serving to support the sense of self and/or to provide personalgain, and capacity for intimacy is lacking (Table 2).

Our own approach to characterizing and understandingnarcissistic personality disorder is compatible with the al-ternative model developed by the DSM-5 Work Group andalso with psychodynamic models of narcissistic personalitydisorder based in object relations theory. From a psychody-namic perspective, a specific form of self or identity dynamicis at the core of narcissistic pathology (15). Rather than theflexible and reality-based self-experience that characterizesnormal identity formation, the sense of self in narcissisticpersonality disorder is brittle and somewhat removed fromreality; what characterizes narcissistic personality disorderacross the spectrum is a more or less fragile sense of selfthat is predicated on maintaining a view of oneself as excep-tional. This characterization applies not only to grandiose

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narcissists, but also to those in the vulnerable subtype,where grandiosity is cloaked in feelings of inferiority anddeficiency. Maintaining a grandiose sense of self can providea more or less stable self-experience for the individual withnarcissistic personality disorder, but comes at a cost, re-quiring a retreat fromordenial of realities that donot supportgrandiosity, and leaving the individual excessively reliant onexternal feedback to support not only positive self-regard butalso self-definition. The specific pathology of identity for-mation that characterizes narcissistic personality disorderalso lends itself to characteristic disruptions in interpersonalfunctioning. On the one hand, individuals with narcissisticpersonality disorder often have a profound need for others tosupport their sense of self and also to help with self-esteemregulation. On the other hand, genuine engagement withothers can threaten the stability of the grandiose sense of self,by confronting the individual with the painful reality thatothers have attributes that they lack. As a result, those withmore grandiose features tend to engage in superficial rela-tionships organized to support self-esteem and self-definition,while thosewithmore vulnerable features tend towithdrawfrom social situations; for both types, self-regulatory needsleave little room for genuine interest in the needs or feelingsof others.

PREVALENCE AND COMORBIDITY

The prevalence of narcissistic personality disorder remainspoorly defined, reflecting the lack of clarity around thediagnosis. Commonly cited prevalence estimates rangefrom 0% to 5.3% in the general population (11). Prevalencein clinical samples has been reported to range from 1% to17% (11). In a recent large adult community sample, riskfactors included male sex, younger age, and single maritalstatus (2).

Narcissistic personality disorder is frequently comorbidwith other disorders, particularly substance use disorders,bipolar disorder, and other personality disorders (2, 23, 24),andcomorbiddisordersareoftenwhatfirstbrings individualswith narcissistic personality disorder to clinical attention. Thedegree of comorbidity is linked to severity (25). Narcissisticpersonality disorder most commonly co-occurs with antisocial,histrionic, borderline, schizotypal, and passive-aggressive per-sonality disorders (3); comorbidity with antisocial personalitydisorder has the most profound negative impact on prognosis.

Grandiose and vulnerable narcissistic subtypes are associatedwithdifferentpatternsofcomorbidity(22).Depressionandanxietyare more common in the vulnerable narcissistic group, as arenonsuicidal self-injuryand suicide attempts (16, 17, 19). In contrast,thosewiththegrandiose subtypeor in grandiose statesmayberelatively free of subjective distress unless confronted with pro-fessionalor interpersonal failures (15, 18).Grandiosetraits tendtobe related to substance abuse and comorbidity with antisocial andparanoid personality disorder (19).

CLINICAL PRESENTATION ANDCLINICAL CHALLENGES

Individuals with narcissistic personality disorder constitutesome of the highest-functioning patients seen in outpatientsettings and also some of the most impaired and intractableamong patients seen in emergency departments and on in-patient units. In fact, of all the personality disorders, nar-cissistic personality disorder spans the broadest spectrum ofseverity (15). As a result, it is useful to distinguish not onlybetween grandiose/overt and vulnerable/covert clinicalpresentations, but also among different levels of severityof narcissistic personality disorder. In general, as severity ofnarcissistic pathology increases, aggression, which can bedirected at oneself as well as others, becomes more evident,interpersonal functioningdeteriorates, and deficien-cies in moral functioningbecome increasinglyprom-inent, posing significantchallenges to clinical man-agement (26, 27). Moresevere formsofnarcissisticpersonality disorder chal-lengeclinicianstolimitpatients’destructiveandself-destructivebehavior. In addition, it is necessary tominimize secondarygain(benefits derived from being ill), which often involves insistingthat patients seek appropriate employment and may requireinvolvement of family members in treatment.

At the highest level of functioning, patients like Mr. A areable to achieve the admiration necessary to gratify theirgrandiose needs. These individuals may function successfully,althoughtheymaybe susceptible tobreakdowns inresponse tosetbacksoradvancingage.LikeMr.A,psychopathologymaybeevident primarily in a transactional view of intimate relations,which are characterized by superficiality and lack of genuineconcern for theneedsor the feelingsof theother. Individuals inthis group rarely seek treatment; when they do, it is often onlyat the insistence of significant others or during an acute crisis.

At themiddle level of functioning, patients likeMr.Bpresentwith an obviously distorted, grandiose sense of self and havelittle interest in intimacy. These individuals may function ad-equately or even well professionally, despite significant in-terpersonal difficulties, or theymay refuse towork, especially ifthey do not have access to narcissistically gratifying employ-ment. Mr. B demonstrates grandiosity in his refusal to take onwork he sees as beneath him, preferring to be unemployed,entitlement in his demands for medication in the emergencydepartment, and financial exploitation of his parents and girl-friend. Problems in his sense of self are joined with a view ofothers as a means to an end rather than a source of mutualgratification. Motivation for treatment can be limited; Mr. Bwould likely have no interest in treatment unless his familydemanded it as a condition of continued financial support.

At a lower level of functioning are patients like Mr. C,who present with comorbid borderline personality traits. In

It is useful to distinguish notonly between grandiose/overt and vulnerable/covertclinical presentations, butalso among different levelsof severity of narcissisticpersonality disorder.

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contrast to the higher-functioning group, these individualsexhibit a sense of self that is poorly defined andunstable; theyfrequently oscillate between pathological grandiosity andsuicidality.Mr.Cdemonstrates self-directed aggression inhisnoncompliance with diabetes care, antisocial features to theextent that hemisrepresents the cause of his hyperglycemia tohis physicians, and extremely poor interpersonal functioningcharacterized by a lack of interest in relationships. In additionto demonstrating features of lower-level narcissistic pathology,Mr. C presents the challenge of vulnerable narcissism, appearingsubmissive and inadequate, but with a self-concept based ona covert sense of superiority. The gap between an unrealistic and

extremelyfragilesenseofselfandobjectiverealityleads to a lack of engagement in theworld, as anymeaningful contact with others (including treat-mentproviders) challengeshis covertgrandiosity.

Finally, at the greatest level of severity arethose like Ms. D who suffer from “malignant nar-cissism” (28).The illnessesof thesepatientsarecharacterized by the typical symptoms of nar-cissistic personality disorder; however, thesepatients also display prominent antisocial be-havior, tend toward paranoid features, and takepleasure in their aggression and sadism towardothers. Individuals in this group are the mostdifficult to treat: chronic lying and the sadisticpleasure in controlling and even frightening andintimidating clinicians can overwhelm any pos-sibility of working therapeutically. In addition,secondary gains, which can be financial or in-terpersonal,provideapowerfulmotivation for thepatienttomaintainthestatusquo;oftenthereisnohope for changeunless the treatment teamworkswith the patient’s social system to limit or elimi-nate secondary gain.

ASSESSMENT

Because of the sometimes subtle presentationof narcissistic personality disorder, especiallyat thehigher-functioning endof the spectrum,and because of the centrality of interpersonaldifficulties in the disorder, a systematic clin-ical interview may be the most reliable wayto diagnose narcissistic personality disorder.Kernberg’s structural interview (29) is one suchclinical interview, and it is also available inmodified form as a semistructured interview(30). While structured assessments for narcis-sistic personality disorder, in both self-reportand structured interview formats, have dem-onstratedreliabilityandutility forresearch, theyadd little to the interview of a skilled clinician.

In the clinical interview, focusing on thepatient’s description of significant others canhelp in diagnosing narcissistic personality

disorder. These descriptions are characteristically dis-missive or derogating or, alternatively, colored by idealization.Most striking, however, is the markedly superficial and vague,shadowy quality of the narcissistic individual’s experience ofothers. In addition, individuals with narcissistic personalitydisorder demonstrate a tendency to describe others in terms ofhow others are similar to or different from themselves. Incontrast, the narcissistic individual’s sense of him- or herselfmay be more intact and nuanced, albeit colored by grandiosityor self-deprecation. The clinician’s personal reactions to theindividual with narcissistic personality disorder can call at-tention to the diagnosis. Common reactions to patients with

TABLE 1. DSM-5 Criteria for Narcissistic Personality Disordera

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lackof empathy, beginning by early adulthood and present in a variety of contexts, asindicated by five (or more) of the following:1. Has a grandiose sense of self-importance (e.g., exaggerates achievements andtalents, expects to be recognized as superior without commensurateachievements).

2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, orideal love.

3. Believes that he or she is “special” and unique and can only be understood by orshould associate with, other special or high-status people (or institutions).

4. Requires excessive admiration.5. Has a sense of entitlement (i.e., unreasonable expectation of especially favorable

treatment or automatic compliance with his or her expectations).6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her

own ends).7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of

others.8. Is often envious of others or believes that others are envious of him or her.9. Shows arrogant, haughty behaviors and attitudes.

a Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of MentalDisorders, Fifth Edition. Arlington, Va., American Psychiatric Association, 2013, pp. 669–670.Copyright 2013, American Psychiatric Association. Used with permission.

TABLE 2. Proposed Criteria for Narcissistic Personality Disorder in the AlternativeDSM-5 Model for Personality Disordersa

A. Moderate or greater impairment in personality functioning, manifested bycharacteristic difficulties in two or more of the following four areas:1. Identity: Excessive reference to others for self-definition and self-esteemregulation; exaggerated self-appraisal inflated or deflated, or vacillating betweenextremes; emotional regulation mirrors fluctuations in self-esteem.

2. Self-direction: Goal setting based on gaining approval from others; personalstandards unreasonably high in order to see oneself as exceptional, or too lowbased on a sense of entitlement; often unaware of own motivations.

3. Empathy: Impaired ability to recognize or identify with the feelings and needs ofothers; excessively attuned to reactions of others, but only if perceived as relevantto self; over- or underestimate of own effect on others.

4. Intimacy:Relationships largely superficial andexist to serve self-esteemregulation;mutuality constrained by little genuine interest in others’ experiences andpredominance of a need for personal gain.

B. Both of the following pathological personality traits:1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt orcovert; self-centeredness;firmly holding to thebelief that one is better thanothers;condescension toward others.

2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and bethe focus of the attention of others; admiration seeking.

a Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of MentalDisorders, Fifth Edition. Arlington, Va., American Psychiatric Association, 2013, pp. 767–768.Copyright 2013, American Psychiatric Association. Used with permission.

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narcissistic personality disorder include feeling idealized andpressured to provide a magic cure, feeling belittled and de-valued, feeling treated like someone who is incompetent andhas nothing to offer, or feeling like a sounding board, ignored,without recognition of the clinician as an individual or anyinterest in what he or she might have to say (19, 31, 32).

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for narcissistic personality disorderincludesbipolar illness, substance abuse, depressive disorders,especially treatment refractory depression, and anxiety dis-orders, aswell asotherpersonalitydisorders.All are frequentlycomorbid with narcissistic personality disorder, complicatingdiagnostic and clinical decision making; it is often unclearwhether symptoms of anxiety or depression, for example,reflect a comorbid diagnosis or are primarily an expression ofpersonality pathology. While manic states can mimic many ofthe features of grandiose narcissism, the admiration seekingand devaluation of others characteristic of narcissistic per-sonalitydisorder are typically absent inmanic individuals. Onecan imagine that Mr. A, when excited by a new business idea,might demonstrate the kind of expansiveness and exuberantenthusiasmseen inhypomania. In this setting, his need to havehis superior creativity and effectiveness admired by otherswould help to distinguish his behavior from that of someonewho is hypomanic. Chronic substance abuse can affect psy-chological functioning to simulate narcissistic personalitydisorder; the individual with a chronic substance use disordermay become exploitative, self-focused, lacking in empathy, andruthless, often in conjunction with antisocial features. This syn-drome could potentially be at playwithMr. B, and establishingthe narcissistic personality disorder diagnosis would requirecareful assessment of his substance abuse history as well as ofhis personality functioning across time. Symptoms associatedwith major depression, dysthymia, social anxiety, and gener-alized anxiety disorder overlap with features of vulnerablenarcissism. In this setting, one canavoidmissing thenarcissisticpersonality disorder diagnosis by careful evaluation of thepatient’s sense of self and interpersonal functioning. For ex-ample, despite Mr. C’s complaints of depression and socialanxiety, his covert grandiosity is incompatible with a di-agnosis of a major affective or anxiety disorder alone.Similarly, Ms. D’s grandiosity and entitlement do not fitwith the diagnosis of major depression, despite her manyyears of treatment. In addition, the absenceof allmeaningfulrelationships demonstrated by both Mr. C andMs. D wouldbe difficult to account for on the basis of depression andanxiety.

Thepersonalitydisordersmostcommonly in thedifferentialdiagnosis for narcissistic personality disorder are histrionic,borderline, and antisocial. It is the characteristic grandiosityand need for admiration that most clearly distinguish narcis-sistic personality disorder from these other diagnostic groups.Narcissistic personality disorder and borderline personalitydisorder can be further distinguished by the relative instability

of the sense of self, along with the impulsivity and self-destructiveness of borderline personality disorder. Mr. C, whopresents with comorbid borderline and narcissistic personalitydisorders, illustrates these features. Histrionic personality dis-order and narcissistic personality disorder are both character-izedbytheneedtobethecenterofattention,but individualswithhistrionic personality disorder have a greater capacity for de-pendent relations than do those with narcissistic personalitydisorder, and they are more emotionally expressive and lessdismissiveof others.Despitehis superficiallygood interpersonalfunctioning and attention seeking, Mr. A can be distinguishedfrom the individual with histrionic personality disorder onthe basis of his callous and self-serving attitude toward thewomen in his life, his lack of overt emotionality, and hisview of himself as exceptional. Antisocial personalitydisorder and narcissistic personality disorder share thetraits of exploitation, superficiality, and lack of empathy,but even at the more severe end of the spectrum, in-dividuals with narcissistic personality disorder do notdemonstrate the total breakdown of moral functioning andabsence of any capacity for loyalty that typifies antisocialpersonality disorder, nor is narcissistic personality disor-der typically associated with the history of childhoodconduct disorder that is common in antisocial personalitydisorder.

TREATMENT

The efficacy of psychotherapeutic and psychopharmaco-logical treatment approaches for narcissistic personalitydisorder has not been systematically or empirically inves-tigated (3). Clinical practice guidelines for the disorder haveyet to be formulated, and psychopharmacologic interventionis symptomdriven.Regardless of severity, the grandiosity anddefensiveness that characterize narcissistic personality dis-order militate against acknowledging problems and vulner-abilities andmake engagement in any form of psychotherapydifficult (33).

In patients presenting with major psychiatric disorders,co-occurring narcissistic personality disorder is known toincrease the likelihood of treatment dropout and may slowsymptom change (34, 35). With this group of patients, dis-cussion of diagnostic issues, including the contribution ofpersonality pathology to the symptom picture, should pre-cede initiation of treatment. Discussion of personality pa-thology helps to establish realistic expectations on the partof the patient and opens the door to discussion of treatmentsfor underlying narcissistic pathology. Failure to have thissort of discussion can result in polypharmacy or multiplecourses of ineffective treatments devoted to chasing re-fractory symptoms, as exemplified by the case ofMs. D in thevignettes.

When it comes to treatments targeting narcissistic per-sonality disorder per se, current treatment recommendationsare based largely on clinical experience and theoretical for-mulations. Psychodynamic formulations have led to the

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proliferation of different treatment approaches, and casereports suggest that these treatments can be effective forsome patients. Most influential have been those of Kernberg(36, 37) and Kohut (38, 39), each of which focuses on clinicaldevelopments in the relationship between therapist and pa-tient in long-termpsychotherapy. In theabsenceofempiricallysupported treatments for narcissistic pathology, it is commonpractice to utilize efficacious treatments for near-neighbordisorders, typically with treatment modifications based ontheoretical and clinical rationales regarding differences in thedisorders (22). Thus, for patients with narcissistic personalitydisorder, we recommend referral for empirically supportedtreatments for borderline personality disorder that haveadaptations for narcissistic personality disorder. In particular,werecommendmentalization-based therapy (40), transference-focused psychotherapy (41–43), and schema-focused psycho-therapy (44).All three treatments targetpsychological capacitiesthought to underlie and organize descriptive features of nar-cissistic personality disorder. Dialectical behavioral therapy (45)is an additional option for patients with comorbid borderlinepersonality disorder and significant self-destructive acting-outbehaviors. All are longer-term treatments that require special-ized training of practitioners.

SUMMARY AND RECOMMENDATIONS

Narcissistic personality disorder is a challenging clinical syn-drome; it has a variable presentation, is difficult to treat, andcomplicates the treatment of commonly co-occurring disorders.In the absence of expertise or resources for longer-term treat-mentofpersonalitydisorders, thereare specificapproachesandtechniques that canbe implemented to improve general clinicalmanagement of patientswith the disorder. Based on our reviewof the literature and clinical experience, wemake the followingrecommendations:

1. Obtain a thorough symptom picture and assessment ofpsychological, interpersonal, and vocational functioningin order to make a differential diagnosis and establishthe presence of narcissistic personality disorder, es-pecially in patients who present with substance abuse,affective illness, anxiety, and/or interpersonal or work-related problems.

2. Assess for vulnerable as well as grandiose forms of nar-cissistic pathology. Although grandiose presentationsmaybemore obvious andmay seemmore overtly pathological,vulnerable forms of narcissistic personality disorder areeasy to miss and can be equally debilitating and clinicallychallenging.

3. In any patient for whomnarcissistic personality disorderis in the differential diagnosis, assess carefully for pa-thology ofmoral functioning (dishonesty, exploitation) aswell as frank antisocial features.

4. It is difficult to develop collaborative goals if the patientthinks he or she has a depressive disorder while the

therapist thinks the patient has a personality disorder butis reluctant to share that information. Share diagnosticimpressions with the patient in the setting of providingpsychoeducation and identifying treatment goals. Incharacterizing narcissistic personality disorder for thepatient, focus on problems with self-esteem regulation,lack of satisfaction in their interpersonal lives, and thesubjective distress and/or functional impairments thatbrought the patient to treatment. Some patients maybenefit from explicit discussion of the narcissisticpersonality disorder diagnosis, while others experiencethe diagnosis as injurious andmay do betterwith amoregeneral discussion focusing on phenomenology anddisordered personality functioning.

5. Anticipate that patients with narcissistic personality dis-order typically show significant impediments to beginningtreatment and engaging fully in the treatment. A clinicalapproach involving communicating empathy while fo-cusing on specific treatment goals and monitoring one’sown internal reactions to the patient can help foster thedevelopment of a treatment alliance.

6. Use the patient’s words, or preface interventions withcomments suchas “Asyou said earlier” tohelp thepatientwithnarcissisticpersonalitydisordermore readilyacceptthe clinician’s comments and recommendations.

7. Forpatientswhopresentwith symptomsofdepressionoranxiety or for substance abuse treatment, adopt standardpsychopharmacologic and therapeutic interventions. An-ticipate that co-occurrence of narcissistic personality dis-orderwill complicate treatment, increasing risk of dropout,making it more difficult to establish and maintain a ther-apeutic alliance, and increasing the likelihood of poorresponse to treatment.

8. Attempt to maintain a nonjudgmental and inquisitivestance toward the patient’s difficulties and his or herperception of others, including other clinicians, and steerclear of directly confronting or criticizing the patient’sgrandiosity.

9. Clinicians’ reactions to patients with narcissistic person-ality disorder tend to be powerful and typically negative; itis helpful to anticipate that one will have to monitor andcontain one’s emotional reactions to the patient. Patientsmay begin treatment with idealizations or haughty, de-valuating attitudes, both of which can be difficult forclinicians to tolerate, ormay vacillate quickly between thetwo. Pitfalls to be avoided are to respond defensively,aggressively, ordismissively to thenarcissisticpatientor towithdraw and collude with the patient’s denial of pa-thology through passivity.

10. Attend to negative feelings that the patient may haveabout the treatment and the clinician. If left unaddressed,these feelings pose a serious threat to the treatment. Ifaddressed in an accepting, nonjudgmental fashion, suchdiscussion can support the development of a treatment

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alliance and lead to exploration of themotivations for thepatient’s negative responses to others and, ultimately, tohim- or herself.

AUTHOR AND ARTICLE INFORMATION

From the Department of Psychiatry, Columbia University College ofPhysicians and Surgeons, New York; the Department of Psychology,Pennsylvania State University, University Park; and the Department ofPsychiatry, Weill Medical College of Cornell University, New York.

Address correspondence to Dr. Caligor (ec8@cumc.columbia.edu).

The authors thank their colleagues at the Personality Disorders Instituteand thePersonality Studies Institute, particularlyDrs.OttoKernberg,DianaDiamond, and Barry Stern. They also thank Jacqueline Proszynski for herassistance with the manuscript.

Drs. Caligor and Yeomans receive royalties from American PsychiatricPublishing. Dr. Levy receives royalties from Routledge.

Received June 7, 2014; revision received Sept. 15, 2014; accepted Sept.22, 2014.

AmJ Psychiatry 2015; 172:415-422; doi: 10.1176/appi.ajp.2014.14060723

REFERENCES1. Miller JD, Campbell WK, Pilkonis PA: Narcissistic personality

disorder: relations with distress and functional impairment. ComprPsychiatry 2007; 48:170–177

2. Stinson FS, Dawson DA, Goldstein RB, et al: Prevalence, correlates,disability, and comorbidity of DSM-IV narcissistic personality dis-order: results from the wave 2 National Epidemiologic Survey onAlcohol andRelatedConditions.JClinPsychiatry2008;69:1033–1045

3. Levy KN, Chauhan P, Clarkin JF, et al: Narcissistic pathology:empirical approaches. Psychiatr Ann 2009; 39:203–213

4. Miller JD, Widiger TA, Campbell WK: Narcissistic personalitydisorder and the DSM-V. J Abnorm Psychol 2010; 119:640–649

5. Morey LC, Stagner BH: Narcissistic pathology as core personalitydysfunction: comparing the DSM-IV and the DSM-5 proposal fornarcissistic personality disorder. J Clin Psychol 2012; 68:908–921

6. Pincus AL: Some comments on nomology, diagnostic process, andnarcissistic personality disorder in the DSM-5 proposal for per-sonality and personality disorders. Pers Disord 2011; 2:41–53

7. Ronningstam E: Narcissistic personality disorder in DSM-V: in sup-portof retaininga significantdiagnosis. JPersDisord2011;25:248–259

8. Shedler J, Beck A, Fonagy P, et al: Personality disorders in DSM-5.Am J Psychiatry 2010; 167:1026–1028

9. Shedler J, Westen D: Refining personality disorder diagnosis: in-tegrating science and practice. Am J Psychiatry 2004; 161:1350–1365

10. Westen D, Arkowitz-Westen L: Limitations of axis II in diagnosing per-sonalitypathology in clinical practice.AmJPsychiatry 1998; 155:1767–1771

11. Ronningstam EF: Narcissistic personality disorder: facing DSM-V.Psychiatr Ann 2009; 39:111–121

12. Akhtar S, Thomson JA Jr: Overview: narcissistic personality dis-order. Am J Psychiatry 1982; 139:12–20

13. Fossati A, BeauchaineTP,Grazioli F, et al: A latent structure analysisof Diagnostic and Statistical Manual of Mental Disorders, FourthEdition, narcissistic personality disorder criteria. Compr Psychiatry2005; 46:361–367

14. Gabbard GO: Two subtypes of narcissistic personality disorder. BullMenninger Clin 1989; 53:527–532

15. Kernberg OF: Borderline Conditions and Pathological Narcissism.Northvale, NJ, Jason Aronson, 1975, 1985

16. Miller JD, CampbellWK: Comparing clinical and social-personalityconceptualizations of narcissism. J Pers 2008; 76:449–476

17. PincusAL, LukowitskyMR: Pathological narcissism and narcissisticpersonality disorder. Annu Rev Clin Psychol 2010; 6:421–446

18. Ronningstam EF: Identifying and Understanding the NarcissisticPersonality. New York, Oxford University Press, 2005

19. Russ E, Shedler J, Bradley R, et al: Refining the construct of nar-cissistic personality disorder: diagnostic criteria and subtypes. Am JPsychiatry 2008; 165:1473–1481

20. WinkP:Two faces of narcissism. JPers SocPsychol 1991; 61:590–59721. Wink P: Three narcissism scales for the California Q-set. J Pers

Assess 1992; 58:51–6622. LevyKN:Subtypes, dimensions, levels, andmental states innarcissism

and narcissistic personality disorder. J Clin Psychol 2012; 68:886–89723. Ronningstam EF, Weinberg I: Narcissistic personality disorder:

progress in recognition and treatment. FOCUS 2013; 11:167–17724. ZimmermanM,RothschildL,Chelminski I:TheprevalenceofDSM-

IV personality disorders in psychiatric outpatients. Am J Psychiatry2005; 162:1911–1918

25. Levy KN, Reynoso J, Wasserman RH, et al: Narcissistic personalitydisorder, in Personality Disorders: Toward the DSM-V. Edited byO’DonohueW,FowlerKA,LilienfeldSO.ThousandOaks,Calif, Sage,2007, pp 233–277

26. Kernberg OF: The almost untreatable narcissistic patient. J AmPsychoanal Assoc 2007; 55:503–539

27. Gunderson JG, Ronningstam E: Differentiating narcissistic andantisocial personality disorders. J Pers Disord 2001; 15:103–109

28. Kernberg OF: Severe Personality Disorders. NewHaven, Conn, YaleUniversity Press, 1984

29. KernbergOF:Structural interviewing.PsychiatrClinNorthAm1981;4:169–195

30. Clarkin JF, Caligor E, Stern B, et al: Structured Interview of Per-sonality Organization (STIPO). New York,Weill Medical College ofCornell University, 2004

31. Betan E, Heim AK, Zittel Conklin C, et al: Countertransferencephenomena and personality pathology in clinical practice: an em-pirical investigation. Am J Psychiatry 2005; 162:890–898

32. Gabbard GO: Transference and countertransference: developmentsin the treatment of narcissistic personality disorder. Psychiatr Ann2009; 39:129–136

33. Ronningstam E: Narcissistic personality disorder: a clinical per-spective. J Psychiatr Pract 2011; 17:89–99

34. Ellison WD, Levy KN, Cain NM, et al: The impact of pathologicalnarcissism on psychotherapy utilization, initial symptom severity,and early-treatment symptom change: a naturalistic investigation. JPers Assess 2013; 95:291–300

35. Hilsenroth MJ, Holdwick DJ Jr, Castlebury FD, et al: The effects ofDSM-IVclusterBpersonalitydisorder symptomson the terminationand continuation of psychotherapy. Psychotherapy 1998; 35:163–176

36. KernbergOF: Factors in the psychoanalytic treatment of narcissisticpersonalities. J Am Psychoanal Assoc 1970; 18:51–85

37. Kernberg OF: Pathological narcissism and narcissistic personalitydisorder: theoretical background and diagnostic classification, in Dis-orders of Narcissism: Diagnostic, Clinical, and Empirical Implications.Edited by Ronningstam EF. Washington, DC, American PsychiatricPress, 1998

38. Kohut H: The Analysis of the Self. Madison, Conn, InternationalUniversities Press, 1971

39. Kohut H: The Restoration of Self. Madison, Conn, InternationalUniversities Press, 1977

40. Allen JG, Fonagy P (eds): The Handbook of Mentalization-BasedTreatment. New York, John Wiley & Sons, 2006

41. Diamond D, Yeomans FE, Levy KN: Psychodynamic psychotherapyfor narcissistic personality, in The Handbook of Narcissism andNarcissistic Personality Disorder: Theoretical Approaches, Empir-ical Findings, and Treatments. Edited by Campbell WK, Miller JD.Hoboken, NJ, John Wiley & Sons, 2011, pp 423–433

42. Kernberg OF: An overview of the treatment of severe narcissisticpathology. Int J Psychoanal 2014; 95:865–888

43. Stern BL, Yeomans FE, Diamond D, et al: Transference-focused psy-chotherapy(TFP)fornarcissisticpersonalitydisorder, inUnderstanding

Am J Psychiatry 172:5, May 2015 ajp.psychiatryonline.org 421

TREATMENT IN PSYCHIATRY

and Treating Pathological Narcissism. Edited by Ogrodniczuk J.Washington, DC,AmericanPsychological Association, 2012, pp 235–252

44. Young J, Flanagan C: Schema-focused therapy for narcissisticpatients, in Disorders of Narcissism: Diagnostic, Clinical, and Em-pirical Implications. Edited by Ronningstam EF. Washington, DC,American Psychiatric Press, 1998, pp 239–268

45. Reed-Knight B, Fischer S: Treatment of narcissistic personalitydisorder symptoms in a dialectical behavior therapy framework, inThe Handbook of Narcissism and Narcissistic Personality Disorder:Theoretical Approaches, Empirical Findings, and Treatments. EditedbyCampbellWK,MillerJD.Hoboken,NJ,JohnWiley&Sons,2011,pp466–475

422 ajp.psychiatryonline.org Am J Psychiatry 172:5, May 2015

TREATMENT IN PSYCHIATRY