For clinicians, the assiduous and sustained resistance to change common in patients with narcissistic personality disorder (NPD) has been especially noticeable and trying. The narcissistic patient's persistent denial of problems or limitations and lack of motivation for treatment until faced with a major failure have been documented by Kernberg (1985, 1992) and Millon. However, until recently the natural course of NPD has not received much attention in the clinical and empirical literature, and there is very little documented knowledge about the factors that might contribute to changes. Knowledge about the natural course of a disorder is important in evaluating the benefits of treatment.
In a first prospective follow-up study of patients diagnosed with NPD, we investigated the occurrence of changes in pathological narcissism over time (Ronningstam and Gunderson 1995). Twenty patients with clinical NPD diagnoses were interviewed with the Diagnostic Interview for Narcissism (DIN) (Gunderson and colleagues) at baseline and three years later at follow-up, and the patients' baseline scores were compared to their follow-up scores. The DIN includes 33 characteristics for pathological narcissism, 10 of which overlap with the NPD criteria set in DSM-III-R and DSM-IV. The characteristics are grouped into five sections: grandiosity, interpersonal relations, reactiveness, affect and mood states, and social and moral adaptation. In addition to the DIN, an unstructured interview was given to explore the subjects' interval histories regarding personal, vocational and treatment events, and to identify factors that could have contributed to changes in the patients' behavior and experiences of themselves and others.
A significant decrease in the overall level of pathological narcissism occurred over the three-year period. In particular, the patients' narcissistic features had lessened in the area of their interpersonal relations and patterns of reactivity, and their unrealistic grandiose sense of themselves had substantially diminished. Of the nine NPD criteria in DSM-IV, six showed high changeability (>50 percent, defined as the rate of decrease in the DIN presence score of 2), i.e., grandiose fantasies, uniqueness, arrogant and haughty behavior, entitlement, exploitiveness and lack of empathy. Exaggeration of talents and achievements, need for admiration, and envy proved to be more stable. Sixty percent of the subjects significantly improved while 40 percent sustained a high level of pathological narcissism. This was surprising insofar as, by definition, personality disorders are expected to be stable.
Our findings suggested that what appeared to be a narcissistic personality disorder at baseline actually included two types of pathology: one being a context or state-dependent type of pathology, and the other being a more long-term and stable trait pathology. The unimproved group proved to have had a higher level of pathological narcissism in the area of interpersonal relations at baseline, especially in their capacity to become involved in committed long-term relationships. This implies that severely narcissistically disturbed interpersonal relations may be the essential feature that defines patients with narcissistic personality disorder.
Prior research (Ronningstam and Gunderson 1990), as well as clinical and theoretical literature (Millon; Akhtar and Thomson) showed that the definition of NPD relied heavily upon characteristics of grandiosity. Our research shows that a considerable change in grandiosity occurred over the three-year period. This suggests that grandiose self-experience may be a particular mental state that is context-dependent. As such, grandiosity requires a careful assessment with specific consideration both to the patient's developmental stage-late adolescence, early adulthood, middle age-and to the mental state at the time of diagnostic evaluation.
Corrective Life Events
Another surprising result was that intervening treatment experiences (i.e., treatment length, type and intensity) were relatively equally distributed among the improved and unimproved group. In other words, treatment experiences did not differentiate between those narcissistic patients who had an enduring long-term personality disorder and those whose narcissistic pathology underwent change. What seems, however, to be causally related to the improvement in pathological narcissism were corrective life events.
Three types of such events could be identified through the unstructured interviews: those related to achievements, to interpersonal relations and to disillusionments.
Corrective achievements, such as graduations, promotions, recognitions, acceptance to sought-after schools, programs, or positions, etc., were the most common type of life event that contributed to change in pathological narcissism. These events contributed to a more realistic and accepted sense of the self with less need for grandiose fantasies and exaggerations of talents. The following case vignette describes such development.
Case vignette #1. - Mr. A, an extremely intelligent, shy but arrogant 25-year-old man, was a college student and came for psychotherapy because he had suffered from depression for several years. Although an exceptionally competent student, he constantly felt unappreciated. He tended to devote his time in lectures to "giving the teachers and professors a hard time" by criticizing them, and asking "impossible" questions in order to prove their incompetence and make them embarrass themselves in public. He described himself as extraordinarily superior with feelings of disdain and confusion toward people he experienced as different from himself—people who he felt had lower standards and different values than he. He also described himself as intellectually unique, stressing his specific theoretical and philosophical perspectives and high academic standards. He had several close friends among his male peers, but admitted that he experienced severe problems in relating to young women, had difficulty connecting, and felt shy and insecure.
Mr. A came from a very competitive and successful family background. His father was a famous lawyer in his early 60s, and Mr. A described having a complicated relationship, with mixed feelings toward the father. On the one hand he highly admired and idealized his father; on the other hand he despised the father's demands, values and expectations, and tended to take every opportunity to protest against him. While he envied his father and fantasized about becoming as successful, Mr. A also felt inferior, and believed that he would never become as successful as his father. Often he felt deeply misunderstood by his father. After successfully graduating from college, Mr. A decided to work as a pizza deliverer, a decision that he considered to be unusually risky but in line with his "unique approach" to life.
At follow-up time three years later, Mr. A reported a number of important changes and developments in his life. He had been in individual psychotherapy for 18 months and had specifically focused on depression and insecurity. A new job as a university teacher had, according to Mr. A, contributed to the most important change in his behavior and attitude toward himself and others. As a teacher, he had the opportunity to create the specific teaching atmosphere and technique he felt that his former teachers were unable to do. Through his work, he had learned to interact with people, was forced to and actually successfully managed to understand people with different ideas and values, and made efforts to develop specific teaching methods to facilitate learning and intellectual growth for his students. He described himself as more tolerant of criticism. His sense of pride was associated with a far more realistic self-appraisal and markedly diminished derogatory, arrogant behaviors. His relation with his father was still conflictual, but a more sincere desire to identify with the competent successful father had appeared. His relations to women had improved and a two-year relationship with a girlfriend also contributed to a change in Mr. A's self-esteem.
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