Elsa Ronningstam, PhD

A. Challenging the patient's self-enhancing grandiose behavior and attitudes

B. Encouraging a collaborative exploration of the patient’s own accounts of problems and experiences

C. Treating co-occurring major mental conditions, such as bipolar disorder, substance use, and eating disorders

D. Giving adequate psychopharmacological treatment of overemphasized self-enhancement and attention seeking

A key component of treating narcissistic personality disorder is to encourage a collaborative exploration of the patient’s own accounts of problems and experiences. Key in on fluctuations in functioning, self-esteem, identity, and interpersonal interactions.

New Insights Into Narcissistic Personality Disorder

,” by Elsa Ronningstam, PhD, on which this quiz was based. Click 

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What is the clinical approach to pathological narcissism and narcissistic personality disorder?

Mini Quiz: Narcissistic Personality Disorder

Despite its survival and final inclusion in DSM-5, narcissistic personality disorder remains a controversial diagnosis. With a lifetime prevalence of 6.2%, it is less frequently identified in psychiatric settings but more often seen in private practice and applied to higher-functioning patients.

 Conceptualizations and diagnostic definitions of narcissistic personality disorder have primarily focused on the more strikingly provocative, self-enhancing, entitled interpersonal behaviors and attitudes that tend to capture the attention of clinicians rather than on the patient’s underlying, internal struggles. This has contributed to making the diagnosis more judgmental rather than informative.

[[{"type":"media","view_mode":"media_crop","fid":"46037","attributes":{"alt":"Â© IGUANASBEAR/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_8441292208162","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5310","media_crop_rotate":"0","media_crop_scale_h":"101","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© IGUANASBEAR/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]One of the major advances in recent clinical and empirical studies of narcissistic personality disorder is the recognition of co-occurring vulnerability (eg, insecurity, inferiority, fragility) that accompanies emotion dysregulation.

 Similarly, the proposed hybrid model for personality disorders in DSM-5, which includes both dimensions and central traits, incorporates evaluations of level of functioning, as well as of sense of identity, fluctuations in self- and self-esteem regulation, and empathic capability.

Research in social and personality psychology has added significantly to our general understanding of narcissism. Nevertheless, research on narcissistic psychopathology is still sparse, mainly because of low societal urgency and health costs. Signs of narcissistic personality disorder are often more noticeable within organizational, social, family, and legal or forensic settings. Patients with this personality tend to seek treatment when they are facing serious ultimatums, failures, losses, or other consequential realizations. When in treatment, they are known for their reluctance, negative therapeutic reactions, and early dropout.

Narcissistic personality disorder is often comorbid with other psychiatric disorders for which treatment is sought. However, when such conditions are present, especially substance use disorder, bipolar disorder, eating disorder, or MDD, the clinical indications of pathological narcissism in the initial psychiatric evaluation and treatment planning are likely to be less noticeable or ignored. The underlying contribution of narcissistic personality functioning to a psychiatric disorder may be totally unrecognized; this prevents remission and contributes to relapses and refusal to follow psychiatric treatment recommendations.

The nature of narcissism and its application to psychopathology

Narcissism ranges from healthy and normal to pathological and severely malignant. It is closely related to regulation of self-esteem and emotions and to a sense of control and competence. Narcissism can be a motivating factor and can contribute to exceptional and remarkable accomplishments in higher-functioning people, even when it co-occurs with pathological narcissistic traits and dimensions. It is important to recognize not only the range of pathological narcissistic functioning (ie, self-enhanced/grandiose and vulnerable/insecure), but also the areas or context of the patient’s sense of agency with competence and abilities.

, clinicians tend to assume that competence, self-esteem, and positive interpersonal interactions are deceptive “cover-ups” or “defenses” against more severe narcissistic traits, vulnerability, or the “true self.” The patient’s mistrust, negative reactivity, and treatment discontinuation are often caused by such inferences made early in treatment. An alternative clinical approach, both in evaluation and treatment, is to encourage and collaboratively explore the patient’s own accounts of problems and experiences-and especially of fluctuations in functioning, self-esteem, identity, and interpersonal interactions. The aim is to establish a shared agreement regarding the patient’s narcissistic psychopathology and its interaction with self-esteem and interpersonal functioning.

Mr S, an engineer in a high-tech company, describes his struggle with insecurity in certain interpersonal interactions and social contexts, especially when they involve upper management and competitive colleagues. In these situations, he begins to shake, lose cognitive flexibility, and is unable to access words and expressions. He has been struggling with this since elementary school when he had teachers who scolded him when he could not correctly answer questions, and his parents had forcefully demanded that he “suck it up” and do his best.

Mr S is perceived by his peers, friends, and family as a high-achieving, stoic, critical, demanding man who can easily make others feel insecure or even resentful. Mr S was forced to seek treatment because of his increasing alcohol abuse, which was discovered by his colleagues and immediate supervisor. For many years he had engaged in hidden, controlled but gradually increasing alcohol consumption to manage stress, insecurity, and even fear in interpersonal interactions, both at work and with his wife and son.

This vignette highlights a multifaceted interactional pattern between narcissistic personality functioning and substance use disorder, competence and fragility, internal vulnerability and external self-enhancement. Obviously, Mr S’s substance use served the function of regulating insecurity and numbing intense reactions and emotions, especially in interpersonal contexts. The aim in treatment is to engage and balance Mr S’s abilities and self-esteem, which are related to his competence and commitment, with a gradual processing of his experiences of insecurity, loss of competence, and vulnerability.

Attachment patterns in narcissistic personality disorder

Pathological narcissism and narcissistic personality disorder primarily include avoidant, preoccupied, dismissive, and “cannot classify” interactive patterns.

 The intense preoccupation of patients with negativity, blame, and criticism, as well as their engagement in a range of strategies to manipulate, avoid, and dismiss both the clinician and certain people or contexts in their lives can contribute to stalemates, misguided interpretations, and negative enactment.

Ms G, an intelligent woman in her mid-20s, is an inpatient in an eating disorder program. Many of the sessions with her psychotherapist are spent complaining about program conditions and the way staff and other patients treat her and making various demands (eg, need for individual attention, different treatment modalities). She also feels that the other patients get away with inappropriate behavior without consequences. When her treatment team accedes to her requests, she dismisses them and always finds faults, misguided intentions, or unacceptable conditions. She perceives efforts to help her as being detrimental to her well-being.

She feels increasingly detached and isolated in the program and begins to express sadness and crying in addition to anger and complaints. The therapist attends to her negativity. Ms G is encouraged to explore past interpersonal experiences and to talk about her sadness. She begins to give more coherent descriptions of her mother’s early death and subsequently growing up with her father. She describes numerous subtle but nevertheless challenging experiences, such as her father’s inattention alternating with intense critical responses to her behavior as well as his involvement with different girlfriends that left her feeling overpowered, unseen, and nonexistent.

Her severe eating disorder became a way for Ms G to regulate anger, to take control and gain power, and to invest in her own identity and desired self-image. Once she was able to access her underlying sadness and describe her deeply rooted and previously nonverbalized emotional experiences, she became more actively involved in her treatment. She began to eat and started engaging with some of the other patients, and she began to outline goals for her future.

This vignette demonstrates attachment patterns that can unfold and dominate the therapeutic alliance during the treatment of a patient with a co-occurring eating disorder and pathological narcissism/narcissistic personality disorder. The systematic exploration of underlying experiences and psychological trauma that contribute to reactivity and self-enhancement, as well as to dismissive, avoidant, and preoccupied interactive patterns, can alter narcissistic functioning.

The underlying contribution of narcissistic personality functioning to a psychiatric disorder may be totally unrecognized; this prevents remission and contributes to relapses and refusal to follow psychiatric treatment recommendations.

Recent studies especially in the field of neuroscience have contributed to significant reconceptualization of empathy.

 Identified in terms of ability to understand, process, and share the emotional state and experiences of others, empathic engagement depends on both emotional contagion and cognitive theory of mind, as well as on self-regulatory processes (emotions and self-esteem), motivation, and social interpersonal skills and decisions. DSM-5 conceptualizes empathy as a dimension of personality functioning related to comprehension and appreciation of the experiences and motivations of others, tolerance of differing perspectives, and understanding of the effects of one’s behavior on others.

Clinically defined, empathy is not static; it fluctuates and is affected by a range of contextual as well as emotional, interpersonal, and neuropsychological functions. Studies have found empathic ability in narcissistic personality disorder to be compromised and fluctuating, influenced by the interaction between deficits, capabilities, and motivation.

 More specifically, patients with narcissistic personality disorder have intact cognitive empathic ability and can identify with thoughts, feelings, and intentions of others. However, their capacity for emotional empathy is compromised, especially their ability to care about and share feelings of others.

Ms F, a professional woman and single mother of an 8-year-old son, describes a very emotional situation at work. The young daughter of one of her colleagues had lost her battle with cancer. Everyone in the department was emotionally affected by this tragic event and engaged in various ways to console their grieving colleague. Ms F described the situation as unbearable. She was noticeably upset and frustrated as she complained about the emotional reactions of her colleagues-she felt overwhelmed and had to leave the office.

Ms F also thought that this emotional outpouring was interfering with work and misdirected attention from an important project with a looming deadline that she was in charge of. From her perspective, successfully meeting the deadline was crucial for her upcoming promotion.

The therapist begins by validating Ms F’s challenges and viewpoint and encourages her to further describe her experiences. Ms F shifts mood and perspective and says, “Don’t take me wrong, I realize that my colleague has suffered a terrible loss, and I feel for her. I signed the condolence card and donated money, but I can’t stand all these feelings-I can’t hug her and let her cry on my shoulder the way everyone else is doing.” After a moment of silence and further consideration, Ms F says, “This whole situation reminds me of when my sister suddenly died when I was 8 years old. It was a terrible event, especially for my mother, and I was told to be strong and not show any feelings. I am also afraid of losing my son . . . this whole event just became too personal.”

This vignette clarifies a range of empathic functioning, especially with regards to emotion regulation. The patient’s initial self-enhancement with immediate concerns about her own position and intense negative dismissive reactions toward her colleagues gradually tapered down as her ability for cognitive empathic understanding and concern unfolded. Furthermore, her experiences of loss and accompanying family reactions, as well as her fear of facing a similar loss, interfered with her processing of the present event.

The major shift in treatment of narcissistic personality disorder occurred in the 1960s with the pioneering contributions of Heinz Kohut and Otto Kernberg, who both claimed, although with radically different approaches, that narcissistic personality disorder was treatable with psychoanalytic psychotherapy. Since then, additional treatment modalities have focused on narcissistic personality disorder-in particular transference-focused, metacognitive, and schema-focused therapies.

Patients with NPD have intact cognitive empathic ability and can identify with thoughts, feelings, and intentions of others. However, their capacity for emotional empathy is compromised.

Comorbid conditions such as mood, anxiety, and impulsivity can be treated with psychopharmacology, but there are no psychotropic medications indicated for narcissistic personality disorder. Recent research on emotion processing and regulation has contributed to our understanding of the complex interaction between narcissistic hypersensitivity and reactivity-often hidden but serving as underpinnings for more overt self-enhancing, dismissive, or avoidant interpersonal patterns.

Collaborative exploratory strategies that focus on identifying and unfolding these very individual patterns need to be considered when making treatment decisions. Alliance building and engaging the patient’s sense of agency and reflective ability are essential for change in pathological narcissism. The prognosis for narcissistic personality disorder is relative to the diagnostic definition in terms of traits versus dimensions. A recent study found a 2-year remission rate of 52.5% but high dimensional stability.

 This finding suggests both short-term context-dependent as well as long-term enduring patterns of narcissistic personality disorder. Differentiating these patterns and identifying and applying suitable and optimal treatment strategies are still works in progress.

Dr Ronningstam is Associate Professor (PT) at Harvard Medical School in Boston and Clinical Psychologist at McLean Hospital in Belmont, MA. She reports no conflicts of interest concerning the subject matter of this article.

 Stinson FS, Dawson DA, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.

 Zimmerman MI, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients.

 Pincus AL, Lukowitsky MR. Pathological narcissism and narcissistic personality disorder. 

 Diamond D, Meehan KB. Attachment and object relations in patients with narcissistic personality disorder: implications for therapeutic process and outcome. 

 Decety J, Moriguchi Y. The empathic brain and its dysfunction in psychiatric populations: implications for intervention across different clinical conditions. Biopsychosoc Med. 2007. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2206036/pdf/1751-0759-1-22.pdf. Accessed January 6, 2016.

 Baskin-Sommers A, Krusemark E, Ronningstam E. Empathy in narcissistic personality disorder: from clinical and empirical perspectives. 

 Diamond D, Yeomans FE, Stern S, et al. Transference focused psychotherapy for patients with comorbid narcissistic and borderline personality disorder. 

 Dimaggio G, AttinÃ  G. Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. 

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Articles

Despite its survival and final inclusion in DSM-5, narcissistic personality disorder remains a controversial diagnosis. Here: perspectives on diagnosis, treatment, and prognosis.

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.

 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.

As Mr. A's experiences of realistic academic competence and independent professional responsibility increased, his need for exaggerated superior and unique self-experience and grandiose fantasies diminished as did his need to antagonize and devalue others' achievements. Animosity and arrogant, passive-aggressive oppositional behavior were replaced by active, goal-oriented professional striving, and Mr. A's underlying capacity for interpersonal relations could in that context develop. At baseline he did not present the severe manifestations of narcissistic interpersonal relations such as exploitiveness, lack of commitment, and deep envy and inability for empathy.

Corrective relationships, where the person was able to establish a long-term, close and mutual relation seemed to diminish pathological narcissism in three cases. Changes were evident in diminished need for devaluation, entitlement and exploitive behavior. Two of the subjects had actually become engaged, and one was in the process of getting married.

Case vignette # 2. - Miss B, an attractive, intelligent, self-assertive and articulate woman in her 30s, was caught stealing drugs at a drug company where she had been working as a research assistant since her graduation from college. It became evident that over the last five years she had been using increasing amounts of intravenous drugs, more recently on a daily basis.

She came from a working-class background with parents with high expectations, and she graduated from college magna cum laude. However, the parents decided not to support her continuing education in graduate school and she experienced this as a treachery.Miss B described herself as superior, especially compared to other drug abusers since she had been able to keep herself "clean" and use more sophisticated methods to gain access to drugs. Although hard to please, she usually got what she wanted. She dreamt about becoming a famous journalist, and she loved to drive her car recklessly, believing that she would not be caught. After graduation from college, three problem areas gradually emerged and became more apparent despite Miss B's intense efforts to deny their presence and consequences. A feeling of indecisiveness and lack of certainty made it difficult for her to identify her purpose and track in life. A pattern of relationships developed, especially to boyfriends, characterized by quick, intense involvement and abrupt withdrawal when the relationship stabilized and became more close. She especially feared spending sustained time with the same man and expressing and returning feelings and intimacy, and sharing personal private matters. A fear of becoming bored and failing at work also became more predominant, despite her high level of competence.

At follow-up, Miss B described several notable changes in her life. Six months of drug detoxification and drug-abuse-focused treatment and two years of psychotherapy had contributed to a remission of drug dependency and highlighted underlying problems of low self-esteem and inferiority feelings. She had been accepted to graduate school and was studying business. However, the most important and fundamental change, according to Miss B, was that she had met a man and experienced being in love for the first time in her life, and she was actually in the process of getting married.

Contrary to all previous men with whom she had been involved, she experienced that her husband-to-be accepted her, was stronger than she without defeating her, and she could feel secure and able to stay in and develop the relationship. Her self-description was no longer exaggerated and focused on her specialness; she was more realistic and pointed out changes within several areas. She used to think she did not need other people but now realized that she did and that she actually enjoyed them. In the past she felt she was different from other people and constantly misunderstood. She now realized that she had, through her tough, independent and self-sufficient demeanor, actually made people unnecessary in her life.

The most important change according to Miss B was her new capacity to tolerate and enjoy closeness and intimacy. This experience had a major impact on improving her self-esteem. Grandiose fantasies still sustained, but now related to success within the field she was studying. She still had strong feelings of envy and difficulties empathizing with other peoples' sadness, which made her helpless and disgusted.

Miss B's low self-esteem, compensatory grandiosity, recklessness and drug dependency developed out of increasing difficulties in the context of close and intimate relations. However, the absence of more severe narcissistic features (deep devaluating, condescending, ruthless, paranoid, and exploitive attitudes and behavior) in her interpersonal relations at baseline made it possible to attach, first to treaters and later to a man. The correctional achievements and being accepted to graduate school also improved her self-esteem.

Corrective disillusionment involved experiences that challenged the person's previous grandiose self-experience and actually resulted in an adjustment toward a self-concept more in accord with their actual capabilities. This could be the realization of personal, intellectual or vocational limitations, failure to achieve goals in life, or facing losses or lost opportunities in life. (However, if these disillusions are too severe and experienced without support, a development into a worsening narcissistic pathology can occur.)

Case vignette #3. - Mr. C, a man in his mid-40s, considered himself to be goal-oriented and superintelligent, with strong puritan values, quick reasoning skills and an extraordinary leadership capacity. Although happily married with two teenage sons and one younger daughter, he considered himself to be a loner, not interested in wasting time on meaningless social activities. He had a top managing position in a small Canadian company where he had worked since graduation from high school. Showing a bragging, self-praising and self-centered manner, devaluating behavioral styles of others, he did admit that he actually envied them for their social belonging.

When he reached his early 40s, two things happened in Mr. C's life. When his company suddenly and unexpectedly underwent a major expansion, he was sent to one of the most challenging business schools in the country for graduate education in order to meet the company's new needs for business expertise. At this time his sons reached adolescence and developed lifestyles, value systems and spheres of interests that disgusted and threatened Mr. C. He could not find reasonable and adequate ways to communicate with or to influence his sons. He considered himself a failure as a parent and struggled with intense aggressive impulses, urges to either detach from them totally or to punish them in various ways.

As he had been a straight-A student in college and the most intellectually accomplished person in his environment, Mr. C was at first consternated when he discovered the high level of intelligence among the students in the graduate program. It was with a combination of humbleness, envy and admiration he gradually accepted that the majority of the other students were extremely capable and that he, despite enormous efforts, only managed to maintain a B to B-plus level.

At follow-up this man, who was in the process of moving back and reinstating himself into a new position in his company, was remarkably more humble, and had less intense aggressive reactions, bragging and self-inflating behavior. He felt that he had reached the maximum of his capacity professionally and as a father, and although satisfied with his results in graduate school, he felt dethroned and incompetent in his parental role because he realized that he could not convince his sons about the importance of his own values and lifestyle. However, his intense anger was replaced with a new and more realistic ambition to become a friend and supporter of his sons.

Mr. C's experience of shortcomings and limitations in both professional and personal life was an enormous challenge for his self-esteem. However, the sustained support from his loyal wife, and his own personal flexibility and capacity to integrate initially unacceptable aspects of himself, made it possible to modify his grandiose self-experience into more realistic concepts. Although grandiosity and reactivity improved, the narcissistic interpersonal style with devaluation, envy and some arrogant behavior still remained.

This first prospective study of narcissistic patients raises questions about the construct validity of NPD. It seems as if patients with identifiable pathological narcissism and NPD actually can have grandiosity with higher degree of changeability, as well as pathologically narcissistic relations that can remain stable over time. These results also raise the question whether people with NPD differ in their capacity to gain from life events or environmental influence-whether people with certain types of narcissistic psychopathology, including more narcissistic interpersonal relations, have more difficulties in accommodating to or benefiting from environmental experiences. If these results can be replicated with other samples and with an assessment instrument that identifies and differentiates covert forms of pathological narcissism (Akhtar & Thomson; Gabbard; Cooper and Ronningstam) from overt types, a redefinition of the diagnostic category of NPD would be necessary. 

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 	Gabbard GO. Two subtypes of narcissistic personality disorder. Bull Menninger Clin. 1989;53(6):527-532.


 	Gunderson JG, Ronningstam E, Bodkin A. The diagnostic interview for narcissistic patients. Arch Gen Psychiatry. 1990;47(7):676-680.


 	Kernberg O. Borderline Conditions and Pathological Narcissism. New York: Jason Aronson; 1992.


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 	Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry. 1995;152(2):253-257.

For clinicians, the assiduous and sustained resistance to change common in patients with narcissistic personality disorder (NPD) has been especially noticeable and trying. 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.

Author | Elsa Ronningstam, PhD

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