John G. Gunderson, MD

 (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.

Questions to consider when reading the case:

1. In what ways might the therapist help the patient address her problems?

2. If therapeutic efforts fail, how much time should transpire before the therapist advises the patient s/he is unable to help?


Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility.

At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very much interested in helping her meet her treatment goals.

The greater difficulty was that Kathy used up quite a bit of time in therapy dwelling on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.


In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel 

. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his or her demands.

The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention.

Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.

[Editor's note: For further reading, please see “

Borderline Personality Disorder and Resistance to Treatment

,” by Lois W. Choi-Kain, MD and John G. Gunderson, MD, from which this case was adapted.]

Articles

Patients with borderline personality disorder or narcissistic personality disorder (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them.

Treatment Resistance in a Woman With Borderline Personality Disorder

When the term “borderline” was first used in 1938 by the psychoanalyst Adolf Stern, he was defining a group of patients who were “extremely difficult to handle effectively by any psychotherapeutic method.”

 In the early 1950s, Robert Knight emphasized their regressive responses to unstructured treatments.

 In hospitals, borderline patients were referred to as “help-rejecting complainers.”

” evolved as a way to describe how individuals with borderline personality disorder (BPD) destroyed their well-meaning therapists’ ability to be effective because of unconscious motivations of masochism, envy, and sadism. In light of the reports of resistance to treatment and the formulations of the mechanisms behind this resistance that blamed the patient, borderline became associated with treatment resistance and poor prognosis. At best, a diagnosis of BPD was a statement of therapeutic pessimism. At its worst, the diagnosis brought expectations of 

Findings from longitudinal research and the development of empirically validated BPD-specific treatments have since helped transform its reputation as an untreatable disorder into one that can be quite responsive to treatment. Two prospective longitudinal studies have shown that BPD psychopathology progressively improves, with impressive remission rates of 40% to 50% in 2 years and 70% to 80% by 10 years.

Empirically validated treatments have demonstrated how therapies need to be specifically tailored for successful treatment of BPD. The first of these, dialectical behavioral therapy (DBT) was developed only after it was realized that patients with BPD resisted a traditional behavioral approach. DBT incorporated techniques of validation and the concept of acceptance to a cognitive-behavioral framework.

was developed for personality-disordered patients who were “nonresponders” to-or “relapsers” from-standard cognitive-behavioral therapy.

 Several of these approaches explicitly address the borderline patient’s typical treatment-interfering behaviors so that his or her responses are not personalized or overreactive.

Originally, the concept of treatment resistance was defined in 

. Freud described the phenomenon of resistance broadly as “whatever interrupts the progress of analytic work.” The term “resistance” often referred to defenses or aspects of character structure that were obstacles to therapists. Currently, treatment resistance often refers to psychiatric symptoms that do not respond to otherwise effective treatments. The most widely recognizable use of this modern meaning of resistance is treatment-resistant depression, which describes a form of depression that does not remit despite reasonable and extensive (usually psychopharmacological) treatment. Both psychological resistance to treatment and the resistance of symptoms to respond as expected refer to a variety of phenomena that can render generally effective treatments ineffective.

BPD is associated with both forms of resistance, and these underlying sources may overlap. Particular forms of defenses exhibited by patients with BPD can constitute therapeutic resistance. However, when BPD coexists with mood disorders, those disorders often fail to respond to treatments as well as expected.

Here we present case vignettes to illustrate treatment of therapeutic resistance that clinicians commonly encounter. We first discuss treatment resistance related to an Axis I diagnosis that is comorbid with BPD. This is followed by a discussion of 2 other forms of therapeutic resistance-entitlement and dynamics between the patient with BPD and his family. We offer recommendations about how to manage these different forms of resistance.

Comorbidity as a source of treatment resistance for Axis I disorders

Patients with BPD often present with a history of diagnosis and treatment of multiple Axis I disorders, mainly in the realms of mood, anxiety, substance use, and eating.

 In such patients, it is important to determine whether BPD is present because it, like other personality disorders, is a commonly cited factor of treatment resistance for comorbid disorders.

 Failure to recognize the effect of comorbid BPD or mood disorders often leads both the patient and the clinician to put undue hope on the expected response to medications.

Sara, a 25-year-old woman with a history of repeated cutting and depression, was hospitalized when she took an overdose of an antidepressant after an angry breakup with a boyfriend. Her inpatient psychiatrist diagnosed depression and attempted unsuccessfully to treat her with medications. Electroconvulsive therapy was tried, without any improvement in either her mood or cutting behavior. 

Every time Sara threatened to cut herself, the staff responded with increased monitoring. Eventually, she was constantly observed, her clothes were confiscated, and she was required to wear a gown at all times. The treatment team was afraid that without these constraints, Sara would kill herself. When Sara was finally discharged, the psychiatrist’s diagnosis had been changed to BPD, but the patient nonetheless clung to her primary diagnosis of major depressive disorder (MDD). Because the emphasis had been on MDD for so long, her stance toward treatment-passive and expecting a lot from medications-was predetermined. Her outpatient therapist struggled to get Sara to collaborate with her to discuss the events and feelings that preceded her impulses to cut herself. Sara believed that treatment should focus on making her “feel better” and that this depended on getting the right medication. She continually demanded medication changes and perceived the therapist’s questions as “not caring” or a “waste of time.”

For clinicians who lack experience in treating patients with BPD, scenarios like this one are common. Some believe that treatment of a comorbid Axis II pathology can be deferred until after a patient has been discharged, despite the clear relationship between acute symptoms and interpersonal conflicts or other social stressors. In this vignette, Sara’s treatment team diligently attended to her depressive symptoms, but the approach they used encouraged an undue hope that somatic treatments would resolve her depression. It also encouraged a passive role on Sara’s part; she was not held responsible for any part of getting better. Her failure to stop cutting herself could be interpreted as her resistance against treatment, but it was almost certainly related to the misinformed strategies taken by the treatment team. Sara’s treatments reinforced her belief that her problems were outside herself and that she could rely on someone else to fix them.

Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms, but comorbid BPD decreases the likely response to medications. Psychotherapeutic interventions that require activity and responsibility on the patient’s part are most effective. When there are ongoing borderline issues (such as recurrent self-harm and extreme reactivity to interpersonal issues), these issues need to be a central focus in the ongoing treatment from the start.

 By giving such patients tools to manage their anxiety, their affects, and their impulses in lieu of self-harm, we give them the opportunity to manage their own safety. This helps them begin to focus inwardly rather than depend on rescue by others.

Patients with BPD or narcissistic personality disorder (or both) can feel 

 and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.

Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility. At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very interested in helping her meet her treatment goals. 

The greater difficulty was that in therapy, Kathy dwelled on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.

In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel misunderstood, criticized, and angry. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his demands.

The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention. Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.

Another important source of resistance in treating patients with BPD is their notion that change may entail betraying their family in particular ways as well as giving up habits they may feel work well for them in avoiding feelings.

Melody is the oldest child in a close-knit family. She has always been athletic, but she also has a long history of recurrent sports-related injuries. Melody is preoccupied with performance and sensitive to criticism. At home, negative feelings were not talked about: her parents thought they were shameful. Recurrent injuries were the only manner in which she could elicit sympathetic reactions from her parents. 

When Melody went to college and encountered academic difficulties, she started to fall down stairs and trip over things repeatedly. After each accident, her family came rushing to take care of her. When it was found out that Melody’s accidents were deliberate, she began psychotherapy.

At first, Melody was highly anxious and sat in silence, unable to verbalize her feelings. Over time, however, she began to talk about her accidents as ways to not think about missing home and to explain her failure to excel at school. Whenever she spoke about her fears of parental disapproval, she would have the impulse to hurt herself. Her parents became fearful and encouraged psychiatric hospitalizations every time she spoke about her difficulties. Melody became more anxious and angry as a result. She noted that her old way of hurting herself (accidents) was more effective in diverting her attention away from unwanted feelings and gaining her parents support than talking about feelings.

When her family was asked to be involved in her treatment, both Melody and her parents decided that therapy was not helpful and terminated the treatment.

This vignette illustrates a common situation in which self-harm functions to divert attention away from emotional difficulties and to enlist noncritical caregiving support. The behavioral “acting out” is itself a common form of resistance. Both Melody and her parents resisted the process of replacing self-harm with self-reflection and verbalization of feelings in therapy. When patients like Melody start the difficult tasks of change and confronting negative affects, they will feel worse before they feel better. It is helpful to teach borderline patients and their families that this is expected and is how therapy can work.

The vignettes presented here illustrate several forms of resistance that clinicians can expect to encounter in working with patients with BPD. We have not attempted to be comprehensive about all the forms of resistance encountered. A few of the other common resistances include deceit, projection, and “splitting.” Clinicians should appreciate that what may seem like willful deceit can often better be understood as the patient’s defensive ability to dissociate or deny, or to lose his mentalizing abilities, when stressed.

Projection can also become a formidable means of resistance. The clinician needs to seek out that sometimes-modest fraction of the patient’s complaints and attributions that are true and begin to validate them.

This principle is also central in responding to splitting. Clinicians who are idealized by their patients should accept the partial truth of this, while clinicians who are vilified should acknowledge that they did or said something that makes the patient’s 

Our review is intended to illustrate that the patient’s resistance to treatment can be aggravated by a therapist’s misunderstandings of BPD. It is easy to blame the patient for responding poorly to treatments (being “resistant”) without recognizing that when treatments don’t reflect an understanding of BPD, the treatments can aggravate these resistances.

These comments are not meant to minimize the diverse array of resistances that patients with BPD present. These patients will 

, but when their particular forms of resistance to treatment are understood as learned behaviors that have served adaptive function, we can move toward a more empathic and sympathetic therapeutic posture. Resistance can then be replaced by more truly adaptive responses.

 Stern A. Psychoanalytic investigation and therapy in the borderline group of neuroses. 

 Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. 

 Zanarini MC, Frankenburg FR, Reich DB, et al. Subsyndromal phenomenology of borderline personality disorder: 10-year follow-up study. 

Cognitive-Behavioral Therapy of Borderline Personality Disorder.

Cognitive Therapy for Personality Disorders: A Schema-Focused Approach. 

Sarasota, FL: Professional Resource Press; 1994.


 Gunderson JG, Morey LC, Stout RL, et al. Major depressive disorder and borderline personality disorder revisited: longitudinal interactions. 

Borderline Personality Disorder: A Clinical Guide. 

Washington, DC: American Psychiatric Press, Inc; 2008.


 Souery D, Papakostas GI, Trivedi MH. Treatment-resistant depression. 

 Fan AH, Hassell J. Bipolar disorder and comorbid personality pathology: a review of the literature. 

 Gunderson JG, Stout RL, Sanislow CA, et al. New episodes and new onsets of major depression in borderline and other personality disorders

Historically, borderline patients were considered “help-rejecting complainers.” Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms.

Our evolving understanding of borderline personality disorder (BPD) and its treatment is reflected in each of the contributions to this Special Report of 

. This evolution includes the surprising evidence that this disorder has more significant genetic determinants and many patients have a far better prognosis than had previously been thought. John M. Oldham, M.D., describes newer conceptions of borderline psychopathology as the combination of different phenotypes (e.g., affective instability and impulsive aggression) that have neurobiological correlates, and he indicates that such considerations suggest that a dimensional model has advantages compared to the traditional categorical approach to diagnosis.

The evolution of our knowledge about treatment of BPD is equally dramatic. From an earlier conception of treatment that rested largely on long-term, intensive psychoanalytic therapy and long-term hospitalization, current treatments are less intensive, more diverse and decidedly more specific to borderline psychopathology. The development of a form of behavioral therapy--dialectical behavior therapy (DBT)--which received empirical validation a decade ago, was instrumental in bringing about these changes.

Dialectical behavior therapy departs from usual behavioral therapy insofar as its developer, Marsha Linehan, Ph.D., discovered that patients with BPD require validation and acceptance before change is possible. As described by Anthony W. Bateman, M.A., FRCPsych, psychoanalytic therapies are now receiving a much-needed boost from more recent research. Bateman and Peter Fonagy, Ph.D., FBA, developed a therapy--mentalization-based treatment (MBT)--which was found to be effective with patients with BPD. Readers who are not familiar with MBT will receive a valuable introduction in Bateman's article to a treatment that seems destined to soon take its place beside DBT as an empirically based therapy for BPD. Also of note, the form of psychotherapy long championed by the psychoanalytic leader Otto F. Kernberg, M.D.--now refined, manualized and named transference-focused psychotherapy (TFP)--is going through empirical testing. The efficacy of MBT and potentially of TFP for patients with BPD offers a significant opportunity for psychoanalysis to regain a place within modern psychiatry.

However, it would be unwise to suggest that the competing claims for either behavioral or psychoanalytic models should receive more attention than the claims for supportive therapy as described by David J. Hellerstein, M.D., and colleagues. The importance of support is clearly evident in that both behavioral (DBT) and psychoanalytic (MBT or TFP) approaches needed significant modifications of standard practices to include more supportive interventions before they could be made useful for patients with BPD. The importance of supportive interventions is also evident in the data from longitudinal studies that document the potential for rapid and early remissions from effective case management. Not surprisingly, as Hellerstein and co-authors describe, supportive therapy also requires modifications to be suitable for this patient group.

The article by Paul S. Links, M.D., FRCPC, and colleagues is a clinically wise discussion of assessing and managing the recurrent suicide risks that characterize patients with BPD. Of particular note may be their admonition about the use of hospitals as part of the safety management of these patients. As a reaction against the failures of long-term hospitalization, many psychiatrists have tried too hard to avoid hospitalizing their patients with BPD. Links and colleagues rightly note that modern short-term hospitalizations have few of the regressive dangers that previously existed.

Together, these articles provide a useful update on new knowledge and new conceptions about BPD, a disorder that, despite the considerable gains, remains one of psychiatry's most vexsome problems and one of society's major health care priorities. Increased public awareness, support by the National Institute of Mental Health and foundations for research, and the prospect of overdue investments in drug trials by the pharmaceutical industry all promise that the current surge of knowledge will continue to grow.

acknowledges Dr. Gunderson for his work in planning and reviewing this special report. Dr. Gunderson is professor of psychiatry at Harvard Medical School and is director of the Center for Treatment and Research on Borderline Personality Disorder at McLean Hospital.

Our evolving understanding of borderline personality disorder and its treatment includes the surprising evidence that this disorder has more significant genetic determinants and many patients have a far better prognosis than had previously been thought. Treatment approaches have also become less intensive and more diverse and specific. This is a disorder that, despite the considerable gains, remains one of psychiatry's most vexsome problems and one of society's major health care priorities.

New Knowledge and New Conceptions

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. 

 	Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. 1982;139(1):12-20.


 	Cooper A, Ronningstam E. Narcissistic Personality Disorder. In: Tasman A, Riba MB, eds. American Psychiatric Press Review of Psychiatry, Vol.  11. Washington: American Psychiatric Press; 1992.


 	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.


 	Kernberg O. Internal World and External Reality. New York: Jason Aronson; 1985.


 	Millon T. Disorders of Personality DSM III: AXIS II. New York: Wiley & Sons; 1981.


 	Ronningstam E, Gunderson. Identifying criteria for narcissistic personality disorder. Am J Psychiatry. 1990;1477:918-922.


 	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.

John G. Gunderson, MD

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