Prevalence and treatment of narcissistic personality disorder in the community: a systematic review

Narcissistic personality disorder in the ICD-11: Severity and trait profiles of grandiosity and vulnerability

Modern diagnostic and classification frameworks such as the ICD-11 and DSM-5-AMPD have adopted a dimensional approach to diagnosing personality disorder using a dual "severity" and "trait" model. As narcissistic personality has historically struggled to be adequately captured in dominant diagnostic systems, this study investigated the utility of the new ICD-11 framework in capturing diverse narcissistic expressions. Participants were mental health clinicians (N = 180, 67% female, age = 38.9), who completed ratings of ICD-11 personality severity, trait domains and a clinical reflection for two hypothetical case vignettes reflecting either prototypical "grandiose" or "vulnerable" narcissism. The majority of clinicians (82%) endorsed a diagnosis of personality disorder for both grandiose and vulnerable vignettes. Discriminant elements of personality impairment included rigid, unrealistically positive self-view, low empathy and high conflict with others for grandiosity, and incoherent identity, low self-esteem and hypervigilant, avoidant relations with others for vulnerability. Regarding trait profile, grandiose narcissism was predominately dissocial whereas vulnerable narcissism was primarily associated with negative affectivity and detachment. Qualitative responses highlight distinct clinical themes for each presentation. These findings suggest that clinicians using the ICD-11 framework are able to identify common core elements of personality dysfunction in grandiose and vulnerable narcissism while also recognizing their distinctive differences.

Mediators of change in psychological interventions for adult offenders with personality disorders: A scoping review of the literature

Offenders with personality disorder cause disproportionate harm to society and pose significant challenges for those responsible for their care and rehabilitation. Personality disorders are heterogeneous in terms of symptoms, as well as their pathways to offending behaviour. Thus, there is limited evidence regarding effective interventions. One solution might be to focus on how interventions are delivered as well as what is delivered. Within the non-offender personality disorder literature, the identification of potential mediators of change has enabled interventions to focus on 'how' they are delivered (e.g., therapeutic alliance) rather than the intervention itself. We explore the evidence and present a scoping review of the available literature on the mechanisms of change in psychological treatments for offenders with personality disorder. Only one study was found in the scoping review, highlighting a significant gap in the evidence base. We discuss the implications of this finding and potential future directions.

Examining the Therapeutic Effect of Ceremonial Ayahuasca on Narcissistic Personality and Antagonistic Externalizing in Adults

Changes in narcissistic traits (e.g., entitlement) following the ceremonial use of ayahuasca were examined across three timepoints (baseline, postretreat, 3-month follow-up) in a sample of 314 adults using self- and informant-report (N = 110) measures. Following ceremonial use of ayahuasca, self-reported changes in narcissism were observed (i.e., decreases in Narcissistic Personality Inventory [NPI] Entitlement-Exploitativeness, increases in NPI Leadership Authority, decreases in a proxy measure of narcissistic personality disorder [NPD]). However, effect size changes were small, results were somewhat mixed across convergent measures, and no significant changes were observed by informants. The present study provides modest and qualified support for adaptive change in narcissistic antagonism up to 3 months following ceremony experiences, suggesting some potential for treatment efficacy. However, meaningful changes in narcissism were not observed. More research would be needed to adequately evaluate the relevance of psychedelic-assisted therapy for narcissistic traits, particularly studies examining individuals with higher antagonism and involving antagonism-focused therapeutic approaches.

The Longitudinal Effect of Narcissistic Admiration and Rivalry Traits on Relationship Satisfaction

This research estimates how changes in admiration and rivalry narcissistic traits correlate with changes in relationship satisfaction over time. Longitudinal analyses based on data from the Panel Analysis of Intimate Relationships and Family Dynamics (pairfam) studies were used to investigate this question. Findings show associations between heightening rivalry narcissistic traits and decreased levels of relationship satisfaction among men and women, and between heightening admiration narcissistic traits and decreased levels of relationship satisfaction among men. When the two aspects were estimated together, accounting for collinearity, heightening admiration narcissistic traits were not associated with changes in relationship satisfaction among men, while, among women, they correlated with increased levels of relationship satisfaction. These findings advance previous propositions in recent literature and shed light on gender differences in this regard.

Adverse childhood experiences and grandiose narcissism - Findings from a population-representative sample

BACKGROUND

In the development of narcissism, besides genetic factors, hostile educational conditions, including adverse childhood experiences (ACEs), are discussed as causal factors. ACE may play a causal role in the development of antagonistic behavior due to negative interpersonal experiences. However, studies assessing the role of ACEs in the etiology of narcissism are still inconsistent, particularly regarding grandiose narcissism. This may be due to the complexity of grandiose narcissism, which can be distinguished into agentic (admiration) and antagonistic (rivalry) facets. Understanding the role of early traumatic events in the etiology of grandiose narcissism may be important for psychotherapeutic treatment in both, patients with trauma history and narcissistic patients.

OBJECTIVE

We aimed to specify the role of ACEs in grandiose narcissism by differentiating between admiration and rivalry.

PARTICIPANTS AND SETTING

In a cross-sectional survey conducted from November 2017 to February 2018, a representative sample of the German population above the age of 14 (N = 2531) was selected in a random route approach.

RESULTS

Increased numbers of ACEs were associated with higher mean scores for rivalry in females (B = 0.04, p = 0.02) and males (B = 0.08, p < 0.01), while no significant associations were seen for admiration. Focusing on individual ACEs, in males, all maltreatment experiences were associated with narcissistic rivalry, with the exception of physical neglect, while in women only emotional maltreatment and emotional neglect were significant. Associations with household dysfunction were shown only in men. There were no significant associations between individual ACEs and admiration.

CONCLUSIONS

Our results suggest emotional coldness and negative relationship experiences play a role in the development of, in particular, antagonistic and unfavorable narcissistic traits, such as admiration. Therapy with individuals who have experienced ACEs should take into account possible narcissistic personality traits related to ACEs to facilitate successful treatment. Thus, our findings may help building a therapeutic alliance though a better understanding of the development of current behavioral problems for both patient and psychotherapist.

The Alleged Epidemic of Social Narcissism: Implications for Nurse Leaders

Research indicates that narcissistic personality disorder and subclinical narcissism may be reaching epidemic proportions within American society. It is thus probable that nursing administrators will encounter narcissistic behavior among their staff, supervisors, and/or patients and patient family members. It is therefore crucial that nurse leaders understand the causes of narcissism and how narcissistic behaviors might be addressed within health care settings. An awareness of these issues can help decrease the damage that narcissistic behaviors can have on individuals and institutions.

Parents' Personality-Disorder Symptoms Predict Children's Symptoms of Anxiety and Depressive Disorders - a Prospective Cohort Study

Personality disorder (PD) symptomatology is characterized by interpersonal problems and emotional dysregulation, which may affect offspring of parents with PD symptoms. Notably though, studies are needed to discern (i) whether parental PDs forecast symptoms of psychiatric disorders in offspring during their childhood years and (ii) whether such prospective relations obtain after accounting for common causes (e.g., genetics, common methods). To address these issues, we followed up a community sample of Norwegian children biennially from ages 4 to 8 (n = 594), using a semi-structured psychiatric interview (PAPA/CAPA) to capture DSM-IV defined symptoms of emotional disorders. Parental symptoms of personality disorders were captured by the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q), whereas depression and anxiety in caregivers were measured using the Beck Depression Inventory -II and Beck Anxiety Inventory, respectively. Upon applying a hybrid fixed and random effects method that takes into account all unmeasured time-invariant confounders, we found that: (i) Parental symptoms of DSM-IV defined Cluster A and C were related to symptoms of anxiety disorders in offspring two years later, even after accounting for children's initial levels of anxiety and parental anxiety, whereas (ii) Parental DSM-IV Cluster B predicted symptoms of depressive disorders in children, adjusted for children's initial levels of depression and parental depression. Clinical implications of the results are discussed.

Mom-and-Pop Narcissism: The Impact of Attention Seeking and Grandiosity on Couples' Experience of the Transition to Parenthood

Various studies have demonstrated associations between personality disorders and relationship satisfaction. The authors examine the associations between attention seeking and grandiosity, both features of narcissistic personality disorder, and relationship satisfaction before and after the transition to parenthood. The authors then expand their analysis to parental satisfaction and postpartum depression (PPD). Nonclinical couples (N = 103 couples) expecting their first child completed measures of grandiosity, attention seeking, and relationship satisfaction before birth, and of relationship satisfaction, parental satisfaction, and PPD symptoms 3 months afterward. Attention seeking was associated with less parental satisfaction and more PPD symptoms, and with less prepartum relationship satisfaction for participants' partners. For men, attention seeking was also associated with prepartum relationship satisfaction. Grandiosity was associated with a decrease in relationship satisfaction after birth, although, surprisingly with fewer PPD symptoms for participants' partners. The authors discuss how these findings might be related to changes in social support and work-life balance during the transition to parenthood.

On the uses and abuses of narcissism as a public health issue

Psychiatry understands narcissism as a pathological condition associated with poor social outcomes and difficulty relating to others. Millennials have been depicted by psychological research as 'narcissistic', and the term has lost accurate meaning. We underline the intellectual laxity of conflating social changes with narcissism and suggest ways forward.

Foundations of Arrogance: A Broad Survey and Framework for Research

We consider the topic of arrogance from a cross-disciplinary viewpoint. To stimulate further research, we suggest three types of arrogance (individual, comparative, and antagonistic) and six components contributing to them, each logically related to the next. The components progress from imperfect knowledge and abilities to an unrealistic assessment of them, an unwarranted attitude of superiority over other people, and related derisive behavior. Although each component presumably is present to some degree when the next one operates, causality might flow between components in either direction. The classification of components of arrogance should reduce miscommunication among researchers, as the relevant concepts and mechanisms span cognitive, motivational, social, and clinical domains and literatures. Arrogance is an important concept warranting further study for both theoretical and practical reasons, in both psychopathology and normal social interaction. Everyone seems to have qualities of arrogance to some degree, and we consider the importance of arrogance on a spectrum. We contend that humankind can benefit from a better understanding of the cognitive limitations and motivational biases that, operating together, appear to contribute to arrogance. We bring together information and questions that might lead to an invigorating increase in the rate and quality of cross-disciplinary research on arrogance.

Current understanding of narcissism and narcissistic personality disorder

This article reviews historical contributions to the conceptualisation of narcissism and narcissistic personality disorder (NPD), including its evolution as a clinical diagnosis within the DSM classification of mental disorders. It discusses the epidemiology and aetiology of NPD, noting that empirical studies of both are limited. The challenges of managing patients with prominent narcissistic traits are presented, and the psychological therapies specifically designed for the treatment of patients with NPD are summarised.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Executive functioning in people with personality disorders

PURPOSE OF REVIEW

This review summarizes recent executive functions research to better delineate the nosology of personality disorders.

RECENT FINDINGS

This review indicates that there are consistent impairments in executive functioning in people with personality disorders as compared with matched controls. Only five disorders were considered: borderline, obsessive-compulsive, antisocial, narcissistic, and schizotypal. Significant deficits are observed in decision-making, working memory, inhibition, and flexibility. Relevant data for the remaining personality disorders have not yet been published in relation to the executive functions.

SUMMARY

People with personality disorders could present a pattern of neurocognitive alterations that suggest a specific impairment of the prefrontal areas. The executive dysfunctions could partially explain the behavioral alterations in people with personality disorders.Further research should adopt broader considerations of effects of comorbidity and clinical heterogeneity, include community samples and, possibly, longitudinal designs with samples of youth.

Psychoanalytic-Interactional Therapy versus Psychodynamic Therapy by Experts for Personality Disorders: A Randomized Controlled Efficacy-Effectiveness Study in Cluster B Personality Disorders

BACKGROUND

With regard to cluster B personality disorders, most psychotherapeutic treatments focus on borderline personality disorder. Evidence-based treatments for patients with other cluster B personality disorders are not yet available. Psychoanalytic-interactional therapy (PIT) represents a transdiagnostic treatment for severe personality disorders. PIT has been applied in clinical practice for many years and has proven effective in open studies. In a randomized controlled trial, we compared manual-guided PIT to nonmanualized pychodynamic therapy by experts in personality disorders (E-PDT) in patients with cluster B personality disorders.

METHODS

In an inpatient setting, patients with cluster B personality disorders were randomly assigned to manual-guided PIT (n = 64) or nonmanualized E-PDT (n = 58). In addition, a quasi-experimental control condition was used (n = 46) including both patients receiving treatment as usual and patients waiting for treatment. Primary outcomes were level of personality organization and overall psychological distress. As secondary outcomes, depression, anxiety and interpersonal problems were examined.

RESULTS

No significant improvements were found in the control patients. Both PIT and E-PDT achieved significant improvements in all outcome measures and were superior to the control condition. No differences were found between PIT and E-PDT in any outcome measure at the end of treatment. The type of cluster B personality disorder had no impact on the results.

CONCLUSIONS

In an inpatient setting, both PIT and E-PDT proved to be superior to a control condition in cluster B personality disorders. In a head-to-head comparison, both treatments appeared to be equally effective. Further research on the treatment of cluster B personality disorders is required.

Narcissistic personality disorder: an integrative review of recent empirical data and current definitions

Although concepts of pathological narcissism are as old as psychology and psychiatry itself, only a small number of clinical studies are based on the criteria for narcissistic personality disorder (NPD), as defined in the Diagnostic and Statistical Manuals of Mental Disorders (DSM). As a result, NPD appears to be one of the most controversially discussed nosological entities in psychiatry. Whereas the majority of empirical studies used self or other ratings of NPD criteria to address issues of reliability and validity of the diagnostic category (i.e., internal consistency, factor structure, discriminant validity), only recent research has applied experimental designs to investigate specific features of NPD (e.g., self-esteem, empathy, shame). The aim of this review is to summarize available empirical data on NPD and relate these findings to current definitions of NPD (according to the DSM-5, [1]). In order to do so, this review follows the five steps to establishing diagnostic validity proposed by Robins and Guze [2], i.e., (1) clinical description, (2) laboratory studies, (3) delimitation from other disorders, (4) family studies, and (5) follow up studies. Finally, this review suggests pathways for future research that may assist further nosological evaluation of NPD and contribute to the overall goal, the improvement of treatment for patients.

The relationship between personality disorders and Axis I psychopathology: deconstructing comorbidity

The purpose of this review is (a) to study and systematically review the recent literature examining the co-occurrence and relationships between Axis I psychiatric disorders and Axis II personality disorders, specifically the six originally proposed for the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, and (b) to consider the clinical utility of the current Axis I and Axis II approach in the DSM-IV-TR and apply findings to state a position on the issue of collapsing together Axis I and Axis II. Community surveys or prospective cohort studies were reviewed as a priority. Our review indicates that the associations between clinical disorders and personality disorders clearly varied within each disorder and across the six personality disorders. Our understanding has advanced, particularly related to the clinical utility of comorbidity, and there may be sufficient evidence to support moving borderline personality disorder to Axis I. However, it seems premature to conclude that comorbidity is best conceptualized by having all disorders in a single category or by deleting disorders so that comorbidity is reduced. Our review suggests some priorities for future research into comorbidity, such as including personality disorders in future multivariate comorbidity models.

Mirror, mirror on the wall: reflecting on narcissism

This article introduces a special issue of the Journal of Clinical Psychology: In Session focused on the conceptualization and treatment of narcissism. Obscured by an ongoing debate about how best to define pathological narcissism, clinicians have often lost sight of the fact that narcissistic investment in the self is a normal developmental trend that can be disturbed to varying degrees by environmental stresses and failures of nurturing. Using case presentations, contributing authors demonstrate the following: the importance of understanding the closely interrelated grandiosity and vulnerability associated with narcissistic difficulties; variation in the expression of narcissistic "types"; the role of perfectionism and sadomasochism; and the possibility that narcissistic issues are present across all types of personality psychopathology. Specific alliance-building recommendations are offered, and the greater utility of defining narcissism dimensionally rather than categorically is explored. A clinical case in the current article illustrates each of these central ideas. Together, the discussions presented in this issue invite greater insight into, and appreciation of, narcissistic phenomena, along with examples of effective and empathic treatment approaches.

Design of a multicentered randomized controlled trial on the clinical and cost effectiveness of schema therapy for personality disorders

Background

Despite international guidelines describing psychotherapy as first choice for people with personality disorders (PDs), well-designed research on the effectiveness and cost-effectiveness of psychotherapy for PD is scarce. Schema therapy (ST) is a specific form of psychological treatment that proved to be effective for borderline PD. Randomized controlled studies on the effectiveness of ST for other PDs are lacking. Another not yet tested new specialized treatment is Clarification Oriented Psychotherapy (COP). The aim of this project is to perform an effectiveness study as well as an economic evaluation study (cost effectiveness as well as cost-utility) comparing ST versus COP versus treatment as usual (TAU). In this study, we focus on avoidant, dependent, obsessive-compulsive, paranoid, histrionic and narcissistic PD.

Methods/Design

In a multicentered randomized controlled trial, ST, and COP as an extra experimental condition, are compared to TAU. Minimal 300 patients are recruited in 12 mental health institutes throughout the Netherlands, and receive an extensive screening prior to enrolment in the study. When eligible, they are randomly assigned to one of the intervention groups. An economic evaluation and a qualitative research study on patient and therapist perspectives on ST are embedded in this trial. Outcome assessments (both for clinical effectiveness and economic evaluation) take place at 6,12,18,24 and 36 months after start of treatment. Primary outcome is recovery from PD; secondary measures include general psychopathological complaints, social functioning and quality of life. Data for the cost-effectiveness and cost-utility analyses are collected by using a retrospective cost interview. Information on patient and therapist perspectives is gathered using in-depth interviews and focus groups, and focuses on possible helpful and impeding aspects of ST.

Discussion

This trial is the first to compare ST and COP head-to-head with TAU for people with a cluster C, paranoid, histrionic and/or narcissistic PD. By combining clinical effectiveness data with an economic evaluation and with direct information from primary stakeholders, this trial offers a complete and thorough view on ST as a contribution to the improvement of treatment for this PD patient group.

Trial registration

Netherlands Trial Register (NTR): NTR566

Validity aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, narcissistic personality disorder construct

BACKGROUND

The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, narcissistic personality disorder (NPD) construct has been criticized for being too narrowly defined, for example, by focusing on overt grandiosity at the expense of exhibitionism and narcissistic vulnerability and thus covering only parts of the domain of narcissism. The purpose of this study was to elucidate several validity aspects of the NPD construct.

METHODS

The material consisted of data from 2277 patients (80% of whom had a personality disorder [PD]) who were admitted to units connected to The Norwegian Network of Psychotherapeutic Day Hospitals. The Axis II diagnoses were assessed by Structured Clinical Interview for DSM, Fourth Edition, Axis II Personality Disorders.

RESULTS

The frequency of NPD was very low (0.8%). Male patients were overrepresented both on a diagnostic level and on criteria levels. The NPD category was positively associated with other cluster B disorders and negatively associated with avoidant PD. The criteria "demands excessive admiration" and "fantasies of unlimited success" correlated almost as highly with the histrionic PD category and loaded primarily on a histrionic factor. The dominant NPD factor also included the antisocial criterion of "showing no regret having injured others." The major part of the patients' personality pathology could be attributed to other PD criteria.

CONCLUSIONS

The results challenge the notion of NPD as a distinct diagnostic category. Rather, narcissism should be conceived as personality dimensions pertinent to the whole range of PDs. The results support the views put forward by Russ et al (Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry 2008;11:1473-1481) that what clinicians conceive as narcissism consists of several subtypes (dimensions). Our data support the existence of a grandiose/malignant type and an exhibitionistic type. Unfortunately, there was no measure of hypersensitivity. The proposal to delete NPD as a prototype category in the DSM, Fifth Edition, seems well justified. However, the proposed trait domain of antagonism in the DSM, Fifth Edition, seems to account better for the grandiose/malignant dimension than the exhibitionistic/histrionic dimension.

Psycho-education with problem solving (PEPS) therapy for adults with personality disorder: a pragmatic multi-site community-based randomised clinical trial

BACKGROUND

Impairment in social functioning is a key component of personality disorder. Therefore psycho-education and problem solving (PEPS) therapy may benefit people with this disorder. Psycho-education aims to educate, build rapport, and motivate people for problem solving therapy. Problem solving therapy aims to help clients solve interpersonal problems positively and rationally, thereby improving social functioning and reducing distress. PEPS therapy has been evaluated with community adults with personality disorder in an exploratory trial. At the end of treatment, compared to a wait-list control group, those treated with PEPS therapy showed better social functioning, as measured by the Social Functioning Questionnaire (SFQ). A definitive evaluation is now being conducted to determine whether PEPS therapy is a clinically and cost-effective treatment for people with personality disorder

METHODS

This is a pragmatic, two-arm, multi-centre, parallel, randomised controlled clinical trial. The target population is community-dwelling adults with one or more personality disorder, as identified by the International Personality Disorder Examination (IPDE). Inclusion criteria are: Living in the community (including residential or supported care settings); presence of one or more personality disorder; aged 18 or over; proficiency in spoken English; capacity to provide informed consent. Exclusion criteria are: Primary diagnosis of a functional psychosis; insufficient degree of literacy, comprehension or attention to be able to engage in trial therapy and assessments; currently engaged in a specific programme of psychological treatment for personality disorder or likely to start such treatment during the trial period; currently enrolled in any other trial. Suitable participants are randomly allocated to PEPS therapy plus treatment as usual (TAU) or TAU only. We aim to recruit 340 men and women. The primary outcome is social functioning as measured by the SFQ. A reduction (i.e., an improvement) of 2 points or more on the SFQ at follow-up 72 weeks post-randomisation is our pre-specified index of clinically significant change. Secondary outcomes include a reduction of unscheduled service usage and an increase in scheduled service usage; improved quality of life; and a reduction in mental distress.

DISCUSSION

PEPS therapy has potential as an economical, accessible, and acceptable intervention for people with personality disorder. The results from this randomised controlled trial will tell us if PEPS therapy is effective and cost-effective. If so, then it will be a useful treatment for inclusion in a broader menu of treatment options for this group of service users.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number - ISRCTN70660936.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.