Change in Attachment and Reflective Function in Borderline Patients with and without Comorbid Narcissistic Personality Disorder in Transference Focused Psychotherapy

Abstract

Research has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in the literature in identifying the clinical characteristics of these NPD/BPD patients. In this article, we present recent research describing patients with comorbid NPD/BPD, as compared with patients with BPD without NPD (BPD), from two randomized clinical trials for the treatment of borderline personality disorder, with a particular emphasis on attachment status and mentalization. We anchor our discussion of these patients in object relations and attachment theory, and we describe our treatment approach, transference focused psychotherapy (TFP). We conclude by using case material to illustrate our research findings, highlighting the significant differences between patients with NPD/BPD and BPD/non-NPD in terms of their attachment classification.

Internal Processing in Patients With Pathological Narcissism or Narcissistic Personality Disorder: Implications for Alliance Building and Therapeutic Strategies

“…Internal processing is also affected by considerable underpinnings, such as inheritance and temperament, including hypervigilance, aggressivity, frustration intolerance, and high novelty seeking (Cloninger, 2000;Torgersen et al, 2012). Attachment patterns, in particular dismissive, avoidant, and anxiouspreoccupied patterns (Diamond et al, 2014), and gaze-that is, implications of being seen and seeing associated with shame, humiliation, and retreat (Steiner, 2006)-are also significant developmental components that affect narcissistic functioning. Internalized unintegrated self-object relations play a major role in experiences of and reactions to self and others in social and interpersonal contexts (O. F. Kernberg, 1976).…”

“…Reflective ability and mentalization (Fonagy, Gergely, Jurist, & Target, 2002) in patients with PN or NPD are compromised or fluctuating and can remain out of reach in treatment (Diamond et al, 2014). Self-reflection encompasses abilities to identify and connect internal experiences with type and level of visceral and bodily arousal; to connect thought and feelings in daily life; and to realize that one's own perception of interpersonal relationships is subjective and may differ from external reality (Dimaggio & Lysaker, 2018).…”

Dos and Don'ts in Treatments of Patients With Narcissistic Personality Disorder

“…Fourth, given the mentalization deficits of NPD patients (Diamond, Levy, et al, 2014), a number of mentalizing-based strategies are especially helpful (Allen, Fonagy, & Bateman, 2008). These include challenging assumptions and beliefs that are held with certainty, redirecting the patient from reporting to reflecting, and helping the patient shift back and forth from curiosity about self versus others as well as from feelings to thinking.…”

“…Connolly, Bujosa, & O'Neall, 2005;Ball, Maccarelli, LaPaglia, & Ostrowski, 2011;Bamelis, Evers, Spinhoven, & Arntz, 2014;Clarkin, Levy, Lenzenweger, & Kernberg, 2007;Vinnars, Barber, Norén, Gallop, & Weinryb, 2005). In addition, treatment modalities for NPD patients with comorbid borderline personality disorder (BPD) have been outlined (Diamond, Clarkin, et al, 2014). Specific pharmacological treatments for NPD are lacking, and typical treatment strategies involve symptomatic treatment of comorbid conditions (Ronningstam & Weinberg, 2013).…”

“…NPD predicts poor use of treatment services, higher rate of sudden or premature termination of treatment (Campbell et al, 2009;Ellison, Levy, Cain, Ansell, & Pincus, 2013), and higher symptom persistence following therapy (Jansson, Hesse, & Fridell, 2008). Clinical observations suggest that comorbid NPD in BPD patients impedes progress in such therapies as mentalization-based treatment (A. W. Bateman & P. Fonagy, personal communication, MBT training workshop, June 29, 2013, McLean Hospital, MA) and transference-based psychotherapy (Diamond, Clarkin, et al, 2014). Specific features associated with NPD were found to impede treatment progress as well.…”