Recent Development and Future Directions in Assessment and Treatment of Pathological Narcissism
The aim of this Symposium is to provide updates on recent studies of pathological narcissism that can have relevance for clinical approaches to assessment and treatment of patients with narcissistic personality pathology. Four presenters will discuss results from studies focusing on identifying range and manifestations of pathological narcissism, and on interpersonal interactional patterns as unfolding in sessions or perceived by relatives. The discussant will focus on clinical integration and applications of results from the studies.
First speaker David Kealy presents: Grandiose fantasy and contingent self-esteem: Investigating
Brief self-report assessment of pathological narcissism, comprising grandiosity and vulnerability, is advantageous for (1) screening for in-depth assessment of narcissistic pathology; (2) clinical intake usage to inform case formulation and treatment planning; and (3) facilitating research on pathological narcissism where brevity of assessment is warranted. The Pathological Narcissism Inventory (PNI) has been abbreviated to a 28-item version (Brief PNI) and a 12-item version (Super-Brief PNI). Although studies have employed the Super-Brief PNI, reports on its psychometric properties and associations with clinical variables are limited, which may restrict its use as a clinical screening tool. This presentation reports on the investigation of the Super-Brief PNI regarding factor structure and optimal length. Confirmatory factor analyses and correlations were conducted across three samples, including undergraduate students, community members, and psychiatric outpatients. Associations with other narcissism measures, interpersonal problems, emotion regulation difficulties, self-presentation concerns, psychological distress, and mindfulness were examined and compared with the Brief PNI. Optimal model fit was observed for Contingent Self-Esteem and Grandiose Fantasy subscales to higher-order pathological narcissism, reflecting deficient/vulnerable and fantasized/grandiose self-image. Expected associations with clinically salient variables were significant. Clinical application will be illustrated using a case formulation of a young adult with identity and self-esteem difficulties.
Second Speaker Ueli Kramer presents: In-session social interaction in patients with pathological narcissism: a process-outcome analysis
In-session social interaction difficulties may be particularly relevant for patients with personality disorders. Patients with BPD showed difficulties in early sessions, especially low levels of intra- and interpersonal trust and elevated intensity of interaction maneuvers (Singer et al 2020). Question remains how such difficulties may manifest in patients with pathological narcissism and if these social interaction difficulties affect in-session outcome. A sample of patients (n=14) with pathological narcissism (according to DSM-5) undergoing long-term Clarification-Oriented Psychotherapy (COP; Sachse, 2020) was included in the study. Session five was video-taped and rated by an external judge using the Borderline Interaction Problems Scale (BIPS; Signer et al., 2020). Outcome was assessed at the end of the psychotherapy. Activated assumptions related to intrapersonal and interpersonal trust were associated with severity of pathological narcissism. The intensity of interaction maneuvers assessed in the beginning of COP predicted the outcome in the end of the psychotherapy. Pathological narcissism impacts interpersonal relationships via the individual’s assumptions related to trust and interaction maneuvers. The present study showed that specific aspects of problematic in-session interaction may be related to both the severity of problems and the outcome of effective psychotherapy, thus making it a key variable to be targeted in intervention.
Third Speaker Nicholas Day presents: Repetitive relationship themes told by people living with a narcissistic relative.
Difficulty having stable and mutually satisfying relationships is a central feature of pathological narcissism, whereby antagonistic behaviors often result in strong negative reactions from others. We sought to examine the moment-to-moment interpersonal patterns that emerge with individuals with pathological narcissism, when compared to ‘neutral’ comparisons. Participants (N = 15) were romantic partners (73.3%) and family members (26.6%) in a close and long-term relationship (+ 10 years) with an individual with pathological narcissism. Participants told verbatim relationship narratives, analyzed using Core Conflictual Relationship Theme method. Ratings of individuals relationship style were also completed within different situational contexts. A total of 133 relationship episodes were analyzed, comprising 783 components (wishes, responses of others and responses of self). Identified wishes (e.g., for love, for support) were not significantly different between groups, however there was significant disharmony in narratives involving relatives with pathological narcissism (e.g., rejecting, subjugating, withdrawing behaviors). Relationship style was rated as predominately insecure. These results reflect the cycles of relationship dysfunction for individuals with pathological narcissism and their partners and family members. Treatment implications point to the risk of therapists withdrawing and dismissing a patient with high pathological narcissism in the countertransference.
The Discussant Elsa Ronningstam presents: Clinical implications of present studies. These four studies show progress in applying a dimensional approach indicating pathological narcissism as either or both covert and intrapsychic, as well as overtly behavioral and interpersonal. Attention to co-occurrence and fluctuations in the range of indicators and severity of pathological narcissism is important, especially as narcissistic personality pathology can be anchored and noticeable both in sense of identity and self-esteem, as well as in sense of competence and interpersonal reactivity and interactions. This suggests an open and adjustable treatment approach, including treatment frame and case formulation, building trust and reliability in the treatment alliance, and inviting the patients’ active involvement and sense of agency in working towards awareness and change. Patients’ challenging interactions, including antagonism, enactments, and negativity continues to be high priority for further studies of interventions. Similarly, patients’ avoidance and hiding, often behind other-directed adjustment and attention is also a main concern. The presenters point to encouraging development of patients’ own narratives for informing of their internal experiences as well as integrating contradictions and opposites, to consolidate sense of identity and self-esteem, Therapists’ strategies to manage and transform challenging counter transference and reactions into proactive and consolidating approaches and interventions remains a major focus for continuing studies.