Sharing a Diagnosis of Narcissistic Personality: a Challenging Decision with Associated Risks and Benefits
- 3 Downloads
Purpose of Review
This paper aims to examine diagnostic sharing of narcissistic personality from multiple vantage points and to describe strategies that might help clinicians in patient management.
In recent years, clinicians increasingly have been motivated to discuss with patients the diagnosis of borderline personality disorder (BPD), an intervention bolstered by the emergence of empirically validated treatments for BPD and by advocacy organizations calling for diagnostic sharing. Despite these advances, clinical experience suggests that the diagnosis of narcissistic personality, including narcissistic personality disorder (NPD) or clinically significant narcissistic traits, is rarely shared with patients. We review emerging information about diagnostic classification and assessment, epidemiology, heritability, neurobiology, prognosis, and the utility of evidence-based treatments, which may facilitate a conversation on diagnosis (as demonstrated in multiple clinical scenarios provided as examples).
Diagnostic sharing has become a central element in the informed consent process. Understanding the risks and benefits of sharing a diagnosis of narcissistic personality is essential for clinical practice.
KeywordsNarcissistic personality disorder Narcissism Diagnosis Psychoeducation
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 6.van den Dungen P, van Kuijk L, van Marwijk H, van der Wouden J, Moll van Charante E, van der Horst H, et al. Preferences regarding disclosure of a diagnosis of dementia: a systematic review. Int Psychogeriatr. 2014;26(10):1603–18. https://doi.org/10.1017/S1041610214000969.CrossRefPubMedGoogle Scholar
- 12.Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 2011;(6):CD002831. https://doi.org/10.1002/14651858.CD002831.pub2.
- 17.• Zanarini MC, Conkey LC, Temes CM, Fitzmaurice GM. Randomized controlled trial of web-based psychoeducation for women with borderline personality disorder. J Clin Psychiatry. 2018;79(3). https://doi.org/10.4088/JCP.16m11153. This randomized controlled trial of internet-based psychoeducation for 80 woman who met DSM-IV criteria for BPD showed reduced symptom severity for up to one year.
- 19.• Zimmerman M, McGonigal P, Moon SS, Mehring L, LaHaye J, Berges A, et al. Does diagnosing a patient with borderline personality disorder negatively impact patient satisfaction with the initial diagnostic evaluation? Ann Clin Psychiatry. 2018;30(3):215–9. This study of 1,093 patients compared patient satisfaction with an initial evaluation in patients diagnosed with BPD as compared with non-BPD diagnoses and found no significant difference. PubMedGoogle Scholar
- 21.Linehan MM. DBT skills training manual. 2nd ed. New York: Guilford Press; 2014.Google Scholar
- 22.Hersh RG, Caligor E, Yeomans FE. Fundamentals of transference-focused psychotherapy: applications in psychiatric and medical settings. Cham: Springer; 2017.Google Scholar
- 23.Miller JD, Lynam DR, Hyatt CS, Campbell WK. Controversies in narcissism. Annu Rev Clin Psychol. 2017;13:291–315. https://doi.org/10.1146/annurev-clinpsy-032816-045244.CrossRefPubMedGoogle Scholar
- 24.Gunderson JG, Links P. Handbook of good psychiatric management for borderline personality disorder. Washington, DC: American Psychiatric Association Publishing; 2014.Google Scholar
- 27.• Ronningstam E. NPD basic: a brief overview of identifying, diagnosis and treatment narcissistic personality disorder. New York: National Education Alliance for Borderline Personality Disorder; 2016. This is a primer written for clinicians, patients and families on narcissistic personality published by an advocacy organization. Google Scholar
- 31.Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, 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. J Clin Psychiatry. 2008;69(7):1033–45.CrossRefGoogle Scholar
- 32.• Caligor E, Petrini M. Narcissistic personality disorder: epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis. In: Uptodate. 2018. https://www.uptodate.com/contents/narcissistic-personality-disorder-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis. Accessed 16 July 2019. This is a comprehensive and updated summary of narcissistic personality disorder including epidemiology, pathogenesis, clinical manifestations, course, assessment and diagnosis.
- 38.Pulay A, Goldstein R, Grant B. Sociodemographic correlates of DSM-IV personality disorder; results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). In: Campbell WK, Miller JD, editors. The handbook of narcissism and narcissistic personality disorder: theoretical approaches, empirical findings, and treatments. Hoboken: Wiley; 2011. p. 167–80.Google Scholar
- 42.Giner L, Blasco-Fontecilla H, Mercedes Perez-Rodriguez M, Garcia-Nieto R, Giner J, Guija JA, et al. Personality disorders and health problems distinguish suicide attempters from completers in a direct comparison. J Affect Disord. 2013;151(2):474–83. https://doi.org/10.1016/j.jad.2013.06.029.CrossRefPubMedGoogle Scholar
- 43.Blasco-Fontecilla H, Baca-Garcia E, Dervic K, Perez-Rodriguez MM, Lopez-Castroman J, Saiz-Ruiz J, et al. Specific features of suicidal behavior in patients with narcissistic personality disorder. J Clin Psychiatry. 2009;70(11):1583–7. https://doi.org/10.4088/JCP.08m04899.CrossRefPubMedGoogle Scholar
- 44.• Gabbard GO, Crisp H. Narcissism and its discontents: diagnostic dilemmas and treatment strategies with narcissistic patients. Washington, DC: American Psychiatric Association Publishing; 2018. This book on narcissism is written for clinicians of different orientations in clear and accessible language. CrossRefGoogle Scholar
- 45.Caligor E, Kernberg OF, Clarkin JF, Yeomans FE. Psychodynamic therapy for personality pathology: treating self and interpersonal functioning. Washington, DC: American Psychiatric Association Publishing; 2018.Google Scholar
- 46.Behary W, Dieckmann E. Schema therapy for narcissism: the art of empathic confrontation, limit-setting, and leverage. In: Campbell WK, Miller JD, editors. The handbook of narcissism and narcissistic personality disorder: theoretical approaches, empirical findings, and treatments. Hoboken: Wiley; 2011. p. 455–6.Google Scholar
- 47.Reed-Knight B, Fischer S. Treatment of narcissistic personality disorder symptoms in a dialectical behavioral therapy framework: a discussion and case example. In: Campbell WK, Miller JD, editors. The handbook of narcissism and narcissistic personality disorder: theoretical approaches, empirical findings, and treatments. Hoboken: Wiley; 2011. p. 466–75.Google Scholar
- 48.Weinberg I, Finch E, Choi-Kain L. Implementation of good psychiatric management for narcissistic personality disorder: good enough or not good enough? In: Choi-Kain L, Gunderson J, editors. Applications of good psychiatric management for borderline personality disorder: a practical guide. Washington, DC: American Psychiatric Association Publishing; 2019. p. 254–80.Google Scholar
- 50.Cain NM, Pincus AL, Ansell EB. Narcissism at the crossroads: phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clin Psychol Rev. 2008;28(4):638–56. https://doi.org/10.1016/j.cpr.2007.09.006.CrossRefPubMedGoogle Scholar
- 51.• Yakeley J. Current understanding of narcissism and narcissistic personality disorder. BJPsych Advances. 2018;5(24):305–15. This review article discusses the history of the concept of narcissism, its evolution as a clinical diagnosis, current understanding of NPD and treatment options. CrossRefGoogle Scholar
- 52.Pincus AL, Lukowitsky MR. Pathological narcissism and narcissistic personality disorder. Annu Rev Clin Psychol. 2010;6:421–46. https://doi.org/10.1146/annurev.clinpsy.121208.131215.CrossRefPubMedGoogle Scholar
- 60.Ellison WD, Levy KN, Cain NM, Ansell EB, Pincus AL. The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: a naturalistic investigation. J Pers Assess. 2013;95(3):291–300. https://doi.org/10.1080/00223891.2012.742904.CrossRefPubMedGoogle Scholar