Elsa Ronningstam, Ph.D.
and John Gunderson, M.D.
Psychiatric Times February 1996 Vol.XIII Issue 2
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.
Corrective Life EventsAnother 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.
Real AchievementsAs 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.
New QuestionsThis 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.
Dr. Ronningstam is instructor in psychology at Harvard Medical School and assistant psychologist at the Psychosocial Center, McLean Hospital, Belmont, Mass.
Dr. Gunderson is professor of psychiatry at Harvard Medical School and director of the Psychosocial Center at McLean Hospital, Belmont, Mass.References1. Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. 1982;139(1):12-20.
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