Elsa Ronningstam

Early discontinuance of borderline patients from psychotherapy.

Sixty newly hospitalized patients with borderline personality disorder who began psychotherapy were followed for 6 months. Thirty-six discontinued their therapy—most often (N =26) this was due to covert opposition, familial resistance, or angry dissatisfaction with treatment. The dropouts were healthier on some baseline measures than those who continued in therapy. Clinical implications that may diminish dropouts are discussed.

Narcissistic PersoNality DisorDer iN DsM V—iN suPPort of retaiNiNg a sigNificaNt DiagNosis

Narcissistic personality disorder, NPD, has been excluded as a diagnostic category and independent personality disorder type in the Personality and Personality Disorder Work Groups recent proposal for DSM-5 Personality and Personality Disorders. The aim of this paper is to present supporting evidence in favor of keeping NPD as a personality type with a set of separate diagnostic criteria in DSM-5. These include: the prevalence rate, extensive clinical and empirical reports and facts, its psychiatric, social and societal significance especially when associated to functional vocational and interpersonal impairment, social and moral adaptation, and acute suicidality. Proposals for a clinically relevant and empirically based definition of narcissism, a description of the narcissistic personality disorder type, and a set of diagnostic criteria for NPD are outlined.

Narcissistic personality disorder: a current review.

The diagnosis of narcissistic personality disorder in the DSM-IV has been criticized foremost for its limitations in capturing the range and complexity of narcissistic pathology. The attention to the narcissistic individual’s external, symptomatic, or social interpersonal patterns—at the expense of his or her internal complexity and individual suffering—has also added to the diagnosis’ low clinical utility and limited guidance for treatment. Recent studies and reviews have pointed to the need for change in the diagnostic approach to and formulation of narcissism. This review focuses specifically on studies of features that add to the identification, understanding, and treatment of patients with pathological narcissistic functioning and narcissistic personality disorder. They have been integrated into a regulatory model that includes the functions and fluctuations of internal control, self-esteem, perfectionism with accompanying self-criticism, shame, and empathic ability and functioning.

Common factors in empirically supported treatments of borderline personality disorder.

In this article, we examine the manuals of empirically supported psychotherapies for borderline personality disorder (BPD) by comparing their common and specific treatment strategies. We compare these treatments using a previously constructed scale of treatment interventions. Individual psychotherapies for BPD have several common strategies: clear treatment framework, attention to affect, focus on treatment relationship, an active therapist, and exploratory and change-oriented interventions. Use of interpretations, supportive interventions, designating treatment targets, attention to patient functioning, multimodal treatment, and support for therapies varied across the psychotherapies. We discuss these findings in the context of clusters of BPD symptoms, reports regarding overlap in treatment interventions used by various psychotherapies, and the effectiveness of specific treatment strategies.

Narcissistic personality disorder: a clinical perspective.

Narcissistic traits and narcissistic personality disorder (NPD) present specific diagnostic challenges. While they are often readily and straightforwardly identified, their presentation in some patients and the reasons for which such patients seek treatment may conceal significant narcissistic pathology. Recently, several empirical studies have confirmed that the phenotypic range of people with NPD includes individuals with insecure, shy, and hypersensitive traits with prominent internalized narcissistic features and functioning. Other studies have confirmed that internal emotional distress, interpersonal vulnerability, fear, pain, anxiety, a sense of inadequacy, and depressivity can also co-occur with narcissistic personality functioning. This paper focuses on integrating these findings into the diagnostic evaluation and initial negotiation of treatment for NPD. In patients with narcissistic traits or NPD, it is important to give attention to the two sides of character functioning, which include both self-serving and self-enhancing manifestations as well as hypersensitivity, fluctuations in self-esteem, and internal pain and fragility. This article highlights some of these seemingly incompatible clinical presentations of narcissistic traits and NPD, especially as they co-occur with depressivity and perfectionism, and it discusses implications for building a treatment alliance with a patient with such a predominant disorder of character functioning. The article also discusses the importance of retaining the NPD diagnosis as a separate type of personality disorder, with this range of features, in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-5). (Journal of Psychiatric Practice 2011;17:89–99)

Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals.

OBJECTIVE Many reports of treatments for suicidal patients claim effectiveness in reducing suicidal behavior but fail to demonstrate which treatment interventions, or combinations thereof, diminish suicidality. In this study, treatment manuals for empirically supported psychological treatments for suicidal patients were examined to identify which interventions they had in common and which interventions were treatment-specific. METHOD Empirically supported treatments for suicidality were identified through a literature search of PsychLit and MEDLINE for the years 1970-2007, employing the following search strategy: [suicide OR parasuicide] AND [therapy OR psychotherapy OR treatment] AND [random OR randomized]. After identifying the reports on randomized controlled studies that tested effectiveness of different treatments, the reference list of each report was searched for further studies. Only reports published in English were included. To ensure that rated manuals actually correspond to the delivered and tested treatments, we included only treatment interventions with explicit adherence rating and scoring and with adequate adherence ratings in the published studies. Five manualized treatments demonstrating efficacy in reducing suicide risk were identified and were independently evaluated by raters using a list of treatment interventions. RESULTS The common interventions included a clear treatment framework; a defined strategy for managing suicide crises; close attention to affect; an active, participatory therapist style; and use of exploratory and change-oriented interventions. Some treatments encouraged a multimodal approach and identification of suicidality as an explicit target behavior, and some concentrated on the patient-therapist relationship. Emphasis on interpretation and supportive interventions varied. Not all methods encouraged systematic support for therapists. CONCLUSION This study identified candidate interventions for possible effectiveness in reducing suicidality. These interventions seem to address central characteristics of suicidal patients. Further studies are needed to confirm which interventions and which combinations thereof are most effective.

Eleven Deaths of Mr. K.—Contributing Factors to Suicide in Narcissistic Personalities

Abstract The objective of this paper is to discuss and illuminate the problem of abrupt suicide in relatively well-functioning individuals without a major DSM-IV mental illness. A case of a man diagnosed with narcissistic personality, who first allegedly staged a suicide attempt and later, without overt warning, killed himself in the context of financial losses and divorce, will be discussed. The paper addresses how and why a life event can generate an internal subjective experience that evokes a sudden deadly self-attack. Discussion of eleven explanatory hypotheses serves to further the understanding of these seemingly inexplicable events. We conclude that additional studies are necessary, especially of the interconnected interaction between life event, psychological functioning, and neurobiological correlates to expand understanding and develop proactive treatment strategies.

Pathological narcissism and narcissistic personality disorder in Axis I disorders.

&NA; This paper presents available information on the comorbidity of narcissistic personality disorder (NPD) and pathological narcissism with major mental illness. A review of empirical studies reporting on the prevalence of NPD in Axis I disorders, and of theoretical and clinical literature on narcissistic pathology in major mental illness, forms the basis for an analysis of this interface. The results show that prevalence rates of NPD in Axis I disorders rarely exceed those found in the general psychiatric or personality disorder populations (i.e., less than 22%). NPD was found at high rates in individuals with a substance use disorder (12–38%) or bipolar disorder (4–47%); it was present at very low rates or absent in persons with obsessive‐compulsive disorder. Higher prevalence rates were reported in the studies that used the Millon Clinical Multiaxial Inventory I or II than in those that employed the Structured Interview for DSM‐III Personality Disorders or the Structured Interview for DSM‐III‐R Personality Disorders‐Revised. There is no evidence implicating a significant relationship between NPD and any specific Axis I disorder. A comparison of theoretical and clinical studies with empirical ones reveals major differences in the views regarding the presence and significance of NPD in Axis I disorders. However, the results highlight trends of interacting comorbidity between NPD and substance use disorders, bipolar disorder, depression, and anorexia nervosa.

Suicide Fantasy as a Life-Sustaining Recourse

The suicide literature tends to lump all suicidal ideation together, thereby implying that it is all functionally equivalent. However obvious the claim that suicidal ideation is usually a prelude to suicidal action, some suicidal daydreaming tends to inhibit suicidal action. How are we to distinguish between those daydreams that augur an impending attempt from those that help patients calm down?

Comparing Three Systems for Diagnosing Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) has been a widely used diagnostic entity. However, opinions about its descriptive validity differ considerably. Hitherto, three diagnostic systems have been developed, those by DSM-III, Akhtar and Thomson, and Kernberg. This paper compares these three systems with respect to concordance among diagnostic criteria, and conceptual themes around which the criteria cluster. The results indicate low concordance among the specific criteria used in these systems but a consensus about the conceptual themes describing self-experience, interpersonal relations and other aspects of NPD. This suggests that NPD is comprised of some core characteristics. However, a reconceptualization of the understanding of NPD must precede further empirical investigations.