Elsa Ronningstam, Ph.D. Igor Weinberg, Ph.D. Narcissistic Personality Disorder: Progress in Recognition and Treatment Abstract: This review will address pathological narcissism and narcissistic personality disorder (NPD)—the clinical presentation, the challenges involved in diagnosing NPD, and significant areas of co-occurring psychopathology (i.e., affective disorder, substance usage, and suicide). Major depressive disorder is the most common comorbid disorder in patients with pathological narcissism or NPD. Need for self-enhancement and chronic disillusionment with self make these individuals particularly susceptible to substance use. Suicidal preoccupation in these patients is characterized by the absence of depression, lack of communication, self-esteem dysregulation, and life events that decrease self-esteem. The diagnostic focus on patients’ external characteristics and interpersonal behavior tends to dismiss the importance of their internal distress and painful experiences of self-esteem fluctuations, self-criticism, and emotional dysregulation. A collaborative and exploratory diagnostic approach to pathological narcissism and NPD is outlined that aims at engaging the patients and promoting their curiosity, narration, and self-reflection. Alliance building with a narcissistic patient is a slow and gradual process and mistakes are common. A central task is to balance these patients’ avoidance and sudden urges to reject the therapist and drop out of treatment with the goal of encouraging and enabling them to face and reflect upon their experiences and behavior. Implications for treatment and possible areas or indications of change include: interpersonal and vocational functioning; sense of agency and self-direction; emotion regulation and ability to understand, tolerate, and modulate feelings; reflective ability; and ability to mourn the loss of wished for or unreachable internal self-states, relationships, and external ideals. INTRODUCTION CASE VIGNETTE #1: “STRIVING FOR PERFECTION AND FACING DESPAIR” Ms. B, a 24-year-old research assistant in bio- technology, began treatment after her second near- lethal suicide attempt. She described herself to the therapist as the top achiever in her lab, very meticulous and determined to do research projects according to optimal scientific standards in order to reach reliable results. However, despite evidence of her competence, Ms. B struggled with the horrific fear of making mis- takes. Her internal requirements for absolute perfection combined with extremely harsh self-criticism caused constant doubts that her work would meet the stan- dards she had set up for herself. She spent a lot of time studying and preparing to make sure that her super- visor, whom she admired for his exceptional skills and reputation, acknowledged her and supported her plans for a career in the field. She described recurrent episodes of getting trapped inside herself on a rollercoaster of aspirations and ambitions, demands, self-criticism, self-hatred, doubts, and fear, especially when facing new tasks and projects. At those times, she lost her ability to think clearly and concentrate and began to think about suicide. Usually she managed those sit- uations by excessive alcohol consumption, but she had also begun to come in late and even cancel work. On two Author Information and CME Disclosure Elsa Ronningstam, Ph.D., Harvard Medical School, McLean Hospital, Boston Psychoanalytic Society and Institute Igor Weinberg, Ph.D., Harvard Medical School, McLean Hospital The authors report no competing interests. Address correspondence to Elsa Ronningstam, Ph.D., McLean Hospital, 115 Mill St., Belmont, MA 02478; e-mail: ronningstam@e-mail.com focus.psychiatryonline.org FOCUS Spring 2013, Vol. XI, No. 2 167 CLINICAL SYNTHESIS