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Chapter 52. Narcissistic Personality Disorder

Elsa F. Ronningstam, Ph.D.; John T. Maltsberger, M.D.
DOI: 10.1176/appi.books.9781585622986.263007

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After Freud said that patients with narcissistic neuroses did not form transferences, many assumed such patients were untreatable by psychoanalytic methods. In the late 1960s, Kernberg and Kohut revived interest in the study and treatment of narcissistic personality disorder (NPD) when they introduced two radically different approaches: an ego-psychological object relations perspective and a self psychological approach. More than 40 years of intense debate on understanding and treating NPD have led to some consensus about specific therapeutic challenges and procedures and the benefits that come from them. Clinicians can choose among the broad range of treatment modalities that are now available (see Ronningstam 1998). Beyond psychoanalysis and long-term individual psychotherapy, we have short-term objective focused psychotherapy and cognitive, family, couples, and group therapy; we also have modalities that focus on component problems of NPD, such as anger management, work interactions, shyness, and intimacy. Nevertheless, research on the course and outcome of treatment or the comparison of treatment modalities for narcissistic patients remains virtually nonexistent. Treatment planning for these patients must still rely on accumulated clinical experience, and the choices of modalities and strategies depend on the particular complexion of a patient's narcissistic functioning.

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Figure 52–1. A dimensional regulatory model for narcissism—from normal narcissism to narcissistic personality disorder.Source. Reprinted from Ronningstam E: Identifying and Understanding the Narcissistic Personality. New York, Oxford University Press, 2005, p. 111. Copyright 2005, Oxford University Press. Used with permission.
Table Reference Number
Table 52–1. Paradigms for the psychoanalytic treatment of narcissistic personality disorder
Table Reference Number
Table 52–2. DSM-IV-TR outward descriptors and subjective correlates in narcissistic personality disorder

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