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Narcissistic Personality Disorder: A Clinical Perspective

Ronningstam, Elsa PhD

Journal of Psychiatric Practice®: March 2011 - Volume 17 - Issue 2 - p 89–99
doi: 10.1097/01.pra.0000396060.67150.40

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)

Harvard Medical School and McLean Hospital, Belmont, MA

Please send correspondence to: Elsa Ronningstam, PhD, McLean Hospital, AOPC Mailstop 109, 115 Mill Street, Belmont MA 02478.

The author express appreciation to Steven Huprich, PhD, for valuable comments. The author declares no conflicts of interest.

© 2011 Lippincott Williams & Wilkins, Inc.