Transference-Focused Psychotherapy for Pathological Narcissism and Narcissistic Personality Disorder (TFP-N)

Multimodal approaches to the treatment of personality disorder

INTRODUCTION

Personality disorder is the most common of all psychiatric disorders and is best perceived as a diagnostic spectrum extending from no personality dysfunction to severe personality disorder. The position of each person on the spectrum is determined mainly by problems in interpersonal social dysfunction, self-perception and awareness, and dangers to the self and others.

AREAS COVERED

In this review, the authors examine the psychological and psychodynamic treatments, pharmacotherapy, neuromodulation and other related approaches, environmental treatments and therapeutic communities. Although many published studies refer to individual categories these are now linked to the diagnostic spectrum in this review.

EXPERT OPINION

There is some evidence that focused psychological treatments linked to education, particularly systems training for emotional predictability and problem solving (STEPPS), mentalization based therapy and dialectical behavior therapy, are successful in treating moderately severe personality disorder, especially regarding self-harm but there is also benefit from well organized standard care that is similarly effective. There is no good evidence that drug treatment is of any more than transient or limited benefit in all forms of personality disorder. Brain stimulation approaches have limited evidence. Psychodynamic approaches, environmental interventions, nidotherapy and therapeutic communities appear to be of some value, but good data are few. There are few long-term studies of treatment effectiveness but enough data to show that personality disorder can remit, and more attention needs to be made to adjusting to the problems of personality disorder rather than removing core features.

Challenges and Pearls of Evaluation and Treatment of Adolescents and Emerging Adults With Scrupulosity Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) affects approximately 1% to 2% of youth.1 Patients with OCD may present with varying degrees of insight into the excessiveness of their compulsive behaviors. This is certainly true among youth, of whom 20% to 45% are thought to have poor or absent insight.2 Scrupulosity OCD-characterized by intrusive guilt and fear about moral or religious wrongdoing-is associated with worse symptom severity and insight.3 This form of OCD involves obsessive fear about offending a deity or acting immorally, leading to compulsions like excessive praying, reassurance-seeking, and avoidance of perceived immoral activities. Ritualistic practice and seeking penance are accepted practices in many religions, thus the line between acceptable religious observance and OCD is both difficult and important to distinguish. This may be especially true among adolescent populations who are in the process of developing and internalizing a moral identity. Because scrupulosity rituals may be seen positively within religious communities, diagnosis and treatment are sometimes delayed3. In this article, we present two de-identified cases of adolescence-onset scrupulosity OCD that feature some additional diagnostic challenges and highlight specific recommendations (ie, "pearls" of wisdom) for this youth population.

A case report of the treatment of narcissistic personality disorder with transference focused psychotherapy

The following case study provides a description of the transference-focused psychotherapy (TFP) treatment of a young man diagnosed with narcissistic personality disorder (NPD). TFP is an individual, psychodynamic therapy developed to treat a range of personality disorders. TFP is evidence-based for the treatment of borderline personality disorder and has been adapted for the treatment of NPD. This case illustrates the application of the strategies and techniques of TFP to treatment of NPD as well as challenges clinicians may face in arriving at timely diagnosis of the disorder. Although no specific treatment for NPD has been empirically validated, TFP utilizes the therapeutic techniques identified across modalities for successful treatment of pathological narcissism. This report describes how treatment interventions such as goal setting, developing a therapeutic alliance, using a treatment contract and addressing treatment interfering behaviors contributed to this patient's improvement in self-reflection, formation of healthier and more flexible ideas about self and other, increased self-agency, tolerance of normative disillusionments and increase in empathy.

Developments in Group Transference-Focused Psychotherapy

Several evidence-based psychotherapies for personality disorders have been developed in recent decades, including transference-focused psychotherapy (TFP), a contemporary model of psychodynamic psychotherapy developed by Otto Kernberg. Kernberg established Group TFP (TFP-G) as an alternative or adjunct treatment to individual TFP. Although not yet manualized, TFP-G is used in publicly and privately funded mental health services, including outpatient clinics, subacute hospitals, therapeutic inpatient units, partial hospitalization services, and rehabilitation services serving people with borderline personality. Kernberg's model of TFP-G psychotherapy, its application in clinical settings, and what differentiates it from other group psychotherapy models is described as well as illustrated with some examples useful to practitioners.

Conversion to Transference-Focused Psychotherapy from Other Treatments by the Same Therapist: Pitfalls and Benefits

Borderline personality disorder and broadly speaking, borderline personality organization, including narcissistic personality disorder, can be effectively treated by transference-focused psychotherapy (TFP), which is a modern object relations-based structured psychoanalytic psychotherapy. TFP can be taught successfully to therapists from a wide array of backgrounds, not only to psychoanalysts, provided they have a basic grasp of psychodynamic concepts, including object relations theory. We initially thought that starting with a new patient would always be easier than conversion to TFP from a different method. Our supervisory experience supported this only partially. To learn more, we distributed a survey among therapists who completed formal TFP training or participated in supervision for at least 1 year. Only four of the 36 respondents felt that starting with a new case was easier. Conversion was a lot more common than we had expected (in fact, it seemed to be an almost inevitable part of training), and it often took place without appropriate supervision of the process. Moving from supportive therapy to TFP was the most difficult for the therapist, and often for the patient. All respondents felt that they would treat all new patients with borderline personality organization with TFP from the outset or, if indicated or necessary, begin with a preliminary treatment using TFP elements. Our findings strongly suggest that conversion needs to be taught in training seminars, and should not be left to be dealt with entirely in supervision.

Pathological narcissism: An analysis of interpersonal dysfunction within intimate relationships

Pathological narcissism is marked by deficits in psychosocial functioning. Difficulties in relationships include instances of aggression, devaluation and control; however, few studies have examined these relationships from the perspective of partners and family members. We studied participants who were in relationships with relatives high in narcissistic traits (N = 436; current romantic partners [57.3%]; former romantic partners [21.1%]; family members [15.4%]). Participant responses were analysed thematically, and their underlying mental health problems were also measured. Thematic analysis of participant responses indicated themes of abuse from the relative with narcissism (physical, verbal, emotional and sexual) as well as the relative imposing challenging financial and sexual behaviours. There were complex interpersonal themes of mutual idealization but also devaluation. In response, participants reported high levels of anxiety, depression, self-aggression, sickness and somatic concerns. Further, participants expressed overt outward hostility towards their relative with narcissism, but also dependency strivings and frustrated dependency themes. Partners and their relative with narcissism appeared locked into interpersonal and intrapersonal dynamic conflicts. Clinical implications include specific attendance to alliance issues, dependency themes, and a focus on limit setting to establish personal safety.

The Transdiagnostic Relevance of Self-Other Distinction to Psychiatry Spans Emotional, Cognitive and Motor Domains

Self-other distinction refers to the ability to distinguish between our own and other people's physical and mental states (actions, perceptions, emotions etc.). Both the right temporo-parietal junction and brain areas associated with the human mirror neuron system are likely to critically influence self-other distinction, given their respective contributions to theory of mind and embodied empathy. The degree of appropriate self-other distinction will vary according to the exact social situation, and how helpful it is to feel into, or remain detached from, another person's mental state. Indeed, the emotional resonance that we can share with others affords the gift of empathy, but over-sharing may pose a downside, leading to a range of difficulties from personal distress to paranoia, and perhaps even motor tics and compulsions. The aim of this perspective paper is to consider how evidence from behavioral and neurophysiological studies supports a role for problems with self-other distinction in a range of psychiatric symptoms spanning the emotional, cognitive and motor domains. The various signs and symptoms associated with problematic self-other distinction comprise both maladaptive and adaptive (compensatory) responses to dysfunction within a common underlying neuropsychological mechanism, compelling the adoption of more holistic transdiagnostic therapeutic approaches within Psychiatry.