UNASSIGNED: The study was set out to establish the potential for psychotherapy to effect improvements in patients with narcissistic personality disorder (NPD). Eight patients with NPD who improved in treatment were identified. Consensus clinician/investigator diagnostic scores from before and after the psychotherapies were retroactively established on the Diagnostic Interview for Narcissism (DIN) and the Diagnostic Statistic Manual for Psychiatric Disorders, 5th Edition (DSM-5) Personality Disorder Section II criteria. Psychosocial functioning (work or school, romantic relationships) before and after the psychotherapies was retroactively evaluated as well. At the completion of the therapies after 2.5 to 5 years, all patients had improved, no longer met DIN or DSM-5 criteria for NPD, and showed better psychosocial functioning. Symptomatic improvements were associated with large effect sizes. In conclusion, changes in NPD can occur in treatment after 2.5 to 5 years. Future research should identify patient characteristics, interventions, and common processes in such improved cases that could help with development of treatments.

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.

In order to effectively treat individuals suffering from Narcissistic Personality Disorder (NPD), it is crucial to establish therapeutic goals and identify tasks to achieve them. However, this is a challenging process with NPD patients because they often struggle to find meaningful goals beyond the pursuit of status. Moreover, in order to change Furthermore, to promote change, they must confront painful emotions such as shame, guilt, or fear, which they habitually try to avoid. Additionally, they face difficulties in forming a positive perception of their therapists and cooperating towards mutually agreed-upon goals and tasks. As a consequence, NPD patients ask for change but hardly engage themselves in the work necessary to achieve it. Therapists therefore need to pay the uttermost attention to drafting, negotiating and continuously updating a reasonable and realistic therapeutic contract. In this paper we describe the story of a man in his thirties with NPD who was ridden with depression, guilt, envy and anger and did not find ways to pursue the healthy and adaptive behaviors he would need to pursue in order to leave a richer social life. The therapist overcame ruptures in the therapeutic alliance and then involved the patient in a process where they set the steps to follow, making sure the patient was convinced they made sense. After a contract was reached progress became possible. Implications for the role of the therapeutic contract in NPD treatment are discussed.

Traditionally, narcissistic characteristics are considered relatively stable, although clinical accounts and recent research show that additional narcissistic states are variable and fluctuate in actuality. Narcissism research tends to focus on cross-sectional, group-based, trait approaches. Momentary ecological assessments allow one to discover individuals\' true colors by observing narcissistic experiences while they unfold in real-time and real-world settings. Within momentary ecological assessments, inspecting single cases enables insight into individual dynamics and presentations. Consequently, this research collected grandiose and vulnerable narcissistic trait and state data 10 times a day for 6 days. Based on the highest trait scores, two individual cases are presented per category: predominantly grandiose narcissistic, predominantly vulnerable narcissistic, and combined narcissistic. Overall, the descriptions provide evidence for the dynamics within and between grandiose and vulnerable narcissistic states. Further, broad patterns for each narcissistic dimension were uncovered, in which the grandiose subdimension experienced mainly grandiosity, and the vulnerable and combined subdimensions experienced both grandiosity and vulnerability. Out of the three, the combined subdimension experienced the highest instability and levels of daily vulnerability. However, each individual case showed unique fluctuation patterns that highlight the importance of personalized, real-life assessments in research and clinical care.

Although interest in within-person variability in grandiose narcissism is growing, measurement tools are lacking that allow studying fluctuations in this personality characteristic in a differentiated manner (i.e., distinguishing narcissistic admiration and rivalry). This study explores whether a measurement approach using the six-item version of the Narcissistic Grandiosity Scale (NGS Rosenthal et al. (2007)) and six additional newly formulated adjectives allows assessing state admiration and rivalry. Structural characteristics and convergent validity of this approach were examined in an experience sampling study in which 114 adults participated, providing state assessments twice a day (total number of observations = 1306). Multilevel bifactor analyses revealed three factors (i.e., one general and two specific factors) at both within- and between-person levels. Further, admiration and rivalry showed a pattern of within-person associations with fluctuations in self-esteem and Big Five states that were consistent with theoretical expectations. Finally, average state admiration and average state rivalry correlated substantively with trait measures of these respective constructs assessed one week prior to the experience sampling design.

Experiential techniques can be used to address maladaptive interpersonal patterns in patients with personality disorders (PDs) as long as they are delivered minding about the therapeutic relationship. We present the case study of Laura, a 38-year-old woman presenting with covert narcissism, generalized anxiety disorder, depression, and complicated grief treated with metacognitive interpersonal therapy. Laura initially refused to engage in any experiential work out of fear of being judged and abandoned by her therapist. To navigate this therapeutic obstacle, the therapist focused on exploring and eventually repairing early alliance ruptures. Thereafter, Laura engaged in experiential work, which helped her address her narcissistic interpersonal patterns. After 2 years, Laura\'s symptoms and narcissistic problematic behaviors decreased. This case study can help us understand how experiential techniques can be successfully used in PD psychotherapy as long as attention to the therapy relationship is paid.

Dylann Roof killed nine people in a Black church in 2015 in order to start a \"war\" between the white and Black races. This case is used here to develop a psychoanalytic theory of murderous racism, and even genocide. Major concepts from Freud (self-preservation, hatred, narcissism, life and death drives, delusion), Klein (projective identification), and Bion (psychotic and nonpsychotic parts of the personality) are employed. Particular attention is given to the hearing to determine Roof\'s capacity to represent himself after he dismissed his lawyers, who wanted to use an insanity defense to avoid the death penalty. This hearing was confronted with an undecidable dilemma, which led to legal cooperation with Roof\'s suicidal impulses. The deconstructive approach to undecidability, and its use in questions of law, especially as concerns the relation between psychoanalysis and the death penalty, leads to tentative recommendations for the prevention of racist murder.

OBJECTIVE: Hikikomori, a form of pathological social withdrawal, has been suggested to have comorbidity with autism spectrum disorder (ASD). This study aimed to clarify how characteristics of hikikomori are associated with ASD, including undiagnosed autism spectrum conditions (ASC), in clinical settings.
METHODS: A total of 416 clinical patients were recruited through the Mood Disorder/Hikikomori Clinic at Kyushu University Hospital. A total of 103 hikikomori cases and 221 clinical controls without hikikomori conditions were extracted using a semi-structured interview, and completed a series of self-rated scales, including the Japanese version of the Autism-Spectrum Quotient (AQ-J).
RESULTS: Compared to non-hikikomori controls, hikikomori cases were more likely to have higher autistic tendency based on the AQ-J. The cases showed more severe subjective depressive symptoms based on the self-rated Beck Depression Inventory II, whereas no significant difference was found on interview-based severity evaluation using the Hamilton Depression Rating Scale. Comparison within hikikomori cases based on the AQ-J cut-off score revealed that hikikomori cases with high ASC were significantly more likely to have higher traits of modern-type depression, smaller social networks, and less social support.
CONCLUSIONS: The present data suggest that hikikomori sufferers are more likely to have autistic tendency, and that hikikomori sufferers with high ASC may have much more difficulty in social communication and social interaction. In addition, those with high ASC may also have lower self-esteem and higher complaint tendencies as aspects of modern-type depression traits, which may relate to the occurrence of hikikomori. Thus, evaluating autistic tendencies is important for appropriate interventions in hikikomori. Further investigations should be conducted to validate our pilot findings using structured diagnostic systems of ASD.

People with pathological narcisism, with their conflicted sense of grandiosity and vulnerability, often pose a variety of therapeutic challenges, which may impede these patients\' ability to benefit from psychotherapy. To offer a case illustration and provide insight into the intrinsic difficulties of working with this patient group, we examined the treatment of a fictional character, Alex, from the TV series In Treatment. Based on the Shedler-Westen Assessment Procedure-200 we diagnosed Alex with pathological narcissism, and evaluated the treatment process (seven sessions) by reporting on measurements of session-by-session change in explicit working alliance, implicit language alliance, and ruptures and repairs. Over the course of treatment, the working alliance (Working Alliance Inventory-Observer scale) fluctuated with a particularly low bond at session five, identified as a rupture (Rupture Resolution Rating System). Language analysis (Linguistic Inquiry and Word Count) showed that the unconscious aspects of the alliance started to deteriorate just before the rupture occurred. The results illustrate how therapists might be pulled to collude with narcissistic patients\' grandiosity, with the risk of neglecting their vulnerability. This fictional portrayal of a treatment with a narcissistic patient may be widely shared with researchers, students and therapists alike, offering a common locus of scholarly attention, and an innovative tool for teaching. Given the lack of empirical treatments for pathological narcissism and the great therapeutic challenges narcissistic patients present, further research and development of clinical guidelines are warranted.

Pathological narcissism or narcissistic personality disorder is commonly characterized by an exaggerated sense of self-importance, condescending attitude, need for excessive admiration, diminished empathy and exploitativeness. In contrast to these overt attributes, there is a different presentation of pathological narcissism which is underrecognized, as one\'s preoccupation with hypervigilant, self-effacement and proneness to shame in the context of covert grandiose fantasies. This report illustrates a patient who had this subtype of vulnerable narcissism, and how his defence had been activated to preserve own self agency during a session with the doctor by revealing his paraphilic fantasy.