Change in Attachment and Reflective Function in Borderline Patients with and without Comorbid Narcissistic Personality Disorder in Transference Focused Psychotherapy

Abstract

Research has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in the literature in identifying the clinical characteristics of these NPD/BPD patients. In this article, we present recent research describing patients with comorbid NPD/BPD, as compared with patients with BPD without NPD (BPD), from two randomized clinical trials for the treatment of borderline personality disorder, with a particular emphasis on attachment status and mentalization. We anchor our discussion of these patients in object relations and attachment theory, and we describe our treatment approach, transference focused psychotherapy (TFP). We conclude by using case material to illustrate our research findings, highlighting the significant differences between patients with NPD/BPD and BPD/non-NPD in terms of their attachment classification.

Keywords:

• narcissistic personality disorder
• borderline personality disorder
• attachment
• comorbidity
• adult attachment interview
• reflective function

Additional information

Notes on contributors

Diana Diamond

Diana Diamond, Ph.D., is a professor in the doctoral program in clinical psychology at the City University of New York, and professor of psychology in the Department of Psychiatry at the Weill Cornell Medical College, where she is also a senior fellow in the Personality Disorders Institute. Her most recent book is Attachment and Sexuality. She is a graduate of the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis and is in private practice in New York City.

John F. Clarkin

John F. Clarkin, Ph.D., is a clinical professor of psychology in psychiatry at the Weill Cornell Medical College, and the co-director of the Personality Disorders Institute. He is a past president of the international Society for Psychotherapy Research. He is the author of numerous articles and books on the nature and treatment of borderline personality disorder, including Psychotherapy for Borderline Personality: Focusing on Object Relations.

Kenneth N. Levy

Kenneth N. Levy, Ph.D., is an associate professor in the clinical area of the Department of Psychology at the Pennsylvania State University and adjunct assistant professor of psychology in the Department of Psychiatry at the Weill Cornell Medical College, where he is a senior fellow and the associate director of research at the Personality Disorders Institute. He is an associate editor of the Journal of Psychotherapy Integration and an honorary member of the American Psychoanalytic Association. He maintains a private practice in State College, PA.

Kevin B. Meehan

Kevin B. Meehan, Ph.D., is an associate professor in the Department of Psychology and the Ph.D. program in clinical psychology at Long Island University, Brooklyn, and adjunct clinical assistant professor of psychology in the Department of Psychiatry at Weill Cornell Medical College, where he works at the Personality Disorders Institute (PDI). He maintains a private practice in psychotherapy in downtown Brooklyn.

Nicole M. Cain

Nicole M. Cain, Ph.D., is an assistant professor at Long Island University, Brooklyn, in the clinical psychology Ph.D. program. She is also a research associate of the Personality Disorders Institute at Weill Cornell Medical College.

Frank E. Yeomans

Frank E. Yeomans, M.D., Ph.D., is clinical associate professor of psychiatry at the Weill Medical College of Cornell University, director of training at the Personality Disorders Institute of Weill-Cornell, lecturer in psychiatry at the Columbia University Center for Psychoanalytic Training and Research, and director of the Personality Studies Institute.

Otto F. Kernberg

Otto F. Kernberg, M.D., received his M.D. and completed his analytic training in Chile. He is currently the director of the Personality Disorders Institute at the New York Presbyterian Hospital in Westchester, professor of psychiatry at the Weill Medical College of Cornell University, and a training and supervising analyst at Columbia University Center for Psychoanalytic Training and Research. He has won many awards, including two honorary doctorates, served as president for the International Psychoanalytic Association, and published 26 books.