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Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment. [ABSTRACT FROM PUBLISHER]

The impact of pathological narcissism on psychotherapy has seldom been investigated empirically, despite extensive clinical theory proposing that highly narcissistic individuals should be reluctant to engage in treatment and derive smaller benefits from therapy. In this study, we investigate the relationship between scores on the Pathological Narcissism Inventory (PNI; Pincus et al., 2009), which assesses both narcissistic grandiosity and narcissistic vulnerability, and clinical variables in a sample of outpatients (N= 60) at a community mental health center. Results indicated that grandiosity, but not vulnerability, was negatively related to the use of adjunctive services and positively predicted client-initiated termination of psychotherapy. In addition, grandiosity and vulnerability were related to initial levels of different symptoms in multilevel models using a subsample (n= 41) but not generally related to the linear rate of symptom change in early psychotherapy. The results highlight the clinical utility of assessing pathological narcissism in a real-world psychotherapeutic context. [ABSTRACT FROM AUTHOR]

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Empathy is generally thought of as the ability to share the emotional experiences of others. In scientific terms, this is usually operationalized as an ability to vicariously feel others' mental and emotional experiences. Supporting this account, research demonstrates that watching others experience physical pain activates similar brain regions to the actual experience of pain itself. First-hand experience of social rejection also activates this network. The current work extends these findings by examining whether the “pain” network is similarly implicated in witnessing rejection, and whether emotional closeness modulates this response. We provide evidence for each of these suppositions, demonstrating: (a) that the pain network is activated when watching a friend suffer social rejection, and (b) that interpersonal closeness with that friend modulates this response. Further, we found that the inferior frontal gyrus, critical for representing others' mental and emotional states, mediates the relationship between emotional closeness and neural responses to watching the rejection of a friend. [ABSTRACT FROM PUBLISHER]

Clinicians routinely note the challenges involved in psychotherapy with individuals with BPD, yet little research exists on the therapeutic alliance with this population. An important question is, what patient factors contribute to a disturbed alliance with individuals with BPD? Executive attention has been identified as a mechanism of BPD, and mental state vacillations (e.g., idealization/denigration, incoherence in self-concept) are a hallmark of the disorder. The goals of this study were to examine the link between executive attention and the alliance and assess mental state vacillations as a mediator. Thirty-nine participants diagnosed with BPD, participating in a randomized clinical trial, were administered the Attentional Network Task (ANT). Early psychotherapy sessions were coded using the Working Alliance Inventory (WAI). In addition, six items were generated and coded representing in-session vacillations in mental states. Performance on the ANT was related to the alliance (r=.34, p=.035), as were in-session mental state vacillations (r=.59, p<.001). A model was supported in which in-session mental state vacillations mediated the relationship between executive attention and alliance. Executive attention was related to therapeutic alliance, and this relationship was found to be mediated by in-session mental state vacillations. These findings emphasize the importance of executive attention in the disorder and uncover a link between poor executive attention and mental state vacillations. Mental state vacillations as a mediator suggests a path in which poor executive attention leads to greater vacillations, which leads to poorer working alliance. [ABSTRACT FROM AUTHOR]

A central task of psychotherapy process measurement development is the assessment of reliability and validity. The convention of reporting intraclass correlations (ICCs) for coding procedures assumes that variance in scores can be adequately explained by differences between individuals and error resulting from differences in coders. Given the complex coding procedures that are common in psychotherapy process studies (multiple sessions may be rated by multiple coders on one or more multi-item scales), an ICC may fail to account for all of the relevant sources of variability in obtained scores. If process studies are to provide useful information about the mutative agents in psychotherapy, assessment procedures must be developed that dependably assess the constructs of interest. Generalizability theory provides a framework within which multiple sources of error can be simultaneously evaluated, thus improving the accuracy of reliability estimates and providing critical information for modification and improvement of coding procedures. To illustrate the applicability of generalizability theory to psychotherapy process research, the authors present the design and findings of a study investigating the generalizability of technique scales in the Psychotherapy Process Rating Scale for Borderline Personality Disorder. Implications for measurement development and procedural modifications are discussed. [ABSTRACT FROM AUTHOR]