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Narcissistic Pesonality Disorder http://emedicine.medscape.com/article/1519417-overview Background Narcissistic personality disorder, as described in the case study below, is one of 10 clinically recognized personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition-Text Revision (DSM-IVTR). It is one of 4 Cluster B personality disorders, which are those marked by an intense degree of drama and emotionality. Historically, there has been much debate surrounding the exact definition of the disorder and competing theories exist regarding its etiology and optimal treatment. A relatively new diagnostic entity, narcissistic personality disorder was only formally recognized as a unique personality disorder in 1980 in the DSM-III. However, the term narcissism traces its roots back to 1898 when the British psychologist Havelock Ellis first used the term to describe a pathological form of self-love or autoeroticism.[1] More than a decade later, Otto Rank published the first psychoanalytic paper on narcissism and Sigmund Freud later explored the concept in his 1914 work, On Narcissism.[2] A host of psychologists and psychiatrists since have made important contributions to our theoretical and clinical understanding of the disorder. As defined in the 2000 edition of the DSM-IV-TR, narcissistic personality disorder is a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following criteria:[3]

1. A grandiose sense of self-importance (eg, the individual exaggerates achievements and talents and expects to be recognized as superior without commensurate achievements) 2. A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love 3. A belief that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. A need for excessive admiration 5. A sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) 6. Interpersonally exploitative (ie, takes advantage of others to achieve his or her own ends) 7. A lack of empathy (is unwilling to recognize or identify with the feelings and needs of others) 8. Envy of others or a belief that others are envious of him or her 9. A demonstration of arrogant and haughty behaviors or attitudes Case study Mr. L is a 26-year-old third-year medical student who has been suffering from depression and anxiety for several years and is currently engaged in psychotherapy. Mr. L is an overachiever who has always excelled academically he was at the top of his class at Princeton, received a Rhodes scholarship to study at Oxford, and was granted admission to many of the nation's best medical schools. In addition to his academic accomplishments, Mr. L prides himself on his physical appearance and considers himself to be much better looking than his medical school peers.

During his first therapy session with the psychiatrist, Mr. L brings in a copy of his curriculum vitae as well as copies of his medical school essays and insists that the psychiatrist read these before beginning the session. He states with a small chuckle, "I'm different than most of your clients." In addition, Mr. L asks the psychiatrist, "Exactly how long have you been doing this? You look really young, like you could be my age. I took quite a few advanced courses in psychology at Princeton. Where did you go to medical school again?" During subsequent sessions, Mr. L talks at length about his disdain for his medical school professors, classmates, and the medical school curriculum in general. He feels that many of his professors are not that bright and that their understanding of fundamental medical concepts is cursory at best. He recounts an episode during one of his internal medicine rotations when the attending professor was asked a question by a junior resident but could not provide an adequate answer. Mr. L knew the answer and stated it without hesitation, declaring to the psychiatrist, "It was clear to everyone on rounds that I knew more than both the attending and the resident, I can't believe those a**holes didn't give me Honors on that rotation. They were just jealous that a medical student knew more than them." Socially, Mr. L has very few close friends and believes that this is because he doesn't meet people who are up to his high intellectual and physical standards. He has 1 or 2 medical school peers who he studies with on a sporadic basis, but beyond this, his interactions with classmates are superficial and devoid of any real friendship. When asked if he has ever gotten into any conflicts with his peers, Mr. L recounts a recent episode when he took the only copy of a valuable study guide out of the school library so that he could read it at home at his leisure. When one of his fellow classmates found out and demanded that Mr. L return the book to the library, Mr. L scoffed and refused, stating, "I can't believe Tom had the guts to ask

me to return the book. It's not like it would have done him any good anyway; he's only going into Psychiatry, I'm the one going into Surgery." Pathophysiology The exact mechanism of the development of narcissistic personality disorder is unknown. Biological, psychological, social, and environmental factors all likely play a role, but further research is necessary to confirm this supposition. Several psychodynamic theories point to an unhealthy early parent-child relationship as salient in the development of the disorder. Epidemiology Frequency United States According to current research, narcissistic personality disorder is present in 0.5% of the general United States population[4] and in 2-16% of those who seek help from a mental health professional. It is found in 6% of the forensic population[5,
9]

, 20% of the military population (the actual disorder as well as

narcissistic traits)[6, 7, 9] , and in 17% of first-year medical students.[8, 9] International Narcissistic personality disorder is not recognized as a separate diagnostic entity outside of the United States. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) lists only 8 personality disorders (as opposed to the 10 found in the DSM-IV-TR). What the DSM-IV-TR defines specifically as narcissistic personality disorder falls under the ICD-10 heading of "Other Specific Personality Disorders" or "eccentric,

impulsive-type, immature, passive-aggressive, and psychoneurotic personality disorders."[10] Mortality/Morbidity Patients diagnosed with narcissistic personality disorder are more likely to have comorbid Axis I diagnoses, such as major depressive disorder, bipolar disorder, substance-related disorders (specifically related to cocaine and alcohol), anxiety disorders, and anorexia nervosa.[11, 12] Race Narcissistic personality disorder has not been shown to have any racial or ethnic predilection. Sex Narcissistic personality disorder is more commonly found in males than in females. Of those diagnosed with the disorder, approximately 75% are male. Age Narcissistic personality disorder manifests by young adulthood (early to mid 20s) and may worsen in middle or old age due to the onset of physical infirmities or a decline in physical attractiveness. (In addition to feeling intellectually and socially superior to others, people who are narcissistic are often quite vain regarding their physical appearance). Narcissistic traits can be exhibited by typical adolescents who are unlikely to go on to develop narcissistic personality disorder.

History Patients with narcissistic personality disorder often present to the healthcare professional after hitting "rock bottom" in their careers or personal lives, or at the strong urging of a family member who insists that they get professional help for their behavior. Because the nature of the disorder involves a haughty disregard for others and an insistence on one's own innate superiority, narcissistic patients are unlikely to recognize their need for treatment and even less likely to voluntarily seek help. For this reason, patients with this diagnosis alone (ie, no concomitant Axis I diagnoses) comprise a very small percentage of the total patient population seen by mental health professionals. To be diagnosed with narcissistic personality disorder, a patient must demonstrate a consistent and long-standing pattern of maladaptive behavior starting in adolescence or early adulthood that exemplifies 5 or more of the following criteria:[3] 1. A sense of grandiosity and self-importance that is not necessarily commensurate with the person's actual achievements or standing. 2. Unrealistic and dearly-held fantasies of extreme success, power, beauty, or romantic love. For example, such a person may choose to remain single rather than date those they deem beneath him or her. 3. An overweening sense of superiority and a constant desire to associate only with the best of everything (eg, best health club, best doctor, best institutions) as a way to enhance one's own self-esteem. For example, an aging business executive who insists on only dating young supermodels or a wealthy socialite who insists on befriending only other high-status society matrons.

4. A desire to always be the center of attention and to be widely admired for his or her achievements. This desire largely stems from low self-esteem. 5. A sense of entitlement and an expectation that others will readily cater to his or her needs. 6. Interpersonally exploitative to the extent that others merely serve to further his or her own wishes and desires. The patient with narcissistic personality disorder is solely concerned with his or her own advancement in life and will manipulate, exploit, or sabotage others to achieve his or her end goal. 7. A lack of empathy and sensitivity to the feelings and experiences of others. People with narcissistic personality disorder often talk at length about themselves with little interest in the experiences of others. 8. A feeling of deep-seated envy towards those he or she perceives to be better situated than themselves. Also present is an egotistical belief that others are envious of him or her. 9. A self-centered and conceited air, as well as a haughty disdain for others. While many people display some degree of the above-mentioned criteria, it is only when the symptoms are pervasive, debilitating, and socially and personally destructive, that narcissistic personality disorder is diagnosed. Patients with narcissistic personality disorder are also acutely sensitive to rejection or criticism and may avoid people or situations where there is the possibility of feeling "less than." When criticized, they may become furious and lash out or withdraw into a shell of sullen hate. At the core, both of these reactions are thought to be due to intrinsically low self-esteem or a feeling of inferiority.[3]

Physical Narcisistic personality disorder is not associated with any defining physical characteristics.[13] Mental Status Examination may reveal depressed mood due to dysthymia or major depressive disorder, both of which may be related to the paradoxically low self-esteem often present in patients with narcissistic personality disorder. Conversely, patients in the throes of narcissistic grandiosity may display signs of hypomania or mania.[3] The following is a sample Mental Status Examination for Mr. L, the patient who was described in the case study at the beginning of this article.
y

General appearance and behavior - Well-groomed, well-dressed male in no acute distress

y y y y y y y

Attitude - Resistant and haughty Psychomotor activity - Normal, no agitation or retardation Eye contact - Intense Affect - Restricted Mood - Angry Speech - Normal rate and tone, high volume; no pressured speech Thought process - No evidence of thought blocking, flight of ideas, loose associations, or ideas of reference; some tangentiality present

Thought content - Denies suicidal ideation and homicidal ideation; denies audiovisual hallucinations; no paranoid delusions elicited or endorsed

y y

Orientation - Oriented to person, place, and time Attention and concentration - Good

y y

Insight - Poor Judgment - Limited

Narcissistic personality disorder is also associated with the abuse of substances, particularly cocaine and alcohol; thus, the physical consequences of such abuse may be apparent on examination. Causes The cause of narcissistic personality disorder is unknown. Currently, genetic links to the disorder have not been determined, but future research into the biological basis of personality disorders may yield more information on the origins of narcissistic personality disorder. From a psychoanalytic standpoint, the 2 main schools of thought regarding the origins of the disorder are the Object Relations model described by Otto Kernberg and the Self-Psychology model developed by Heinz Kohut. Both models posit that an inadequate relationship between parent and child lays the groundwork for the eventual development of narcissistic personality disorder. According to Otto Kernberg, narcissistic personality disorder is the result of a young child having an unempathetic and distant mother who is hypercritical and devaluing of her child. As a defense against this perceived lack of love and to guard against emotional pain, the child creates an internalized grandiose self. Kernberg believed that this grandiose self was a combination of 3 elements: (1) the childs own positive traits, (2) a fantastical, larger-than-life version of himself/herself, and (3) an idealized version of a nurturing mother. In keeping with the Object Relations model, on which Kernberg based much of his theory, the child eventually splits-off the unloveable and needy image of him or herself and

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relegates it to the unconscious, where it later forms the basis for the fragile selfesteem and sense of inferiority present in narcissistic personality disorder.[2] By contrast, Heinz Kohut felt that narcissistic personality disorder was the result of a developmental arrest in normal psychological growth. According to Kohut, narcissism is a natural feature of the young child, who is bound to think of himself or herself as the center of his or her universe. Through the twin processes of mirroring (whereby the parent provides appropriate praise) and idealization (where the child effectively internalizes positive parental images), the normal child without narcissism is able to temper his or her former conception of his or herself as the center of the universe. However, if the parents do not effectively mirror the child or do not provide a basis for the child to idealize them, the child will be stuck with a grandiose, wholly unrealistic sense of self. Kohut believed it was this developmental arrest that eventually lead to the development of narcissistic personality disorder. Differentials
y y y y y y y y y y

Antisocial Personality Disorder Histrionic Personality Disorder Hypomania Major Depressive Disorder Mania Obsessive-Compulsive Disorder Paranoid Personality Disorder Personality Change Due to a General Medical Condition Personality Disorder: Borderline Schizotypal Personality Disorder

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Substance-Related Disorders

Laboratory Studies No specific laboratory studies are used to diagnose narcissistic personality disorder. Nevertheless, due to the high incidence of substance abuse in patients with the disorder, it is wise to obtain a toxicology screen to rule out drugs and alcohol as possible causes of narcissistic character pathology. Other Tests The diagnosis of narcissistic personality disorder is often made after obtaining a history of narcissistic symptoms from pertinent sources (including the patient, the patient's family/friends, and the clinician's own observations of the patient). However, more specific personality tests can also be used to aid in the diagnosis. The usefulness and reliability of these tests is a matter of debate, but they can be helpful in elucidating character pathology outside of the strict confines of the DSM-IV-TR criteria. These personality tests either take the form of self-report questionnaires given directly to the patient or semi-structured interviews conducted by the clinician. Several such tests include the Personality Diagnostic Questionnaire4 (PDQ-4), the Millon Clinical Multiaxial Inventory III (MCMI-III), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), the International Personality Disorder Examination (IPDE), and the Structured Interview for the DSM-IV Personality Disorders (SIDP-IV). Each test uses a series of questions to determine the presence or absence of character pathology and may be a useful aid to the clinician trying to formally diagnose narcissistic personality disorder in a patient.[17]

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Medical Care The mainstay of treatment for narcissistic personality disorder is individual psychotherapy, specifically psychoanalytic psychotherapy. Other therapeutic modalities used to treat the disorder include group, family, and couples therapy, as well as cognitive-behavioral therapy and short-term objective focused psychotherapy.[18] Psychotropic medications are not specifically used to treat narcissistic personality disorder but are often used to treat concomitant anxiety, depression, impulsivity, or other mood disturbances. While individual psychoanalytic psychotherapy is the method of choice for the treatment of narcissistic personality disorder, there has been much debate as to what exactly constitutes optimal treatment. The 2 main schools of thought in this regard are Otto Kernberg's object-relations based approach and Heinz Kohut's selfpsychological approach, both of which provide us with different and seemingly contradictory ways of approaching the narcissistic patient.[18] According to Kernberg's object-relations based approach, the job of the therapist is to actively interpret the patient's narcissistic defenses while at the same time illuminating the patient's negative transferences. Kernberg believed the end goal of therapy was to eradicate or diminish the patient's pathological grandiose self by direct confrontation.[18] By contrast, Kohut advocated a more empathic approach, with the therapist actually encouraging the patient's grandiosity and promoting the development of idealization in the transference. Kohut's end goal was to bolster the patient's inherently deficient self-structure.[18]

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While no definitive studies support one therapeutic stance over another, most clinicians today have come to embrace a style that fuses elements of both Kernberg's and Kohut's viewpoints. A flexible and moderate approach that combines an empathic understanding of the patient's need for narcissistic defenses and a thorough exploration of those defenses is preferred. The therapist should recognize the self-preserving role narcissism plays in the patient's daily life and should use caution in tearing down narcissistic defenses too quickly. At the same time, the therapist will strive to help the patient gain a realistic understanding of his or her own behavioral deficiencies.[18] In addition to individual psychoanalytic psychotherapy, other treatment modalities for narcissistic personality disorder include group therapy and cognitive-behavioral therapy. Group therapy was initially thought to be unsuitable for the patient with narcissism because clinicians assumed that these patients would be unable to handle the requisite give and take inherent in the group process. This was a reasonable assumption given that group processes usually require empathy, patience, and the ability to relate and connect to others (traits that are deficient in those with narcissism). However, studies[19] have suggested that longterm group therapy has therapeutic value for the patient with narcissism by providing the patient with a safe haven in which to explore boundaries, receive and accept feedback, develop trust, and increase self-awareness.[20] Cognitive behavioral therapy has also been shown to have the potential to benefit the narcissistic patient.[21] A specific form of cognitive behavioral therapy, called schema-focused therapy, centers around repairing narcissistic schemas and the defective moods and coping styles associated with them.[22] This very active and work-intensive form of treatment encourages patients to confront narcissistic cognitive distortions, such as black and white thinking and perfectionism, and has

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been shown to have promising results for the treatment of narcissistic personality disorder.[18] Medication Summary No psychiatric medications are tailored specifically toward the treatment of narcissistic personality disorder. Nevertheless, patients with narcissistic personality disorder often benefit from the use of psychiatric medications to help alleviate certain symptoms associated with the disorder, such as depression, anxiety, transient psychosis, mood lability, and poor impulse control. In addition, many patients with narcissistic personality disorder have concomitant Axis I diagnoses for which they are taking regular psychiatric medication. The following is an abbreviated list of sample medications from the 3 major psychiatric drug classes (antidepressants, antipsychotics, and mood stabilizers) that can be used to treat certain symptoms associated with narcissistic personality disorder. Antidepressant, Serotonin Reuptake Inhibitor Class Summary SSRIs such as citalopram may be used to treat depressive symptoms in adult patients with narcissistic personality disorder. Determining whether the patient with narcissistic personality disorder has a formal Axis I diagnosis of major depression or depressive symptoms related to narcissistic pathology is important as this will influence the length and course of treatment.

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Citalopram (Celexa) Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs exist, although, based on metabolism and adverse effects, citalopram is considered the SSRI of choice for patients with head injury. SSRIs are the antidepressants of choice due to minimal anticholinergic effects. All are equally efficacious. The choice depends on adverse effects and drug interactions. Antipsychotic Agent Class Summary Atypical antipsychotic agents such as risperidone may be used in adult patients with narcissistic personality disorder to treat transient psychosis, mood lability, and poor impulse control. Risperidone (Risperdal, Risperdal Consta IM Injection, Risperdal M-Tab) Binds to dopamine D2 receptor with a 20-times lower affinity than for the 5HT2 receptor. Improves negative symptoms of psychoses and reduces incidence of extrapyramidal adverse effects. Response to antipsychotics is less dramatic than in true psychotic Axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time while the symptoms are active.

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Anticonvulsant Class Summary Mood stabilizers such as lamotrigine may be used in adult patients with narcissistic personality disorder to help with affect regulation and impulse control. Lamotrigine (Lamictal) Anticonvulsant that appears to be effective in the treatment of the depressed phase in bipolar disorders. Note: Some literature indicates use of medications like Valproic acid or Lithium as mood stabilizers. Further Inpatient Care Patients with narcissistic personality disorder are usually treated on a longterm outpatient basis. However, inpatient hospitalization is warranted if the patient acutely decompensates or becomes a danger to themselves or others. Shorter hospital stays are usually best for patients with narcissistic personality disorder since prolonged time in the hospital will do little to change the underlying severity of the illness. Hospitalization should only be used as a temporizing measure to stabilize environmental stressors and/or adjust medication dosages.[13] Further Outpatient Care Long-term, consistent outpatient care is the method of choice in the treatment of narcissistic personality disorder and usually involves a combination of psychotherapy and medication management.

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Inpatient & Outpatient Medications See Medication section. Deterrence/Prevention See Pathophysiology and Causes sections. Complications Patients with Cluster B personality disorders (including narcissistic, borderline, antisocial, and histrionic personality disorders) are at a significantly increased risk for suicide. In the case of the patient with narcissistic personality disorder, sudden life stressors such as job loss or unexpected financial misfortune can lead to "surprise or "shame" suicides.[23] Patients with narcissistic personality disorder are also at increased risk for substance abuse, specifically the abuse of cocaine and alcohol. Prognosis As with all personality disorders, the natural history of narcissistic personality disorder is unfavorable and the condition is typically life long. However, many patients can and do show improvement with appropriate treatment. Recent research also suggests that corrective life events, such as new achievements, stable relationships, and manageable disappointments, can lead to considerable improvement in the level of pathological narcissism over time.[24]

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Patient Education Educating patients with narcissistic personality disorder about the signs and symptoms of the disorder and explaining to them in a supportive way that their behavior is a result of many different factors is important. During this psychoeducational phase of treatment, presenting the patient with reading material is helpful so that he or she may become aware of how the diagnosis specifically applies to them.[18] The Narcissistic Family: Diagnosis and Treatment by Stephanie DonaldsonPressman and Robert M. Pressman, 1997, Jossey-Bass. The Wizard of Oz and Other Narcissists: Coping with the One-Way Relationship in Work, Love, and Family by Eleanor Payson, 2002, Julian Day Publications. Trapped in the Mirror by Elan Golomb, 1995, Perennial Currents. Contributor Information and Disclosures

Author Sheenie Ambardar, MD Physician, Kaiser Permanente Southern California Sheenie Ambardar, MD is a member of the following medical societies: American Psychiatric AssociationDisclosure: Nothing to disclose. Coauthor(s) Spencer Eth, MD Voluntary Professor of Psychiatry, University of Miami, Leonard M Miller School of Medicine; Director of Outpatient Mental Health Programs, Miami VA Healthcare System. Spencer Eth, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Orthopsychiatric Association, American Psychiatric Association, and Phi Beta Kappa

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Disclosure: Nothing to disclose. Specialty Editor Board Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center . Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment Harold H Harsch, MD Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion

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Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching Chief Editor David Bienenfeld, MD Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine . David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry. Disclosure: Nothing to disclose. Acknowledgments Dr. Ambardar would like to thank Dr. Donald C. Fidler, Farnsworth Endowed Chair of Psychiatric Education at West Virginia University, for generously granting permission to use his video clip in the multimedia section of this article.

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References 1. Ellis H. Auto-erotism: a psychological study. Alienist and Neurologist. 1898;19:260-299. 2. Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. Jan 1982;139(1):12-20. [Medline]. 3. American Psychiatric Association. Personality disorders. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Publishing, Inc; 2000:717-731. 4. Torgersen, S. Epidemiology. In: Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing; 2005:129-141. 5. de Ruiter C, Greeven PG. Personality disorders in a Dutch forensic psychiatric sample: convergence of interview and self-report measures. J Pers Disord. Summer 2000;14(2):162-70. [Medline]. 6. Crosby RM, Hall MJ. Psychiatric evaluation of self-referred and non-selfreferred active duty military members. Mil Med. May 1992;157(5):224-9. [Medline]. 7. Bourgeois JA, Hall MJ, Crosby RM, Drexler KG. An examination of narcissistic personality traits as seen in a military population. Mil Med. Mar 1993;158(3):170-4. [Medline]. 8. Maffei C, Fossati A, Lingiardi V, Madeddu F, Borellini C, Petrachi M. Personality maladjustment, defenses and psychopathological symptoms in non-clinical subjects. J Pers Disord. Apr 1995;9:330-345. 9. Ronningstam E. Narcissistic Personality Disorder: Facing DSM-V. Psychiatric Annals. Mar 2009;39:111-121.

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10. Rebecca J. Frey, Ph.D. Narcissistic Personality Disorder. Encyclopedia of Mental Disorders. Available at http://www.minddisorders.com/Kau-

Nu/Narcissistic-personality-disorder.html. Accessed September 8, 2008. 11. Waller G, Sines J, Meyer C, et al. Narcissism and narcissistic defences in the eating disorders. Int J Eat Disord. Mar 2007;40(2):143-8. [Medline]. 12. Ronningstam E. Pathological narcissism and narcissistic personality disorder in Axis I disorders. Harv Rev Psychiatry. Mar-Apr 1996;3(6):326-40. [Medline]. 13. David Bienenfeld, MD. Personality Disorders. eMedicine by WebMD. Available at http://emedicine.medscape.com/article/294307-overview.

Accessed July 1, 2008. 14. Holdwick DJ Jr, Hilsenroth MJ, Castlebury FD, et al. Identifying the unique and common characteristics among the DSM-IV antisocial, borderline, and narcissistic personality disorders. Compr Psychiatry. Sep-Oct

1998;39(5):277-86. [Medline]. 15. Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Personal Disord. Apr 2001;15(2):103-9. [Medline]. 16. Stormberg D, Ronningstam E, Gunderson J, et al. Brief communication: pathological narcissism in bipolar disorder patients. J Personal Disord. 1998;12(2):179-85. [Medline]. 17. Clarkin JF, Howieson DB, McClough J. The Role of Psychiatric Measures in Assessment and Treatment. In: Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing Textbook of Psychiatry. 5th Edition. Arlington, VA: American Psychiatric Publishing; 2008:Chapter 3. 18. Ronningstam EF, Maltsberger JT. Part X: Personality Disorders. In: Gabbard GO. Gabbard's Treatments of Psychiatric Disorders. Fourth

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Edition. Washington DC: American Psychiatric Publishing; 2007:Chapter 52: Narcissistic Personality Disorder, pages 791-804. 19. Roth BE. Narcissistic patients in group therapy: containing affects in the early group. In: Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998:221-238. 20. Alonso A. The shattered mirror: treatment of a group of narcissistic patients. Group. Dec 1992;16:210-219. 21. Young J, Flanagan C. Schema-focused therapy for narcissistic patients. In: Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998:239-268. 22. Young J, Klosko JS, Weishaar ME. Schema Therapy. A Practitioner's Guide. New York: Guilford; 2003. 23. Simon RI. Outpatients. In: Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington DC: American Psychiatric Publishing; 2004:89-90. 24. Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry. Feb 1995;152(2):253-7. [Medline]. 25. Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry. Jun 2003;48(5):301-10. [Medline]. 26. Links PS, Kolla N. Assessing and Managing Suicide Risk. In: Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook Of Personality Disorders. Washington DC: American Psychiatric Publishing; 2005:459.