Narcissistic personality disorder in the ICD-11: Severity and trait profiles of grandiosity and vulnerability.

Modern diagnostic and classification frameworks such as the ICD-11 and DSM-5-AMPD have adopted a dimensional approach to diagnosing personality disorder using a dual "severity" and "trait" model. As narcissistic personality has historically struggled to be adequately captured in dominant diagnostic systems, this study investigated the utility of the new ICD-11 framework in capturing diverse narcissistic expressions. Participants were mental health clinicians (N = 180, 67% female, age = 38.9), who completed ratings of ICD-11 personality severity, trait domains and a clinical reflection for two hypothetical case vignettes reflecting either prototypical "grandiose" or "vulnerable" narcissism. The majority of clinicians (82%) endorsed a diagnosis of personality disorder for both grandiose and vulnerable vignettes. Discriminant elements of personality impairment included rigid, unrealistically positive self-view, low empathy and high conflict with others for grandiosity, and incoherent identity, low self-esteem and hypervigilant, avoidant relations with others for vulnerability. Regarding trait profile, grandiose narcissism was predominately dissocial whereas vulnerable narcissism was primarily associated with negative affectivity and detachment. Qualitative responses highlight distinct clinical themes for each presentation. These findings suggest that clinicians using the ICD-11 framework are able to identify common core elements of personality dysfunction in grandiose and vulnerable narcissism while also recognizing their distinctive differences.

Implementing a whole-of-service stepped care approach to personality disorder treatment: Impact of training and service redesign on clinician attitudes and skills.

Personality disorders are a highly prevalent mental health condition. Historically, clinician attitudes have been negative, and only a small number have specialised training. This study evaluated clinician attitudes and confidence in working with people with personality disorder following the combination of training and implementation of a stepped care whole-of-service approach. A total of 102 multidisciplinary mental health clinicians were trained to implement the stepped care approach, and completed surveys prior to implementation and at 12 months follow up. Clinicians delivered manualised structured psychological therapy as part of the model. Measures assessed changes in attitudes and confidence, and impact of the service changes and therapy approach. Qualitative responses elucidated core themes. Evaluation at 12 months post training and service redesign showed improvements in clinician skills, confidence, theoretical knowledge and attitudes. Qualitative thematic analysis found core themes of improved understanding, clinical skills and improvements in the accessibility and timeliness of treatment. Implementing a whole-of-service model featuring stepped care therapies enhanced clinician attitudes, confidence, skills and knowledge in working with people with personality disorders. Clinicians identified that the whole-of-service model also improved accessibility to treatment, and quality of clinical care to the consumer and their carers.

How negative self-views may interfere with building positive relationships: An experimental analogue of identity dysfunction in borderline personality disorder.

INTRODUCTION: A disturbed, negative sense of self is associated with various interpersonal difficulties and is characteristic of disorders such as borderline personality disorder (BPD). Negative self-views may affect an individuals' ability to build positive relationships, including a therapeutic relationship. However, it is not yet well understood how identity disturbances give rise to interpersonal difficulties. Using an experimental analogue design, we tested whether identity disturbances are associated with interpersonal difficulties. METHODS: Participants were university students (N = 43, age M = 20.51 (SD = 3.08), women N = 32 (74.4%)) who reported moderate to high levels of BPD features, with 34.9% reporting significant BPD features as measured by the Borderline scale of the Personality Assessment Inventory (PAI-BOR). In a within-subject experimental paradigm using a Social Feedback Task, participants received negative, intermediate, and positive evaluations, supposedly from a panel. Using multilevel models, we tested whether negative self-views were associated with how much the participants liked, trusted, and felt close to each of the three panel members who provided either predominantly negative, intermediate, or positive feedback. RESULTS: People with more negative self-views reported lower mood in response to positive feedback. In addition, where people with more positive self-views felt better when receiving feedback that was congruent with their self-views, people with more negative self-views did not report a better mood. Importantly, people with negative self-views felt lower desire to affiliate with the member who provided predominantly positive feedback. Affiliation was not affected when feedback was given by the negative member and intermediate member to those with negative self-views. CONCLUSIONS: The findings validated that those with more negative self-views anticipated and expected more negative responses from others. Negative self-views, as relevant for BPD, may explain how people relate differently to those giving different types of feedback. Pervasive negative self-views may interfere with building new relationships including the therapeutic alliance. It may be helpful for clinicians to be aware of the potential challenges around creating a supportive therapeutic relationship for patients with negative self-views. Overly positive affirmations made by clinicians may inadvertently lower the patient's mood and may impede alliance formation.

Borderline personality disorder and stigma: Lived experience perspectives on helpful and hurtful language.

Borderline personality disorder (BPD) is a severe mental health disorder that is subject to significant stigmatisation. With language being a key reinforcer of stigma, this co-produced study aims to explore the language use regarding BPD and its effect on those with BPD and carers. Recommendations to reduce stigmatisation are provided for both clinicians and researchers. Participants with BPD (consumer n = 33) and those supporting someone with BPD (carer n = 30) discussed their experience of hurtful and helpful language. Reflexive thematic analysis was used to analyse written and verbal responses into core conflictual relationship themes (CCRT) reflecting how different words were heard and experienced. All consumers and carers in the study reported experiences with stigmatising language. Feelings of inadequacy and frustration were common amongst consumers, specifically when they perceived others as trivialising their needs or not seeing them as a unique individual. Carers often reported feelings of frustration when they perceived others as blaming them or not acknowledging their needs. Both consumers and carers reported helpful language as being connecting, validating and accepting. Unhelpful communication patterns have negative consequences for the person's self-understanding (i.e., self-stigma) and their relationships with others, including the therapeutic alliance. A consideration of these communication patterns may foster the use of reflective positive language that is compassionate and hopeful.

Efficacy and recommendations for the delivery of telehealth psychotherapy for people with personality disorder.

OBJECTIVE: There are few studies on the efficacy and acceptability of psychotherapy conducted via telehealth technology for people with personality disorder. This study aims to examine clinician perspectives on virtual psychotherapy. METHOD: Twenty multidisciplinary mental health clinicians (85% female, average age 42 years) with at least 2 years of experience in telehealth psychotherapy contributed quantitative and qualitative ratings of acceptability and efficacy of this modality. RESULTS: Likert scale ratings (1 = not, 5 = very) demonstrated high client acceptability (mean = 4.0), effectiveness (4.0) and high clinician acceptability (4.2) and sustainability (4.2). Three recommendations emerged from qualitative analysis: prioritising frame establishment, ensuring client safety online and maximising alliance-enhancing strategies. CONCLUSIONS: This study, which collected quantitative and qualitative ratings of virtual psychotherapy, found that telehealth psychotherapy can be effective and acceptable for people with personality disorder. Strategies associated with success included strong governance, secure technology and careful attending to relationship management.

Diagnosing borderline personality disorder: Reports and recommendations from people with lived experience.

Borderline personality disorder (BPD) is a severe mental health condition marked by impairments in self and interpersonal functioning. Stigma from health staff may often result in a reluctance to diagnose, impacting recovery trajectories. Qualitative interviews were conducted with participants (N = 15; M Age = 36.4 years, SD = 7.5; 93.3% female) with lived experience of BPD exploring topics of illness onset, insight, experience of diagnosis and treatment. Qualitative responses were analysed within a co-design framework with a member of the research team who identifies as having a lived experience of BPD. On average, participant symptoms emerged at 12.1 years of age (SD = 6.6 years, range 1.5-27), but diagnoses of BPD were delayed until 30.2 years (SD = 7.8 years, range 18-44) resulting in a 'diagnosis gap' of 18.1 years (SD = 9.6 years, range 3-30). Participant explanations for BPD emergence varied from biological, psychological and social factors. Benefits of diagnosis (e.g., fostering insight, aiding treatment planning and reducing isolation) were contrasted with challenges (e.g., stigma and treatment unavailability). Delay in diagnosis was common, and no participants reported receiving a diagnosis of BPD during their adolescence yet 85% felt they would have benefited from a diagnosis in adolescence. Only a quarter (27%) felt highly supported in the diagnostic process. An ideal four-step diagnosis procedure was outlined based on recommendations from participants with a lived experience; this involved the following: (1) explain the process, (2) assess thoroughly, (3) explore how the features are active in everyday life and (4) link diagnosis to evidence-based treatment planning.

Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention.

Background: Borderline Personality Disorder (BPD) is a chronic, debilitating, and difficult to treat condition. BPD has recently been linked to steroid hormone dysregulation and medical conditions characterized by disturbed androgen metabolism. This study aimed to investigate cortisol and testosterone levels in BPD, and changes in hormones following psychological treatment. Methods: Participants with BPD (n = 33) completed a 12-week Dialectical Behavior Therapy group program. Pre and post salivary testosterone and cortisol were analyzed. Baseline hormones in the BPD group were compared to age-and-sex matched controls (n = 33). Non-parametric tests were utilized to investigate group differences, pre-post treatment hormone and symptom changes, and associations between symptoms and hormone levels. Results: Participants with BPD had significantly higher testosterone levels than controls. Mean testosterone levels in females with BPD were double that of female controls. Testosterone and cortisol levels were related, and some BPD symptoms were associated with with hormone levels. BPD symptoms reduced significantly with treatment, however pre to post hormone levels did not change. Conclusions: This study supports an association between BPD symptoms and neuroendocrine dysfunction at baseline, however we found no reduction in hormone dysfunction post treatment. Further research into relationships between stress signaling and neuroendocrine disturbances in BPD may inform aetiological and treatment models. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12618000477224. Registered on 3 April 2018.

Aberrant neural network activation during reliving of autobiographical memories in adolescent depression.

BACKGROUND: Adolescents with depression exhibit negative biases in autobiographical memory with detrimental consequences for their self-concept and well-being. Investigating how adolescents relive positive autobiographical memories and activate the underlying neural networks could reveal mechanisms that drive such biases. This study investigated neural networks when reliving positive and neutral memories, and how neural activity is modulated by valence and vividness in adolescents with and without depression. METHODS: Adolescents (N = 69; n = 17 with depression) retrieved positive and neutral autobiographical memories. On a separate day, they relived these memories during fMRI scanning, and reported on pleasantness and vividness after reliving each memory. We used a multivariate, data-driven approach - event-related independent component analysis (eICA) - to characterize neural networks supporting autobiographical recollection. RESULTS: Adolescents with depression reported their positive memories as significantly less pleasant compared to healthy controls, while subjective vividness was unaffected. Using eICA, we identified a broad autobiographical memory network, and subnetworks related to reliving positive vs neutral memories. These subnetworks comprised a 'self-referential processing network' including medial prefrontal cortex, posterior cingulate cortex/precuneus, and temporoparietal junction, anti-correlating with parts of the central executive network and salience network. Adolescents with depression exhibited aberrant activation in this self-referential network, but only when reliving relatively 'low' pleasant memories. CONCLUSIONS: Our findings provide first insights into how the quality of reliving autobiographical memories in adolescents with depression may relate to aberrant self-referential neural network activation, and underscore the potential of targeting memory reliving in therapeutic interventions to foster self-esteem and diminish depressive symptoms.

Patient perspectives on non-response to psychotherapy for borderline personality disorder: a qualitative study.

BACKGROUND: Despite increasing evidence for the effectiveness of psychotherapy for Borderline Personality Disorder (BPD), estimates show that approximately half of those in treatment do not clinically improve or reach reliable change criteria. There are limited qualitative descriptions of treatment factors associated with non-response from the perspectives of those struggling to improve. METHOD: Eighteen people (72.2% female, mean age 29.4 (SD = 8)) with experience of receiving psychotherapeutic treatment for BPD were interviewed to obtain their perspectives on hindering factors in treatment and what may be helpful to reduce non-response. The data in this qualitative study was analysed thematically. RESULTS: Four domains were created from the insights patients shared on non-response and what may be needed to mitigate it. The focus of Domain 1 was that therapy cannot be effective until two factors are in place. First, the patient needs sufficient safety and stability in their environment in order to face the challenges of therapy. Second, they need to be able to access therapy. Domain 2 described factors the patients themselves contribute. The themes in this domain were described as phases that need to be progressed through before therapy can be effective. These phases were ceasing denial that help is warranted and deserved, taking responsibility for behaviours that contribute to unwellness, and committing to the hard work that is required for change. Domain 3 described how the lack of a safe alliance and ruptures in the safety of the relationship with the therapist can contribute to non-response. Domain 4 was comprised of factors that patients identified as supportive of moving through the barriers to response. The first theme in this domain was prioritising the safety of the therapy relationship. The second theme was giving a clear diagnosis and taking a collaborative approach in sessions. The final theme described the importance of focusing on practical goals with the patient to create tangible life changes. CONCLUSION: This study found that non-response is complex and multifaceted. First, it is clear that systems need to be in place to support access to adequate care and foster life stability. Second, considerable effort may be needed at the engagement phase of therapy to clarify expectations. Third, attention to specific interpersonal challenges between patients and therapists is an important focus. Finally, structured work to improve relationships and vocational outcomes is indicated.

What aspects of mindfulness and emotion regulation underpin self-harm in individuals with borderline personality disorder?

BACKGROUND: Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship. AIMS: This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related. METHODS: Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables. RESULTS: BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation. CONCLUSION: The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies.

How Much Training Do We Need? Assessing the Validity and Interrater Reliability of the PDM-2's Psychodiagnostic Chart among Less Experienced Clinicians.

The Psychodynamic Diagnostic Manual - Second Edition (PDM-2) has emerging evidence supporting its clinical utility, yet one of the main limitations remains the conjecture that considerable training and experience is required. It also remains unclear how the PDM-2 framework compares with current DSM measures of personality pathology such as the Level of Personality Functioning Scale (LPFS). The aim of the present study is to examine these issues by testing whether less clinically experienced second year doctoral psychology students are able to reliably assess patients' level of personality pathology using the PDM-2's Psychodiagnostic Chart (PDC-2), and to investigate the convergence between the PDC-2 and the LPFS. Results showed adequate inter-rater reliability for both of the main PDC-2 axes, with 52% of the variance for the overall personality organization (P-Axis) rating, and 29% of the overall M-Axis score being due to rater consensus. Reliability of individual ratings ranged from fair to excellent for the overall scores on both axes (ICC = 0.59 to .90). Results also showed that student evaluations were valid, with the latter's assessment of the patients' level of personality organization converging both with the experts' rating of the PDC-2 as well as the LPFS. Implications for clinical training are discussed.

Neurocognition of females with substance use disorder and comorbid personality disorder: Divergence in subjective and objective cognition.

At least one in four patients with substance use disorder (SUD) meet criteria for personality disorder and overlapping neurocognitive deficits may reflect shared neurobiological mechanisms. We studied neurocognition in females attending residential SUD treatment by comparing SUD with (n = 20) or without (n = 30) comorbid personality disorder. Neuropsychological testing included working memory, inhibition, shifting, verbal fluency, design fluency, psychomotor speed, immediate and delayed verbal memory, processing speed, premorbid functioning, cognitive screening, and self-reported executive function. As expected, whole-sample deficits included working memory (d = -.91), self-reported executive function (d = -.87), processing speed (d = -.40), delayed verbal memory recall (d = -.39), premorbid functioning (d = -.51), and cognitive screening performance (d = -.61). Importantly, the comorbid personality disorder group showed greater self-reported executive dysfunction (d = -.67) and poorer shifting performance (d = -.65). However, they also evidenced better working memory (d = .84), immediate (d = .95) and delayed (d = .83) verbal memory, premorbid functioning (d = .90), and cognitive screening performance (d = .77). Overall executive dysfunction deficits were concordant with those observed in previous SUD studies. Surprisingly, comorbid personality disorder was associated with a pattern indicating poorer subjective (self-report) but better objective performance on a number of tasks, apart from shifting deficits that may relate to emotion dysregulation. Subjective emotional dysfunction may influence the cognitive deficits observed in the personality disorder group.

Improving treatment outcomes for borderline personality disorder: what can we learn from biomarker studies of psychotherapy?

PURPOSE OF REVIEW: Borderline personality disorder (BPD) is a severe and common psychiatric disorder and though evidence-based psychotherapies are effective, rates of treatment nonresponse are as high as 50%. Treatment studies may benefit from interdisciplinary approaches from neuroscience and genetics research that could generate novel insights into treatment mechanisms and tailoring interventions to the individual. RECENT FINDINGS: We provide a timely update to the small but growing body of literature investigating neurobiological and epigenetic changes and using biomarkers to predict outcomes from evidence-based psychotherapies for BPD. Using a rapid review methodology, we identified eight new studies, updating our earlier 2018 systematic review. Across all studies, neuroimaging ( n  = 18) and genetics studies ( n  = 4) provide data from 735 participants diagnosed with BPD (mean sample size across studies = 33.4, range 2-115). SUMMARY: We report further evidence for psychotherapy-related alterations of neural activation and connectivity in regions and networks relating to executive control, emotion regulation, and self/interpersonal functioning in BPD. Emerging evidence also shows epigenetic changes following treatment. Future large-scale multisite studies may help to delineate multilevel treatment targets to inform intervention design, selection, and monitoring for the individual patient via integration of knowledge generated through clinical, neuroscience, and genetics research.

Sex differences in borderline personality disorder: A scoping review.

Borderline Personality Disorder (BPD) is often perceived to be a female-predominant disorder in both research and clinical contexts. Although there is growing recognition of possible sex differences, the current literature remains fragmented and inconclusive. This scoping review aimed to synthesize available research evidence on potential sex differences in BPD. PsycINFO, PubMed, Scopus and Web-of-Science were searched from January 1982 to July 2022 surrounding the key concepts of sex and BPD. Data searching and screening processes followed the Joanna Briggs Institute methodology involving two independent reviewers, and a third reviewer if necessary, and identified 118 papers. Data regarding BPD symptoms, comorbid disorders, developmental factors, biological markers, and treatment were extracted. Data was summarized using the vote counting method or narrative synthesis depending on the availability of literature. Males with BPD were more likely to present externalizing symptoms (e.g., aggressiveness) and comorbid disorders (e.g., substance use), while females with BPD were more likely to present internalizing symptoms (e.g., affective instability) and comorbid disorders (e.g., mood and eating disorders). This review also revealed that substantially more research attention has been given to overall sex differences in baseline BPD symptoms and comorbid disorders. In contrast, there is a dearth of sex-related research pertaining to treatment outcomes, developmental factors, and possible biological markers of BPD. The present scoping review synthesized current studies on sex differences in BPD, with males more likely to present with externalizing symptoms in contrast to females. However, how this might change the prognosis of the disorder or lead to modifications of treatment has not been investigated. Most studies were conducted on western populations, mainly North American (55%) or European (33%), and there is a need for future research to also take into consideration genetic, cultural, and environmental concomitants. As the biological construct of 'sex' was employed in the present review, future research could also investigate the social construct 'gender'. Longitudinal research designs are needed to understand any longer-term sex influence on the course of the disorder.

Evaluation of a skills-based peer-led art therapy online-group for people with emotion dysregulation.

OBJECTIVE: We developed and piloted a novel art-based online skills program led by a peer mental health professional with lived experience of complex mental health, including Borderline Personality Disorder (BPD). Key challenges of living with BPD and emotion dysregulation were addressed through artmaking informed by a dialectical framework and skills, to evaluate acceptability and efficacy. METHOD: A structured, manualised 2-hour weekly arts-based skills program was piloted for people with BPD over 18 weeks. Evaluation included both quantitative and qualitative measures at commencement and completion. RESULTS: Thirty-eight participants enrolled in the program (89.5% identified she/her pronouns, average age 33.6 years), and 31 completed (82% retention). Multilevel modelling analysis of the primary outcome variable Difficulties in Emotion Regulation Scale (DERS) demonstrated a large improvement over time (effect size Cohen's d = 1.77). Qualitative thematic analysis found participants had improved capacity to regulate emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well. We found that artmaking facilitated processes and helped the expression of difficult emotions, symbolise challenging relationships, and facilitate greater self-understanding. Participants reported high levels of satisfaction, and 77.4% reported that the program had increased wellbeing. CONCLUSION: This novel artmaking program for emotion dysregulation and BPD was acceptable and potentially effective. Peer facilitation using arts-based skills is a modality of therapy for further investigation.

Personal agency and borderline personality disorder: a longitudinal study of outcomes.

BACKGROUND: Low personal agency is the concept of attributing successes and failures to external factors rather than personal characteristics. Previous research supported links between low personal agency and symptoms of borderline personality disorder (BPD). The present research followed patients in an outpatient dialectical behavioural therapy (DBT) group from intake to 12 months follow up to examine the impact of personal agency on outcome. METHODS: Patients (N = 57, age 18-72, 91.5% female) were assessed at intake, after three months of DBT treatment, and 12 months follow up on measures of symptoms and personal agency. Three separate measures were used to assess treatment outcomes: the BPD Checklist, the Personality Inventory for DSM-5 (PID-5), and the Mental Health Inventory (MHI-5). RESULTS: Mixed model analyses found BPD symptoms significantly reduced as a result of DBT treatment and were maintained at follow-up. However, 47% of participants continued to meet BPD criteria 12 months later, despite treatment. Regression analyses indicated that low personal agency at intake was associated with higher BPD symptom severity at post-treatment and 12 month follow up. In addition, low personal agency at intake was associated with greater levels of negative affectivity at post-treatment. Personal agency did not relate to levels of depression and anxiety. CONCLUSIONS: Despite the reductions in BPD symptomology, personal agency did not significantly change over time. Those with lower agency at intake continued to do more poorly at follow up. We speculate that poor outcomes may be contributed to by patients' lack of engagement in recovery due to poor agency and an external locus of control. As such, therapeutic approaches, like DBT, may require additional strategies to appropriately target low personal agency. Further research is needed to understand if other treatment protocols may facilitate positive change in personal agency.

To love and work: A longitudinal study of everyday life factors in recovery from borderline personality disorder.

Although recovery from borderline personality disorder (BPD) is common, not all individuals improve over time. This study sought to examine the features that contribute to response or non-response for individuals at different stages of recovery from BPD over a longitudinal follow-up. Participants were individuals with a diagnosis of BPD that were followed up after 1 year of receiving psychological treatment. There were no significant differences between participants at intake across key indices; however, at 1-year follow-up, two groups were distinguishable as either 'functioning well' (n = 23) or 'functioning poorly' (n = 25) based on symptomatology and functional impairment. Participant qualitative responses were analysed thematically and via Leximancer content analysis. Thematic analysis indicated three key themes: (1) love of self and others, (2) making a contribution through work and study and (3) stability in daily life. Participants who were 'functioning well' described meaningful relationships with others, enjoyment in vocation, and described less frequent or manageable life crises. The 'functioning poorly' group described relationship conflicts, vocational challenges, feelings of aimlessness and purposelessness, instability in daily living and frequent crises. Leximancer content analysis visually depicted these divergent thematic nomological networks. Corroborating quantitative analyses indicated significant differences between these groups for social, occupational and symptom profiles. These findings highlight the centrality of achieving the capacity to 'love and work' in fostering a sense of personal recovery. Treatments may need specific focus on these factors, as they appeared to reinforce symptomatic trajectories of either improvement or poor non-response to therapy.

Living with pathological narcissism: core conflictual relational themes within intimate relationships.

BACKGROUND: Pathological narcissism is a severe mental health condition that includes disturbances in interpersonal functioning. Interpersonal difficulties by those affected include aggressive, domineering, cold and coercive behaviours which often result in strong negative reactions from others. We sought to examine the moment-to-moment patterns that emerge within close relationships between intimate partners and family members. METHODS: Participants (N = 15) were romantic partners (73.3%) and family members (26.6%) in a close and long-term relationship (+ 10 years) with an individual with pathological narcissism. Participants told verbatim relationship narratives involving five narrative interactions with their relative with pathological narcissism and five narrative interactions with others. Transcripts were coded using the using Core Conflictual Relationship Theme method. Participants also completed three versions of the Relationship Questionnaire, reporting on 1. their relationship style 'in general', 2. their relationship style 'with their relative' and 3. the relationship style of their relative. RESULTS: A total of 133 relationship episodes were analysed, comprising 783 components (wishes, responses of others and responses of self). While the identified wishes (e.g., for love, for support) were consistent between relative and non-relative narratives, there was significantly higher disharmony and lower harmony in narratives involving relatives with pathological narcissism. Described disharmony in these relationships involved the relative's rejecting, subjugating and attacking behaviours, and participants rejecting and withdrawing behaviours. There was a prominent deactivation of participants attachment system when interacting with their relative with pathological narcissism, endorsing predominately dismissing relationship styles. Individuals with pathological narcissism were similarly rated as predominately dismissing. CONCLUSIONS: Together, these results reflect the cycles of interpersonal dysfunction for individuals with pathological narcissism and their partners and family members. Treatment implications point to the risk of therapists withdrawing and dismissing a patient with high pathological narcissism in the countertransference. Strategies to monitor and manage these core relational themes in treatment remain a challenge.

Helping patients master core conflictual relationship themes in psychotherapy.

An important component of case formulation is to understand the patient's difficulties in the context of their relationships. The Core Conflictual Relationship Theme (CCRT) method provides a clinical guide for understanding the narratives of relationship conflicts told during therapy. We follow the case of Barbara, a 60 year old with a long history of chronic shyness. Her narratives follow a common CCRT: she wishes to feel safe, but fears that others are out to get her, which makes her withdraw. These patterns have pervasively repeated themselves in the past, present, and across different relationships (self, family, partners, colleagues). The therapist responds carefully by creating safety, tolerating her fears, and working to overcome these CCRT patterns, thus reducing her impulse to withdraw from treatment. Psychotherapists from many theoretical orientations can learn how patients mastering these repetitive negative CCRTs can lead to more adaptive relationship patterns that improve their mental health.