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Comorbidity of Narcissistic Personality Disorder in Patients with Borderline Journal of Personality Disorders, 32(4), 562-575, 2018 © 2018 The Guilford Press HÖRZ-SAGSTETTER ET AL. COMORBID NARCISSISTIC AND BPD BRIEF REPORT CLINICAL CHARACTERISTICS OF COMORBID NARCISSISTIC PERSONALITY DISORDER IN PATIENTS WITH BORDERLINE PERSONALITY DISORDER Susanne Hörz-Sagstetter, PhD, Diana Diamond, PhD, John F. Clarkin, PhD, Kenneth N. Levy, PhD, Michael Rentrop, MD, Melitta Fischer-Kern, MD, Nicole M. Cain, PhD, and Stephan Doering, MD This study examines psychopathology and clinical characteristics of patients with borderline personality disorder (BPD) and comorbid narcissistic personality disorder (NPD) from two international randomized controlled trials. From a combined sample of 188 patients with BPD, 25 also ful- filled criteria for a comorbid diagnosis of NPD according to DSM-IV. The BPD patients with comorbid NPD, compared to the BPD patients without comorbid NPD, showed significantly more BPD criteria (M = 7.44 vs. M = 6.55, p < .001), fulfilled more criteria of comorbid histrionic (M = 3.84 vs. M = 1.98, p < .001), paranoid (M = 3.12 vs. M = 2.27, p = .014), and schizotypal (M = 1.64 vs. M = 1.02, p = .018) personality disorders, and were more likely to meet criteria for full histrionic PD diagnosis (44.0% vs. 14.2%, p < .001). The BPD-NPD group also reported significantly fewer psychiatric hospitalizations in the previous year (M = 0.40 vs. M = 0.82, p = .019) and fewer axis I disorders (M = 2.68 vs. M = 3.75, p = .033). No dif- ferences could be found in general functioning, self-harming behavior, and suicide attempts. The comorbidity of narcissistic and borderline pathology has been shown clinically and empirically to be a complicating factor for both an accurate From Psychologische Hochschule Berlin, Germany (S. H.-S); Department of Psychology, City University of New York (D. D.); Weill Cornell Medical College, New York, New York (D. D., J. F. C., K. N. L.); Pennsylvania State University (K. N. L.); Technische Universität München, Germany (M. R.); Medical University of Vienna, Austria (M. F.-K., S. D.); and Long Island University – Brooklyn, New York (N. M. C.). This research was supported by grants from the National Institute of Mental Health (MH012530; PI: Levy), the International Psychoanalytic Association (PI: Levy), the Kohler Fund of Munich, the Border- line Personality Disorder Research Foundation (BPDRF; PI: Clarkin, Kernberg), the Jubiläumsfonds of the Austrian National Bank (#10636; PI: Doering), and the German Psychoanalytic Society (DPG; PI: Doering). Address correspondence to Dr. Susanne Hörz-Sagstetter, Psychologische Hochschule Berlin (PHB), Am Köllnischen Park 2, 10179 Berlin, Germany. E-mail: [email protected] 562 COMORBID NARCISSISTIC AND BPD 563 diagnosis and psychotherapy (Diamond & Yeomans, 2008; Ellison et al., 2013; Kernberg, 1984; Levy, 2012). Indeed, clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population poses specific clinical chal- lenges and may be among the more difficult to treat within the personality disorder spectrum (Kernberg, 2007; Stone, 1990). The current study exam- ines data from patients with borderline personality disorder recruited for participation in two separate randomized clinical trials (Clarkin, Levy, Len- zenweger, & Kernberg, 2007; Doering et al., 2010) and allowed for the study of the characteristics and clinical differences of the subgroup of borderline patients who also fulfill comorbid narcissistic personality pathology (accord- ing to criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV; American Psychiatric Association, 1994] and fifth edition [DSM-5; American Psychiatric Association, 2013]). The goals of the present study are to examine how BPD patients with a comorbid NPD (re- ferred to as NPD/BPD) differ from BPD patients without comorbid NPD in the context of borderline pathology (referred to as BPD) on the number of axis I and axis II disorders, general functioning, as well as mental health service use, self-harming, and suicidal behavior. The overt characteristics of NPD as defined in the DSM-IV/-5, such as grandiosity, a sense of entitlement, exploitativeness of others, inordinate reli- ance on admiration of others to regulate self-esteem, arrogant haughty be- haviors, exhibitionism, and lack of empathy have now been confirmed by research (see Cain, Pincus, & Ansell, 2008; Levy, Reynoso, Wassermann, & Clarkin, 2007, for reviews). However, the ways that NPD manifests itself in the context of borderline pathology have not been well conceptualized or in- vestigated. In previous research, NPD has been shown to be highly comorbid with other DSM-diagnosed axis II disorders, particularly those in cluster B (histrionic, borderline, and antisocial). In a previous study, Gunderson and colleagues found that the rate of comorbidity of NPD with other person- ality disorders exceeded 50% (Gunderson, Ronningstam, & Smith, 1995). Similarly, Morey and colleagues reported the highest rate of comorbidity on axis II of any personality disorders, with 53.1 % of patients with histrionic personality disorder also fulfilling criteria for NPD, 46% of patients with borderline personality disorder, 35.9% of patients with paranoid personality disorder, and 35.9% of patients with avoidant personality disorder (Morey, 1988). In the recent National Epidemiologic Survey on Alcohol and Related Conditions study (NESARC), the prevalence of NPD in a community sample who met criteria for schizotypal personality disorder was 43.2%, for bor- derline for personality disorder it was 38.9%, and for histrionic personality disorder it was 32.4% (Stinson et al., 2008). Such studies have added to the growing literature that fails to support the DSM’s putative structure of six distinct personality disorders. However, in a recent study Sharp and colleagues (2015), using a bifac- tor model to investigate personality disorder (PD) pathology, evaluated the general factors that account for both common variance shared across PD di- agnoses and the specific, unique sources of variance that may represent more specific forms of personality disorder pathology in a sample of inpatients. 564 HÖRZ-SAGSTETTER ET AL. Interestingly, while BPD items loaded most strongly on the general factor, narcissistic PD’s average loading on the general factor was relatively weak, but quite strong on the factors specific to NPD, such as grandiosity and ar- rogance. These findings suggest that while there is an overlap between the two disorders reflected in the high rates of comorbidity, they are by no means synonymous. Such studies call for more research on the extent to which NPD may be a discrete and separate personality disorder that may affect the pre- sentation and treatment course of personality pathology. In addition, recently there has been increasing attention to narcissistic pathology as a dimensional disorder with varying degrees of pathology in self and object relations (American Psychiatric Association [APA], 2013; Ronningstam, 2011; Skodol, Bender, & Morey, 2014). This is also reflected in the DSM-5, which retains the diagnostic category of NPD unchanged, but in section III also allows for different levels of severity of narcissistic pathol- ogy, as personality disorders in this section are characterized by impairments in self and interpersonal functioning, identity, goal direction, and pathologi- cal personality traits (APA, 2013). Thus, it is increasingly recognized that pathological narcissism has been found at various levels of pathology, and encompasses impairments across a number of dimensions. In Kernberg’s model (Kernberg, 1975; 1997; 2010), pathological narcissism spans a spec- trum of pathology from higher functioning (neurotic) to lower functioning (borderline) levels of personality organization. Higher functioning narcis- sists show an excessive need for admiration from others, attitudes of en- titlement, and exploitativeness toward others, as well as lack of empathy and excessive envy, but they may have made a good superficial adjustment based on achieving admiration from others and self-esteem regulation from a relatively stable grandiose self. By contrast, those with narcissistic pathol- ogy organized at a borderline level include individuals who show the typical manifestations of narcissistic personality disorder (Kernberg, 1997; 2007) but also present with unstable and unintegrated sense of self that is evident in general identity diffusion, lack of anxiety tolerance, and impulse control, as well as more drastic fluctuations in self-esteem and affect regulation, despite the defensive functions of the grandiose self. Contributing to the idea that narcissistic pathology may manifest itself differently depending on the individual’s level of organization are the inves- tigations, both clinical and empirical, that have identified a broad variation of subtypes of pathological narcissism and of the phenotypic expression of narcissism. These subtypes or phenotypes range from the grandiose type, characterized by unbridled grandiosity, the ruthless exploitation of others, and pervasive arrogance (also referred to as “grandiose or overt narcissism”) to the vulnerable type, characterized by chronic feelings of rejection and humiliation and deflated self-concept in the context of preoccupation with hidden grandiose fantasies (often referred to as “vulnerable or covert narcis- sism”) (Akhtar, 2003; Bursten, 1973; Cain et al., 2008;
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