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The cluster of “dramatic” personality disorders includes the antisocial, borderline, histrionic, and narcissistic personality disorders. The behaviors of people with these problems are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying.

These personality disorders are more commonly diagnosed than the others. However, only the antisocial and borderline personality disorders have received much study, partly because they create so many problems for other people. The causes of the disorders, like those of the odd personality disorders, are not well understood. Treatments range from ineffective to moderately effective.

Sometimes described as “psychopaths” or “sociopaths,” people with antisocial personality disorder persistently disregard and violate others’ rights (APA, 2013). Aside from substance use disorders, this is the disorder most closely linked to adult criminal behavior. DSM-5 stipulates that a person must be at least 18 years of age to receive this diagnosis; however, most people with antisocial personality disorder displayed some patterns of misbehavior before they were 15, including truancy, running away, cruelty to animals or people, and destroying property.

Robert Hare, a leading researcher of antisocial personality disorder, recalls an early professional encounter with a prison inmate named Ray:

Like Ray, people with antisocial personality disorder lie repeatedly (APA, 2013). Many cannot work consistently at a job; they are absent frequently and are likely to quit their jobs altogether (Hengartner et al., 2014). Usually they are also careless with money and frequently fail to pay their debts. They are often impulsive, taking action without thinking of the consequences (Lang et al., 2015). Correspondingly, they may be irritable, aggressive, and quick to start fights. Many travel from place to place.

Recklessness is another common trait: people with antisocial personality disorder have little regard for their own safety or for that of others, even their children. They are self-centered as well, and are likely to have trouble maintaining close relationships. Usually they develop a knack for gaining personal profit at the expense of other people. Because the pain or damage they cause seldom concerns them, clinicians commonly say that they lack a moral conscience. They think of their victims as weak and deserving of being conned, robbed, or even physically harmed (see PsychWatch below).

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Surveys indicate that 3.6 percent of adults in the United States meet the criteria for antisocial personality disorder (Sansone & Sansone, 2011). The disorder is as much as four times more common among men than women.

Because people with this disorder are often arrested, researchers frequently look for people with antisocial patterns in prison populations (Pondé et al., 2014). It is estimated that at least 40 percent of people in prison meet the diagnostic criteria for this disorder (Naidoo & Mkize, 2012). Among men in urban jails, the antisocial personality pattern has been linked strongly to past arrests for crimes of violence (De Matteo et al., 2005). The criminal behavior of many people with this disorder declines after the age of 40; some, however, continue their criminal activities throughout their lives (APA, 2013).

Studies and clinical observations also indicate that people with antisocial personality disorder have higher rates of alcoholism and other substance use disorders than do the rest of the population (Brook et al., 2014; Reese et al., 2010). Perhaps intoxication and substance misuse help trigger the development of antisocial personality disorder by loosening a person’s inhibitions. Perhaps this personality disorder somehow makes a person more prone to abuse substances. Or perhaps antisocial personality disorder and substance use disorders both have the same cause, such as a deep-seated need to take risks. Interestingly, drug users with the personality disorder often cite the recreational aspects of drug use as their reason for starting and continuing it.

How Do Theorists Explain Antisocial Personality Disorder? Explanations of antisocial personality disorder come from the psychodynamic, behavioral, cognitive, and biological models. As with many other personality disorders, psychodynamic theorists propose that this one begins with an absence of parental love during infancy, leading to a lack of basic trust (Meloy & Yakeley, 2010; Sperry, 2003). In this view, some children—the ones who develop antisocial personality disorder—respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness. In support of the psychodynamic explanation, researchers have found that people with this disorder are more likely than others to have had significant stress in their childhoods, particularly in such forms as family poverty, family violence, child abuse, and parental conflict or divorce (Kumari et al., 2014; Martens, 2005).

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Many behavioral theorists have suggested that antisocial symptoms may be learned through modeling, or imitation (Gaynor & Baird, 2007). As evidence, they point to the higher rate of antisocial personality disorder found among the parents of people with this disorder (APA, 2013). Other behaviorists have suggested that some parents unintentionally teach antisocial behavior by regularly rewarding a child’s aggressive behavior (Kazdin, 2005). When the child misbehaves or becomes violent in reaction to the parents’ requests or orders, for example, the parents may give in to restore peace. Without meaning to, they may be teaching the child to be stubborn and perhaps even violent.

The cognitive view says that people with antisocial personality disorder hold attitudes that trivialize the importance of other people’s needs (Elwood et al., 2004). Such a philosophy of life, some theorists suggest, may be far more common in our society than people recognize (see Table 13.2). Cognitive theorists further propose that people with this disorder have genuine difficulty recognizing points of view or feelings other than their own (Herpertz & Bertsch, 2014).

Finally, studies suggest that biological factors may play an important role in antisocial personality disorder. Researchers have found that antisocial people, particularly those who are highly impulsive and aggressive, have lower serotonin activity than other people (Thompson et al., 2014). As you’ll recall, both impulsivity and aggression also have been linked to low serotonin activity in other kinds of studies (see page 235), so the presence of this biological factor in people with antisocial personality disorder is not surprising.

Other studies indicate that individuals with this disorder display deficient functioning in their frontal lobes, particularly in the prefrontal cortex (Liu et al., 2014). Among other duties, this brain region helps people to plan and execute realistic strategies and to have personal characteristics such as sympathy, judgment, and empathy. These are, of course, all qualities found wanting in people with antisocial personality disorder.

In yet another line of research, investigators have found that people with antisocial personality disorder often feel less anxiety than other people, and so lack a key ingredient for learning (Blair et al., 2005). This would help explain why they have so much trouble learning from negative life experiences or tuning in to the emotional cues of others. Why should people with antisocial personality disorder experience less anxiety than other people? The answer may lie once again in the biological realm. Research participants with the disorder often respond to warnings or expectations of stress with low brain and bodily arousal (Thompson et al., 2014; Perdeci et al., 2010). Perhaps because of the low arousal, they easily tune out threatening or emotional situations, and so are unaffected by them.

It could also be argued that because of their physical underarousal, people with antisocial personality disorder would be more likely than other people to take risks and seek thrills. That is, they may be drawn to antisocial activity precisely because it meets an underlying biological need for more excitement and arousal. In support of this idea, as you read earlier, antisocial personality disorder often goes hand in hand with sensation-seeking behavior.

Treatments for Antisocial Personality Disorder Treatments for people with antisocial personality disorder are typically ineffective (Black, 2015). Major obstacles to treatment include the individuals’ lack of conscience, desire to change, or respect for therapy (Colli et al., 2014; Kantor, 2006). Most of those in therapy have been forced to participate by an employer, their school, or the law, or they come to the attention of therapists when they also develop another psychological disorder (Agronin, 2006).

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Some cognitive therapists try to guide clients with antisocial personality disorder to think about moral issues and about the needs of other people (Beck & Weishaar, 2011; Weishaar & Beck, 2006). In a similar vein, a number of hospitals and prisons have tried to create a therapeutic community for people with this disorder, a structured environment that teaches responsibility toward others (Harris & Rice, 2006). Some patients seem to profit from such approaches, but it appears that most do not. In recent years, clinicians have also used psychotropic medications, particularly atypical antipsychotic drugs, to treat people with antisocial personality disorder. Some report that these drugs help reduce certain features of the disorder, but systematic studies of this claim are still needed (Brown et al., 2014; Thompson et al., 2014).

People with borderline personality disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity (APA, 2013). These characteristics combine to make their relationships very unstable as well (Paris, 2010, 2005). Some of Ellen Farber’s difficulties are typical:

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Like Ellen Farber, people with borderline personality disorder swing in and out of very depressive, anxious, and irritable states that last anywhere from a few hours to a few days or more (see Table 13.3). Their emotions seem to be always in conflict with the world around them. They are prone to bouts of anger, which sometimes result in physical aggression and violence (Martino et al., 2015; Scott et al., 2014). Just as often, however, they direct their impulsive anger inward and inflict bodily harm on themselves. Many seem troubled by deep feelings of emptiness.

Borderline personality disorder is a complex disorder, and it is fast becoming one of the more common conditions seen in clinical practice. Many of the patients who come to mental health emergency rooms are people with this disorder who have intentionally hurt themselves. Their impulsive, self-destructive activities may range from alcohol and substance abuse to delinquency, unsafe sex, and reckless driving (Kienast et al., 2014; Coffey et al., 2011). Many engage in self-injurious or self-mutilation behaviors, such as cutting or burning themselves or banging their heads (Turner et al., 2015). As you saw in Chapter 7, such behaviors typically cause immense physical suffering, but those with borderline personality disorder often feel as if the physical discomfort offers relief from their emotional suffering. It may serve as a distraction from their emotional or interpersonal upsets, “snapping” them out of an “emotional overload” (Sadeh et al., 2014). Many try to hurt themselves as a way of dealing with their chronic feelings of emptiness, boredom, and identity confusion. Scars and bruises also may provide them with a kind of concrete evidence of their emotional distress (Paris, 2010, 2005).

Suicidal threats and actions are also common (Amore et al., 2014; Zimmerman et al., 2014). Studies suggest that around 75 percent of people with borderline personality disorder attempt suicide at least once in their lives; as many as 10 percent actually commit suicide. It is common for people with this disorder to enter clinical treatment by way of the emergency room after a suicide attempt.

People with borderline personality disorder frequently form intense, conflict-ridden relationships in which their feelings are not necessarily shared by the other person. They may come to idealize another person’s qualities and abilities after just a brief first encounter. They also may violate the boundaries of relationships (Lazarus et al., 2014). They quickly feel rejected and may become furious when their expectations are not met, yet they remain very attached to the relationships (Berenson et al., 2011). In fact, they have recurrent fears of impending abandonment and frequently engage in frantic efforts to avoid real or imagined separations from important people in their lives (Gunderson, 2011). Sometimes they cut themselves or carry out other self-destructive acts to prevent partners from leaving.

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People with borderline personality disorder typically have dramatic identity shifts. Because of this unstable sense of self, their goals, aspirations, friends, and even sexual orientation may shift rapidly (Westen et al., 2011; Skodol, 2005).They may at times have no sense of themselves at all, leading to the feelings of emptiness described earlier.

According to surveys, 5.9 percent of the adult population display borderline personality disorder (Zanarini et al., 2014; Sansone & Sansone, 2011). Close to 75 percent of the patients who receive the diagnosis are women (Gunderson, 2011). The course of the disorder varies from person to person. In the most common pattern, the person’s instability and risk of suicide peak during young adulthood and then gradually wane with advancing age (APA, 2013). Given the chaotic and unstable relationships characteristic of borderline personality disorder, it is not surprising that the disorder tends to interfere with job performance even more than most other personality disorders do (Hengartner et al., 2014).

How Do Theorists Explain Borderline Personality Disorder? Because a fear of abandonment tortures so many people with borderline personality disorder, psychodynamic theorists have looked once again to early parental relationships to explain the disorder (Gabbard, 2010). Object relations theorists, for example, propose that an early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation (Caligor & Clarkin, 2010).

Research has found that this is consistent with the early childhoods of people with borderline personality disorder. In many cases, when they were children, their parents neglected or rejected them, verbally abused them, or otherwise behaved inappropriately (Martín-Blanco et al., 2014). Their childhoods were often marked by multiple parent substitutes, divorce, death, or traumas such as physical or sexual abuse (Newnham & Janca, 2014; Huang et al., 2010). At the same time, it is important to recognize that the vast majority of people with histories of physical, sexual, or psychological abuse do not go on to develop borderline personality disorder (Skodol, 2005).

Borderline personality disorder also has been linked to certain biological abnormalities, such as an overly reactive amygdala, the brain structure that is closely tied to fear and other negative emotions, and an underactive prefrontal cortex, the brain region linked to planning, self-control, and decision making (Mitchell et al., 2014; Stone, 2014). Moreover, people with borderline personality disorder who are particularly impulsive—those who attempt suicide or are very aggressive toward others—apparently have lower brain serotonin activity (Soloff et al., 2014). In accord with these various biological findings, close relatives of those with borderline personality disorder are five times more likely than the general population to have the same personality disorder (Amad et al., 2014; Torgersen, 2000, 1984).

A number of theorists currently use a biosocial theory to explain borderline personality disorder (Neacsiu & Linehan, 2014). According to this view, the disorder results from a combination of internal forces (for example, difficulty identifying and controlling one’s emotions, social skill deficits, abnormal neurotransmitter reactions) and external forces (for example, an environment in which a child’s emotions are punished, ignored, trivialized, or disregarded). Parents may, for instance, misinterpret their child’s intense emotions as exaggerations or attempts at manipulation rather than as serious expressions of unsettled internal states. According to the biosocial theory, if children have intrinsic difficulty identifying and controlling their emotions and if their parents teach them to ignore their intense feelings, they may never learn how properly to recognize and control their emotional arousal or how to handle emotional distress (Herpertz & Bertsch, 2014; Lazarus et al., 2014). Such children will be at risk for the development of borderline personality disorder (Gill & Warburton, 2014).

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Note that the biosocial theory is similar to one of the leading explanations for eating disorders. As you saw in Chapter 9, theorist Hilde Bruch proposed that children whose parents do not respond accurately to the children’s internal cues may never learn to identify cues of hunger, thus increasing their risk of developing an eating disorder (see pages 289–290). Small wonder that a large number of people with borderline personality disorder also have an eating disorder (Gabriel & Waller, 2014). Recall, for example, Ellen Farber’s dysfunctional eating pattern.

Finally, some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly. As a culture loses its stability, they argue, it inevitably leaves many of its members with problems of identity, a sense of emptiness, high anxiety, and fears of abandonment. Family units may come apart, leaving people with little sense of belonging. Changes of this kind in society today may explain growing reports of the disorder (Millon, 2011).

Treatments for Borderline Personality Disorder It appears that psychotherapy can eventually lead to some degree of improvement for people with borderline personality disorder (McMain, 2015; Neville, 2014). It is, however, extraordinarily difficult for a therapist to strike a balance between empathizing with the borderline client’s dependency and anger and challenging his or her way of thinking (Goodman et al., 2014). The wildly fluctuating interpersonal attitudes of clients with the disorder can also make it difficult for therapists to establish collaborative working relationships with them. Moreover, clients with borderline personality disorder may violate the boundaries of the client–therapist relationship (for example, calling the therapist’s emergency contact number to discuss matters of a less urgent nature) (Colli et al., 2014).

Over the past two decades, an integrative treatment for borderline personality disorder, called dialectical behavior therapy (DBT), has been receiving considerable research support and is now considered the treatment of choice in many clinical circles (Linehan et al., 2015, 2006, 2002, 2001). DBT, developed by psychologist Marsha Linehan, grows largely from the cognitive-behavioral treatment model (see MediaSpeak below). It includes a number of the same cognitive and behavioral techniques that are applied to other disorders: homework assignments, psychoeducation, the teaching of social and other skills, modeling by the therapist, clear goal setting, reinforcements for appropriate behaviors, and collaborative examinations by the client and therapist of the client’s ways of thinking.

DBT also borrows heavily from the humanistic and contemporary psychodynamic approaches, placing the client–therapist relationship itself at the center of treatment interactions, making sure that appropriate treatment boundaries are adhered to and providing an environment of acceptance and validation of the client. Indeed, DBT therapists regularly empathize with their borderline clients and with the emotional turmoil they are experiencing, locate kernels of truth in the clients’ complaints or demands, and examine alternative ways for them to address valid needs.

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DBT is often supplemented by the clients’ participation in social skill-building groups (Roney & Cannon, 2014). In these groups, clients practice new ways of relating to other people in a safe environment and receive validation and support from other group members.

DBT has received more research support than any other treatment for borderline personality disorder (Neacsiu & Linehan, 2014; Roepke et al., 2011). Many clients who receive DBT become more able to tolerate stress; develop new, more appropriate, social skills; respond more effectively to life situations; and develop a more stable identity. They also have significantly fewer suicidal behaviors and require fewer hospitalizations than those who receive other forms of treatment (Linehan et al., 2015). In addition, they are more likely to remain in treatment and to report less anger, more social gratification, improved work performance, and reductions in substance abuse (Rizvi et al., 2011).

Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped calm the emotional and aggressive storms of some people with borderline personality disorder (Bridler et al., 2015; Knappich et al., 2014). However, given the numerous suicide attempts by people with this disorder, the use of drugs on an outpatient basis is controversial (Gunderson, 2011). Many professionals believe that psychotropic drug treatment for borderline personality disorder should be used largely as an adjunct to psychotherapy approaches, and indeed many clients seem to benefit from a combination of psychotherapy and drug therapy (Omar et al., 2014).

People with histrionic personality disorder, once called hysterical personality disorder, are extremely emotional—they are typically described as “emotionally charged”—and continually seek to be the center of attention (APA, 2013). Their exaggerated moods and neediness can complicate life considerably, as we see in the case of Lucinda:

People with histrionic personality disorder are always “on stage,” using theatrical gestures and mannerisms and grandiose language to describe ordinary everyday events. Like chameleons, they keep changing themselves to attract and impress an audience, and in their pursuit they change not only their surface characteristics—according to the latest fads—but also their opinions and beliefs. In fact, their speech is actually scanty in detail and substance, and they seem to lack a sense of who they really are.

Approval and praise are their lifeblood; they must have others present to witness their exaggerated emotional states. Vain, self-centered, demanding, and unable to delay gratification for long, they overreact to any minor event that gets in the way of their quest for attention. Some make suicide attempts, often to manipulate others (APA, 2013).

People with histrionic personality disorder may draw attention to themselves by exaggerating their physical illnesses or fatigues. They may also behave very provocatively and try to achieve their goals through sexual seduction. Most obsess over how they look and how others will perceive them, often wearing bright, eye-catching clothes. They exaggerate the depth of their relationships, considering themselves to be the intimate friends of people who see them as no more than casual acquaintances. Often they become involved with romantic partners who may be exciting but who do not treat them well.

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This disorder was once believed to be more common in women than in men, and clinicians long described the “hysterical wife” (Anderson et al., 2001). Research, however, has revealed gender bias in past diagnoses (APA, 2013). When evaluating case studies of people with a mixture of histrionic and antisocial traits, clinicians in several studies gave a diagnosis of histrionic personality disorder to women more than men. Surveys suggest that 1.8 percent of adults have this personality disorder, with males and females equally affected (APA, 2013; Sansone & Sansone, 2011).

How Do Theorists Explain Histrionic Personality Disorder? The psychodynamic perspective was originally developed to help explain cases of hysteria (see Chapter 8), so it is no surprise that psychodynamic theorists continue to have a strong interest in histrionic personality disorder. Most psychodynamic theorists believe that as children, people with this disorder had cold and controlling parents who left them feeling unloved and afraid of abandonment (Horowitz & Lerner, 2010; Bender et al., 2001). To defend against deep-seated fears of loss, the children learned to behave dramatically, inventing crises that would require other people to act protectively.

Cognitive explanations look instead at the lack of substance and extreme suggestibility that people with histrionic personality disorder have. Cognitive theorists see these people as becoming less and less interested in knowing about the world at large because they are so self-focused and emotional. With no detailed memories of what they never learned, they must rely on hunches or on other people to provide them with direction in life (Blagov et al., 2007). Some cognitive theorists also believe that people with this disorder hold a general assumption that they are helpless to care for themselves, and so they constantly seek out others who will meet their needs (Weishaar & Beck, 2006; Beck et al., 2004).

Sociocultural, particularly multicultural, theorists believe that histrionic personality disorder is produced in part by cultural norms and expectations. Until recently, our society encouraged girls to hold on to childhood and dependency as they grew up. The vain, dramatic, and selfish behavior of the histrionic personality may actually be an exaggeration of femininity as our culture once defined it (Fowler et al., 2007). Similarly, some clinical observers claim that histrionic personality disorder is diagnosed less often in Asian and other cultures that discourage overt sexualization and more often in Hispanic American and Latin American cultures that are more tolerant of overt sexualization (Patrick, 2007; Trull & Widiger, 2003). Researchers have not, however, investigated this claim systematically.

Treatments for Histrionic Personality Disorder People with histrionic personality disorder are more likely than those with most other personality disorders to seek out treatment on their own (Tyrer et al., 2003). Working with them can be very difficult, however, because of the demands, tantrums, and seductiveness they are likely to deploy. Another problem is that these clients may pretend to have important insights or to change during treatment merely to please the therapist. To head off such problems, therapists must remain objective and maintain strict professional boundaries (Colli et al., 2014; Blagov et al., 2007).

Cognitive therapists have tried to help people with this disorder to change their belief that they are helpless and also to develop better, more deliberate ways of thinking and solving problems (Weishaar & Beck, 2006; Beck et al., 2004). Psychodynamic therapy and various group therapy formats have also been used (Horowitz & Lerner, 2010). In all these approaches, therapists ultimately aim to help the clients recognize their excessive dependency, find inner satisfaction, and become more self-reliant. Clinical case reports suggest that each of the approaches can be useful. Drug therapy appears less successful except as a means of relieving the depressive symptoms that some patients have (Bock et al., 2010; Grossman, 2004).

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People with narcissistic personality disorder are generally grandiose, need much admiration, and feel no empathy with others (APA, 2013). Convinced of their own great success, power, or beauty, they expect constant attention and admiration from those around them. Frederick, the man whom we met at the beginning of this chapter, was one such person. So is Steven, a 30-year-old artist, married, with one child:

People with narcissistic personality disorder have a grandiose sense of self-importance. They exaggerate their achievements and talents, expecting others to recognize them as superior, and often appear arrogant. They are very choosy about their friends and associates, believing that their problems are unique and can be appreciated only by other “special,” high-status people. Because of their charm, they often make favorable first impressions, yet they can rarely maintain long-term relationships (Campbell & Miller, 2011).

Like Steven, people with narcissistic personality disorder are seldom interested in the feelings of others. They may not even be able to empathize with such feelings (Marcoux et al., 2014; Roepke & Vater, 2014). Many take advantage of other people to achieve their own ends, perhaps partly out of envy; at the same time they believe others envy them. Though grandiose, some react to criticism or frustration with bouts of rage, humiliation, or embitterment (APA, 2013). Others may react with cold indifference. And still others become extremely pessimistic and filled with depression. They may have periods of zest that alternate with periods of disappointment (Ronningstam, 2011).

As many as 6.2 percent of adults display narcissistic personality disorder, up to 75 percent of them men (APA, 2013; Sansone & Sansone, 2011). Narcissistic-type behaviors and thoughts are common and normal among teenagers and do not usually lead to adult narcissism (see MindTech on page 446).

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How Do Theorists Explain Narcissistic Personality Disorder? Psychodynamic theorists more than others have theorized about narcissistic personality disorder, and they again propose that the problem begins with cold, rejecting parents. They argue that some people with this background spend their lives defending against feeling unsatisfied, rejected, unworthy, ashamed, and wary of the world (Roepke & Vater, 2014; Bornstein, 2005). They do so by repeatedly telling themselves that they are actually perfect and desirable, and also by seeking admiration from others. Object relations theorists—the psychodynamic theorists who emphasize relationships—interpret the grandiose self-image as a way for these people to convince themselves that they are totally self-sufficient and without need of warm relationships with their parents or anyone else (Celani, 2014; Diamond & Meehan, 2013). In support of the psychodynamic theories, research has found that children who are abused or who lose parents through adoption, divorce, or death are at particular risk for the later development of narcissistic personality disorder (Kernberg, 2010, 1992, 1989). Studies also show that people with this disorder do indeed earn relatively high shame and rejection scores on various scales and believe that other people are basically unavailable to them (Ritter et al., 2014; Bender et al., 2001).

A number of cognitive-behavioral theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life. They hold that certain children acquire a superior and grandiose attitude when their “admiring or doting parents” teach them to “overvalue their self worth,” repeatedly rewarding them for minor accomplishments or for no accomplishment at all (Millon, 2011; Sperry, 2003).

Many sociocultural theorists see a link between narcissistic personality disorder and “eras of narcissism” in society (Paris, 2014). They suggest that family values and social ideals in certain societies periodically break down, producing generations of young people who are self-centered and materialistic and have short attention spans. Western cultures in particular, which encourage self-expression, individualism, and competitiveness, are considered likely to produce such generations of narcissism. In fact, one worldwide study conducted on the Internet found that respondents from the United States had the highest narcissism scores, followed, in descending order, by those from Europe, Canada, Asia, and the Middle East (Foster et al., 2003).

Treatments for Narcissistic Personality Disorder Narcissistic personality disorder is one of the most difficult personality patterns to treat because the clients are unable to acknowledge weaknesses, to appreciate the effect of their behavior on others, or to incorporate feedback from others (Campbell & Miller, 2011). The clients who consult therapists usually do so because of a related disorder such as depression (APA, 2013). Once in treatment, the clients may try to manipulate the therapist into supporting their sense of superiority. Some also seem to project their grandiose attitudes onto their therapists and develop a love-hate stance toward them (Colli et al., 2014; Shapiro, 2004).

Psychodynamic therapists seek to help people with this disorder recognize and work through their basic insecurities and defenses (Diamond & Meehan, 2013; Messer & Abbass, 2010). Cognitive therapists, focusing on the self-centered thinking of such individuals, try to redirect the clients’ focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize, and change their all-or-nothing notions (Beck & Weishaar, 2014; Beck et al., 2004). None of the approaches have had clear success, however (Paris, 2014).

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