Day Nicholas J S, Biberdzic Marko, Green Ava, Denmeade Georgia, Bach Bo, Grenyer Brin F S
School of Psychology, University of Wollongong, Wollongong, Australia.
Department of Psychology, Bishop's University, Sherbrooke, Canada.
Clin Psychol Psychother. 2025 Mar-Apr;32(2):e70070. doi: 10.1002/cpp.70070.
Narcissistic personality disorder (NPD) is known to comprise two distinct but connected phenotypes related to 'grandiosity' and 'vulnerability', respectively. While evidence suggests differing countertransference responses to narcissism subtype expression, no study has examined this using a qualitative methodology and explored associations with ratings of personality disorder severity.
Mental health clinicians (N = 180, 67% female, age = 38.9), completed qualitative clinical reflections and ratings of overall personality disorder severity towards two hypothetical vignettes displaying pathological narcissism ('grandiose' and 'vulnerable' narcissism respectively), as well as a rating of attitudes towards patients in their routine practice who resemble these vignettes.
Distinct qualitative themes were identified between narcissistic subtype, with grandiose narcissism evoking anger, lack of empathy and hopelessness, compared to sympathy, sadness and discomfort in vulnerable narcissism. In terms of diagnostic category, the grandiose vignette was predominately identified as 'narcissistic personality disorder' (97%), whereas the vulnerable vignette was a mixture of 'depressive disorder' (29%), 'narcissistic personality disorder' (24%), 'trauma and stressor related disorders' (21%) and 'borderline personality disorder' (21%). Attitude scores differed significantly between subtypes, with more negative attitudes towards narcissistic grandiosity than narcissistic vulnerability. The grandiose vignette was also rated as displaying more overall personality impairment, with an association observed between negative clinician attitude scores and increased ratings of personality disorder severity.
Two potential pathways are outlined to interpret these findings. The first is that inordinate stigma towards narcissistic grandiosity negatively biases clinicians when working with these patients due to feelings of anger and frustration. The second is that clinicians are drawn to minimise pathology of vulnerable patients due to their feelings of sadness and empathy. We propose that effective diagnosis and psychotherapy for pathological narcissism rely on clinicians' ability to balance these two dilemmas and resist either extreme.
已知自恋型人格障碍（NPD）包含两种不同但相互关联的表型，分别与“夸大”和“脆弱”相关。虽然有证据表明对自恋亚型表达存在不同的反移情反应，但尚无研究采用定性方法对此进行检验并探讨其与人格障碍严重程度评分的关联。
心理健康临床医生（N = 180，67%为女性，年龄 = 38.9岁）完成了定性临床反思，并对两个展示病理性自恋（分别为“夸大”自恋和“脆弱”自恋）的假设性病例进行了总体人格障碍严重程度评分，以及对日常工作中类似这些病例的患者的态度评分。
在自恋亚型之间识别出了不同的定性主题，与脆弱自恋引发的同情、悲伤和不适相比，夸大自恋引发愤怒、缺乏同理心和绝望。在诊断类别方面，夸大病例主要被诊断为“自恋型人格障碍”（97%），而脆弱病例则是“抑郁症”（29%）、“自恋型人格障碍”（24%）、“创伤及应激源相关障碍”（21%）和“边缘型人格障碍”（21%）的混合。亚型之间态度得分存在显著差异，对自恋夸大的负面态度多于自恋脆弱。夸大病例在总体人格损害方面的评分也更高，临床医生的负面态度得分与人格障碍严重程度评分增加之间存在关联。
概述了解释这些发现的两条潜在途径。第一条是，由于愤怒和沮丧情绪，对自恋夸大的过度污名化会使临床医生在治疗这些患者时产生负面偏见。第二条是，由于悲伤和同理心，临床医生倾向于尽量减少对脆弱患者的病态化。我们认为，病理性自恋的有效诊断和心理治疗依赖于临床医生平衡这两种困境并抵制极端情况的能力。
