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Kernberg, O.F. (2007). The Almost Untreatable Narcissistic Patient. J. Amer. Psychoanal. Assn., 55(2):503-539.

(2007). Journal of the American Psychoanalytic Association, 55(2):503-539

Clinical Topics: Original Papers

The Almost Untreatable Narcissistic Patient

Otto F. Kernberg

Clinical experience in the Personality Disorders Institute at Weill Cornell Medical College suggests that patients with borderline personality organization and a narcissistic personality disorder have a more serious prognosis than all other personality disorders functioning at the borderline level, and that those who in addition present significant antisocial behavior have an even worse prognosis (Clarkin, Yeomans, and Kernberg 1999; Stone 1990). This negative trend culminates in a group of practically untreatable patients with antisocial personality disorder, who represent the most severe cases of pathological narcissism. There are also patients with severe narcissistic personality disorder, functioning at an overt borderline level with significant antisocial features, but not presenting an antisocial personality disorder proper, who at times respond to treatment, while others do not. These patients are explored here, with a focus on particular psychotherapeutic techniques that have proven helpful, as well as on the limits of these technical approaches.

In order to keep this introductory section reasonably short, a certain categorical style is almost unavoidable. But because this section provides the organizing frame for what follows, I beg the reader's indulgence. The narcissistic personality disorder presents, clinically, at three levels of severity. The mildest cases, who appear “neurotic,” usually present indications for psychoanalysis. They typically consult only because of a significant symptom, one that seems so linked to their character pathology that anything but the treatment of their


Director, Personality Disorders Institute, New York Presbyterian Hospital, West-chester Division; Professor of Psychiatry, Weill Cornell Medical College; Training and Supervising Analyst, Columbia University Center for Psychoanalytic Training and Research.

The work reported in this paper was supported by the Borderline Personality Disorders Research Foundation and its founder, Dr. Marco Stoffel, to whom the author wishes to express his profound gratitude. Submitted for publication October 12, 2004.

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