Psychiatry Research 257 (2017) 265–269

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Vulnerable narcissism is associated with severity of depressive symptoms in MARK

dysthymic patients
⁎
Leire Erkorekaa,b,c, , Bárbara Navarroa
a
Barakaldo Mental Health Center, Mental Health Network of Biscay, Barakaldo, Spain
b
Dept. Neurosciences, University of the Basque Country UPV/EHU, Leioa, Spain
c
BioCruces Health Research Institute, Barakaldo, Spain

A R T I C L E I N F O A B S T R A C T

Keywords: Pathological narcissism involves grandiose and vulnerable presentations. Narcissism, and specifically the vul-
Depression nerable presentation, has been associated to depression, although empirical research studying this relationship is
Dysthymia limited. Dysthymia is characterized by a greater treatment resistance and poorer prognosis than other chronic
Hypersensitive narcissism scale depressive disorders. The presence of dysfunctional personality traits may explain it. We aim to explore the
Vulnerable narcissism
association between vulnerable narcissistic traits and severity of depressive symptoms in a sample of dysthymic
Narcissistic personality
patients. To that end, 80 dysthymic outpatients were evaluated. The treating psychiatrist collected socio-
demographic and clinical data and completed the Clinical Global Impression-Severity Scale. Patients completed
the Beck Depression Inventory (BDI) and the Hypersensitive Narcissism Scale (HSNS), that respectively assess
severity of depressive symptoms and vulnerable narcissism. We tested for potential confounders and conducted a
regression analysis to explore whether severity of vulnerable narcissism was associated with greater depressive
symptoms. HSNS was found to be the principal predictor of BDI, and along with age, accounted for 23% of the
variance in BDI. An assessment of personality functioning is therefore recommended in chronically depressed
patients that have been refractory to standard treatments. Psychotherapies that address personality disturbance
should be included in the treatment when necessary.

1. Introduction been highlighted by several authors, since narcissistic patients are more
prompt to seek treatment when they are in a vulnerable self-state
Pathological narcissism involves a dysfunction in the ability to (Ellison et al., 2013; Kealy and Rasmussen, 2012; Pincus et al., 2014).
regulate self-esteem with an excessive need for validation, affirmation Moreover, vulnerable narcissitic traits have been identified across
and pursuit of self-enhancement experiences from the social environ- various personality disorders (Fossati, 2009). It has also been described
ment, and it is particularly troubling when the individual is faced with a strong correlation with neuroticism personality trait (Miller et al.,
disappointments and threats to his positive self-image (Pincus and 2017); which in turn has long been associated to and even proposed as
Lukowitsky, 2010). Currently it is broadly accepted that two major an endophenotype of depression (Goldstein and Klein, 2014).
phenotypic presentations exist: the grandiose form and the vulnerable The relationship between the vulnerable features of pathological
form. Grandiose narcissism is characterized by arrogance, extroversion, narcissism and depression has been addressed by many authors
envy and exploitativeness. This is the presentation best reflected by the (Kernberg, 1975; Kohut, 1971; Ronningstam, 2011; Rosenfeld, 1987).
DSM criteria of narcissistic personality disorder. Vulnerable narcissism, The few studies that have tried to empirically prove this relationship
by contrast, involves fragility, inhibition, introversion, feelings of in- have also associated the vulnerable form with depressive symptoms,
adequacy and avoidance of interpersonal relationships due to hy- both in general population as in psychiatric patients (Ellison et al.,
persensitivity to rejection and criticism, though these individuals also 2013; Huprich et al., 2012; Kealy et al., 2012; Marčinko et al., 2014;
express grandiosity through an overidentification with suffering (Levy, Tritt et al., 2010). These studies, nonetheless, have been conducted
2012; Pincus et al., 2014). Both forms entail significant entitlement and with healthy individuals or with heterogeneous psychiatric samples.
disagreeableness, as well as preoccupation with receiving attention and Based on this background, we have decided to focus the study on
admiration from others. dysthymic disorder (DD). DD is a form of chronic depression char-
The clinical importance of identifying vulnerable narcissism has acterized by depressive symptoms that are milder than those found in

⁎
Correspondence to: Centro de Salud Mental Barakaldo, La Felicidad 9, 48901 Barakaldo, Bizkaia, Spain.
E-mail address: leire.erkorekagonzalez@osakidetza.eus (L. Erkoreka).

http://dx.doi.org/10.1016/j.psychres.2017.07.061
Received 29 March 2017; Received in revised form 7 June 2017; Accepted 29 July 2017
Available online 30 July 2017
0165-1781/ © 2017 Elsevier B.V. All rights reserved.

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L. Erkoreka, B. Navarro Psychiatry Research 257 (2017) 265–269

major depressive disorder and that have been persistent for at least 2 Table 1
years. Although pharmacotherapy has been demonstrated effective Description of the sample (n = 80).
compared to placebo in the treatment of dysthymic patients (Cuijpers
Mean (SD)
et al., 2010; von Wolff et al., 2013), both the condition and the treat- Age 56.39 (10.46)
ment tend to be chronic and it has been associated with a poorer HSNS 32.55 (5.48)
prognosis than other depressive disorders (Rhebergen et al., 2010). BDI 31.01 (7.27)
Besides, DD is the only form of chronic depression in which psy- CGI-S 3.91 (.66)

chotherapy has not clearly proved to be effective (Jobst et al., 2016). n (%)
The presence of dysfunctional personality traits that are not ade- Gender (♀) 68 (85)
Level of education
quately addressed with the regular psychotherapeutic interventions,
Basic 46 (57.5)
such as cognitive-behavioral therapy and interpersonal therapy (Jobst High school 28 (35)
et al., 2016), could explain the poor prognosis and the lack of an ade- University degree 6 (7.5)
quate response to treatment observed in DD. Deficits in interpersonal Occupation
Employed (out of home) 19 (23.8)
behavior have been described by some authors (Constantino et al.,
Housewife 18 (22.5)
2008; McCullough, 2000), as well as a high comorbidity of DD with Unemployed 14 (17.5)
personality disorders (Rothschild and Zimmerman, 2002). We propose Sick leave 18 (22.5)
that vulnerable narcissistic traits may underlie this disorder and explain Pensioner 11 (13.8)
the difficulties to successfully treat it. Marital status
Single 11 (13.8)
Thus, the primary objective of this study is to explore the associa-
Married/Living together 39 (48.8)
tion between vulnerable narcissistic traits and severity of depressive Separated/Divorced 23 (28.8)
symptoms in a sample of dysthymic outpatients. To the best of our Widowed 7 (8.8)
knowledge, this is the first time that such an assessment is made using a Time of evolution
2–5 years 15 (18.8)
homogeneous sample of chronically depressed patients. To that end, we
6–10 years 29 (36.3)
evaluated vulnerable narcissistic traits using the Hypersensitive > 10 years 36 (45.0)
Narcissism Scale (HSNS) and severity of depressive symptoms using the Onset attributed to external stressors (yes) 73 (91.3)
Beck Depression Inventory (BDI). Sociodemographic and clinical char- Current antidepressant treatment (yes) 73 (91.3)
acteristics were collected to explore their influence on that association. Medical comorbidity (yes) 71 (88.8)
Pain disorder associated with a general medical condition (yes) 53 (66.3)
As a secondary aim, the treating psychiatrist completed the Clinical
Global Impression-Severity Scale (CGI-S) to explore the concordance n: number of individuals; SD: standard deviation.
between severity of symptoms as reported by the patients and by the
clinician. 2.2.2. Beck Depression Inventory (BDI) (Beck et al., 1961)
It is a self-reported survey of 21 items, each scored on a 3-point
2. Methods Likert scale, to measure severity of depression. It assesses depressive,
cognitive and somatic symptoms, based on Beck's cognitive theory of
2.1. Participants and procedures depression. Alpha reliabilities of the Spanish BDI range from .83 to .90
(Conde and Useros, 1975; Vázquez and Sanz, 1999).
The sample comprises 80 outpatients diagnosed of dysthymia ac-
cording to ICD-10 F34.1 criteria, obtaining psychiatric treatment at a
community mental health center (Barakaldo Mental Health Center, 2.2.3. Clinical Global Impression (Guy, 1976)
Barakaldo, Spain). Inclusion criteria was the presence of a chronic de- It is a clinician rated scale, comprised of two ordinal subscales de-
pressed mood, for most of the day and for more days than not, lasting at signated as “Severity of Illness” (GGI-S) and “Global Improvement”. We
least 2 years, in which individual episodes had not been sufficiently used the CGI-S subscale, which is a single-item instrument that evalu-
severe or prolonged to justify a diagnosis of recurrent depressive dis- ates the severity of the patient's illness from 1 “normal” to 7 “extremely
order. Those patients with current or past comorbid diagnosis of psy- ill”, according to the clinician's experience. Good concurrent validity
chotic disorder, manic/hypomanic episode, intellectual disability, any and sensitivity to change have been reported for anxiety and depressive
neurological disease, current drug dependence or a primary diagnosis disorders (Leon et al., 1993).
of a personality disorder were excluded from the study.
Participants were informed about the ongoing research during 2.3. Statistical analysis
regular follow-up visits. After providing informed consent they were
included in the study. The treating psychiatrist collected socio- We made a descriptive analysis of the sample using the socio-
demographic and clinical variables (Table 1) and completed the CGI-S. demographic and clinical variables, and tested for potential con-
Patients completed the HSNS and the BDI. All study procedures were founders. Differences in the scores of both HSNS and BDI among the
carried out in accordance with the Declaration of Helsinki. different categories of all of these variables were explored; we con-
ducted ANOVA and t-test to compare means, and Pearson's correlation
2.2. Measures for age. The weighted mean difference was calculated for the HSNS
average scores obtained by Hendin and Cheek's samples (Hendin and
2.2.1. Hypersensitive Narcissism Scale (HSNS) (Hendin and Cheek, 1997) Cheek, 1997), and compared to our sample's average score using t-test.
It is a unidimensional measure designed to assess vulnerable nar- A regression analysis was then conducted introducing HSNS as in-
cissism. It consists of 10 self-reported items, each scored on a 5-point dependent variable, BDI as dependent variable, age as moderator, and
Likert scale, that are summed up to obtain the total score. It was derived controlling for gender. HSNS and age were mean centered prior to
by correlating the items of Murray's (1938) Narcism Scale with an analysis. Spearman's Rho coefficient was calculated to check the asso-
MMPI-based composite measure of hypersensitive narcissism. Some ciation between CGI, as an ordinal variable, and HSNS and BDI, as
authors have reported that it captures two dissociable albeit correlated continuous variables. Finally, a linear regression analysis was con-
facets of vulnerable narcissism: “oversensitivity to judgment” and ducted introducing HSNS as independent variable, CGI as dependent
“egocentrism” (Fossati et al., 2009). The Spanish HSNS showed an variable and controlling for BDI. Statistical analysis was performed
alpha reliability of .73 (Ripoll et al., 2010). using IBM SPSS Statistics 20.0 and PROCESS procedure for SPSS

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Table 2 different studies, and evidences the complexity of this phenomenon.

Results from a regression analysis estimating the effect of HSNS score in severity of de- Nonetheless, all the published investigations have obtained similar re-
pression according to BDI score, examining the moderation by age, and controlling for
sults in terms of an existing relationship between depression and vul-
gender (n = 80).
nerable narcissism.
Coeff. SE t p The subjective experience of suffering reported by the patients
through the BDI, showed a good concordance with the clinical im-
Constant 30.117 2.062 14.601 .000
pression of the clinician, although they differ in the severity. Patients
HSNSa .469 .137 3.409 .001
Agea − .185 .075 − 2.463 .016 describe their symptoms as more severe than the clinician does, but it
HSNS × Age interactb .009 .014 .660 .510 can be explained by the fact that the study setting was a community
Gender 1.211 2.192 .552 .582 mental health center, with a high proportion of patients suffering from
R2 = .243, MSE = 42.151 severe and persistent mental illness, that usually get the highest scores.
F(4, 75) = 6.035, p < .001
As mentioned in the introduction, clinical theorists in the psycho-
BDI: Beck Depression Inventory; HSNS: Hypersensitive Narcissism Scale. dynamic tradition have addressed the association between the vulner-
n = number of individuals; Coeff.: non-standardized regression coefficient. able features of pathological narcissism and depression. Ronningstam
SE: Standard Error; MSE: mean squared error. (2011) states that low self-esteem and feelings of inferiority, combined
a
Mean centered prior to analysis. with grandiose fantasies and proneness to shame and envy, make these
b
R2 increase due to interaction = .004.
individuals specifically susceptible to depression. Kernberg (2009) de-
scribes the treatment-refractory chronic depression as a typical pre-
Release 2.16.1. Weighted mean difference was calculated using fish sentation of some narcissistic patients, and explains it both as a mani-
methods package for R. Raw data are available at Mendeley Data festation of pervasive arrogance and as a failure to accomplish
(Erkoreka and Navarro, 2017). grandiose expectations (Yeomans et al., 2015). The narcissistic-ma-
sochistic character described by Cooper, that includes the conviction of
3. Results one's special plight in life and satisfaction accompanying the feeling
that no one suffers as much as oneself, also links pathological narcis-
Description of the sample, including average scores of the scales and sistic features with depression (Cooper, 1989). These approaches give a
the sociodemographic and clinical variables, is shown in Table 1. The theoretical framework to the relationships found in the different em-
average score of the BDI fell within the range of “severe depression”. pirical works, including ours.
Most patients were considered “mildly ill” or “moderately ill” according A deep sense of dissatisfaction associated to narcissistic issues such
to the CGI-S. In relation to the HSNS score, no cut-offs have been de- as holding unattainable grandiose fantasies or experiencing frequent
fined, but the score obtained by our sample was significantly higher shame, envy, or emptiness, and not a primary depressive disorder,
than that reported by Hendin and Cheek (n = 403, mean [SD] = would better explain the depressive symptoms in these individuals. It
29.288 [5.412], t = 5.329, p = .000) (Hendin and Cheek, 1997). must also be noted that we found no significant differences in the BDI
A significant negative correlation between age and HSNS score (r = scores according to the level of education, the occupation, the marital
− .250, p = .025), and between age and BDI score (r = − .345, p = status and the presence of medical comorbidities (not even a comorbid
.002) was observed. No significant differences were found in the scores pain disorder); only vulnerable narcissistic features and age explained
of HSNS and BDI among the different categories of the rest of socio- the severity of depressive symptoms. Although we hypothesized that
demographic and clinical variables (supplementary Table 1). vulnerable narcissism would be the principal predictor of depression,
Regression analysis (Table 2) revealed that HSNS was significantly we expected that such sociodemographic variables and the presence of
associated with BDI score, and along with age, accounted for 23% of the comorbidities would to some extent influence that association. The lack
variance in BDI. There was no evidence of an interaction of age on the of relationship reinforces the hypothesis that personality dysfunction is
relationship between HSNS and BDI scores. A significant positive cor- the variable that best explains the severity of depression in DD.
relation was observed both between HSNS and CGI (rho = .344 p = We have also found that in our sample aging is linked to lower scores
.002) and between BDI and CGI (rho = .384 p = .000). Even after in both BDI and HSNS. Paradoxically, aging has been associated with
controlling for BDI score, the relationship between HSNS and CGI exacerbation of previous personality traits, and specifically with a greater
showed a strong trend toward significance (Coeff. [SE] = .026 [.013], t narcissistic suffering and midlife decline in functioning (Kernberg, 2009),
= 1.950, p = .055). although not with greater depressive symptoms, which prevalence re-
mains similar across the life cycle (Hales et al., 2009). We have observed
4. Discussion that in our sample there is a relationship between the time of evolution
and age; those with a longer time of evolution are also significantly older.
4.1. Association between vulnerable narcissism and depressive symptoms in Chronicity and the relative mildness of the depressive symptoms present in
DD DD may help patients to adapt themselves and could explain the lower
scores in BDI. Regarding the milder vulnerable narcissistic traits, replica-
These results provide further support for an association between DD tion studies are needed to confirm whether this finding is exclusive to our
and dysfunctional personality traits. Our findings confirm the re- sample or a generalisable fact. Nonetheless, we think that the narcissistic
lationship between vulnerable narcissism and the severity of depressive suffering that has been described associated to aging might be more re-
symptoms, and are coherent with the results obtained by other authors. lated to individuals with a grandiose functioning, whose defenses break
Narcissistic vulnerability has been associated with depressive tem- down when faced with their physical decline. Those with predominantly
perament in a sample of university students (Tritt et al., 2010), with vulnerable manifestations have always exhibited a less defensive func-
depressive tendencies concerning self-criticism in a heterogeneous tioning and a more evident fragility, and it could partly explain our
sample of psychiatric outpatients (Kealy et al., 2012), and with de- findings. Also, our sample is slightly older than that described by Kernberg
pressive symptoms in other samples of heterogeneous psychiatric out- as the usual age of narcissistic collapse, around the mid-forties.
patients (Ellison et al., 2013; Marčinko et al., 2014). Narcissistic vul-
nerability was also found to significantly correlate with a depressive 4.2. Clinical implications
personality disorder measure in both clinical and non-clinical samples
(Huprich et al., 2012). The heterogeneity of terminology used to refer These results are clinically relevant, since they support the im-
to depression makes it difficult to directly compare the results of the portance of assessing personality functioning in dysthymic patients that

267

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L. Erkoreka, B. Navarro Psychiatry Research 257 (2017) 265–269

have been refractory to standard treatments, in order to differentiate 4.4. Conclusions

primary depressive disorders from characterological depression. Some
authors point out the presence of biological symptoms of depression Vulnerable narcissistic traits are associated with the severity of
(eating and sleeping patterns, weight, sexual desire) as crucial to dif- depressive symptoms in DD. Besides, there is a strong correlation be-
ferentiate a primary depressive disorder from a characterological de- tween the intensity of depression reported by the patients and that
pression (Yeomans et al., 2015). It is important to make such a dis- observed by the clinician. Based on our results, a careful assessment of
tinction because characterological depression requires a different personality functioning is recommended in treatment-refractory dys-
treatment strategy. thymic patients. When necessary, psychotherapies that specifically ad-
One major problem in making a correct assessment of pathological dress personality disturbance should be included in the treatment.
narcissism is the absence of the vulnerable features in the DSM diag-
nostic criteria of narcissistic personality disorder. The fact that treat- Acknowledgements
ment seeking is usually triggered by other symptoms (Ellison et al.,
2013), along with a lack of recognition of these traits, may lead to This research did not receive any specific grant from funding
underdiagnosis and consequent undertreatment of patients with pre- agencies in the public, commercial, or not-for-profit sectors.
dominantly vulnerable traits. The authors wish to thank Dr. Ioseba Iraurgi for his assistance with
Our results suggest that dysthymic patients present dysfunctional the statistical analysis, and Iker Zamalloa for the review of the manu-
personality traits that can justify the lack of an adequate response to script.
standard psychotherapies for depressive disorders, and support the re-
commendation of including psychotherapies that address personality Appendix A. Supporting information
disturbance in their treatment. Although evidence about treatments for
pathological narcissism is limited, psychotherapeutic approaches that Supplementary data associated with this article can be found in the
have demonstrated efficacy in borderline personality disorder, such as online version at http://dx.doi.org/10.1016/j.psychres.2017.07.061.
mentalization based therapy (Rossouw, 2015) and dialectical beha-
vioral therapy (Campbell and Miller, 2011) are being used for narcis- References
sistic personality. Furthermore, a specific adaptation of transference
focused psychotherapy for narcissistic personality disorder has been Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for
developed (Stern et al., 2013). Including elements of these interven- measuring depression. Arch. Gen. Psychiatry 4, 561–571.
Campbell, W. Keith, Miller, Joshua D. 2011. Treatment of narcissistic personality disorder
tions in the treatment of dysthymic patients with pathological narcis- symptoms in a dialectical behavior therapy framework. In: The Handbook of
sistic traits may lead to their clinical improvement. Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical
On its part, cognitive-behavioral analysis system of psychotherapy is Findings, and Treatments. John Wiley and Sons Ltd, New York, p. 528.
Conde, V., Useros, E., 1975. Adaptacion castellana de la escala de evaluacion conductual
a psychotherapeutic method specifically developed to treat early-onset para la depresion de Beck. Rev. Psiquiatr. Psicol. Med. Eur. Am. 12, 217–236.
chronic depression. It is based on the assumption that early inter- Constantino, M.J., Manber, R., Degeorge, J., McBride, C., Ravitz, P., Zuroff, D.C., Klein,
personal trauma has led to dysfunctional mechanisms of self-regulation, D.N., Markowitz, J.C., Rothbaum, B.O., Thase, M.E., Arnow, B.A., 2008.
Interpersonal styles of chronically depressed outpatients: profiles and therapeutic
and the interventions are focused on the interpersonal outcome. change. Psychotherapy 45, 491–506. http://dx.doi.org/10.1037/a0014335.
Although it does not address narcissistic issues specifically, to the extent Cooper, A.M., 1989. Narcissism and masochism. The narcissistic-masochistic character.
that it assumes the presence of intra- and interpersonal dysfunction, it Psychiatr. Clin. N. Am. 12, 541–542.
Cuijpers, P., van Straten, A., Schuurmans, J., van Oppen, P., Hollon, S.D., Andersson, G.,
might be a useful psychotherapeutic approach for dysthymic patients
2010. Psychotherapy for chronic major depression and dysthymia: a meta-analysis.
with vulnerable narcissistic features. Clin. Psychol. Rev. 30, 51–62. http://dx.doi.org/10.1016/j.cpr.2009.09.003.
Ellison, W.D., Levy, K.N., Cain, N.M., Ansell, E.B., Pincus, A.L., 2013. The impact of
pathological narcissism on psychotherapy utilization, initial symptom severity, and
early-treatment symptom change: a naturalistic investigation. J. Personal. Assess. 95,
4.3. Limitations and recommendations for further research 291–300. http://dx.doi.org/10.1080/00223891.2012.742904.
Erkoreka, L., Navarro, B., 2017. Dysthymia and Vulnerable Narcissism. Mendeley Data,
The study is limited by the use of self-reports, that may introduce V1. 〈http://dx.doi.org/10.17632/hr444mhf4m.1〉.
Fossati, A., Borroni, S., Grazioli, F., Dornetti, L., Marcassoli, I., Maffei, C., Cheek, J., 2009.
mono-method bias, a type of bias that overestimates the association Tracking the hypersensitive dimension in narcissism: reliability and validity of the
between constructs measured with the same method and informant. Hypersensitive Narcissism Scale. Pers. Ment. Health 3, 235–247. http://dx.doi.org/
Besides, the diagnosis of DD was established by a single clinician, fol- 10.1002/pmh.92.
Goldstein, B.L., Klein, D.N., 2014. A review of selected candidate endophenotypes for
lowing the ICD-10 criteria, and it was not independently corroborated depression. Clin. Psychol. Rev. 34, 417–427. http://dx.doi.org/10.1016/j.cpr.2014.
nor confirmed with the assistance of standardized assessments. 06.003.
Replication in other homogeneous samples of chronically depressed Guy, W., 1976. Early Clinical Drug Evaluation (ECDEU) Assessment Manual. National
Institute Mental Health, Rockville.
patients is also needed to confirm the findings. Finally, it is a cross- Hales, R.E., Yudofsky, S.C., Gabbard, G.O., 2009. Tratado de Psiquiatria Clinica, 5th ed.
sectional study, so only association can be demonstrated. Longitudinal Elsevier-Masson, Barcelona.
studies are needed to explore whether vulnerable narcissistic traits Hendin, H.M., Cheek, J.M., 1997. Assessing hypersensitive narcissism: a reexamination of
Murray's Narcism Scale. J. Res. Personal. 31, 588–599. http://dx.doi.org/10.1006/
really precede and serve as risk factors for DD.
jrpe.1997.2204.
It must be noted that comorbidity between DD and axis II disorders Huprich, S., Luchner, A., Roberts, C., Pouliot, G., 2012. Understanding the association
has already been described (Rothschild and Zimmerman, 2002), but between depressive personality and hypersensitive (vulnerable) narcissism: some
beyond comorbidity, we propose that in some cases chronic depressive preliminary findings: depressive personality and hypersensitive narcissism. Pers.
Ment. Health 6, 50–60. http://dx.doi.org/10.1002/pmh.176.
symptoms might be the symptomatic expression of an axis II disorder. Jobst, A., Brakemeier, E.-L., Buchheim, A., Caspar, F., Cuijpers, P., Ebmeier, K.P., Falkai,
In this respect, similarities and clinical overlap between DD and the P., Jan van der Gaag, R., Gaebel, W., Herpertz, S., Kurimay, T., Sabaß, L., Schnell, K.,
former diagnosis of depressive personality disorder have largely been Schramm, E., Torrent, C., Wasserman, D., Wiersma, J., Padberg, F., 2016. European
psychiatric association guidance on psychotherapy in chronic depression across
described. In addition, depressive personality disorder has also been Europe. Eur. Psychiatry J. Assoc. Eur. Psychiatr. 33, 18–36. http://dx.doi.org/10.
reported to be significantly associated with vulnerable narcissistic traits 1016/j.eurpsy.2015.12.003.
(Huprich et al., 2012). Therefore, discussion on this issue is not new, Kealy, D., Rasmussen, B., 2012. Veiled and vulnerable: the other side of grandiose nar-
cissism. Clin. Soc. Work J. 40, 356–365. http://dx.doi.org/10.1007/s10615-011-
but we consider that in the light of the recent evidence, further in- 0370-1.
vestigation is still needed to identify different phenotypes within DD, Kealy, D., Tsai, M., Ogrodniczuk, J.S., 2012. Depressive tendencies and pathological
and accordingly define the best therapeutic strategy to follow in each narcissism among psychiatric outpatients. Psychiatry Res. 196, 157–159. http://dx.
doi.org/10.1016/j.psychres.2011.08.023.
case.

268

Descargado para Anonymous User (n/a) en Hospital de la Paz de ClinicalKey.es por Elsevier en septiembre 06, 2018.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.
L. Erkoreka, B. Navarro Psychiatry Research 257 (2017) 265–269

Kernberg, O.F., 1975. Borderline Conditions and Pathological Narcissism. Jason Aronson, in major depression, dysthymic disorder and double depression: a 3-year follow-up. J.
New York. Affect. Disord. 124, 148–156. http://dx.doi.org/10.1016/j.jad.2009.10.029.
Kernberg, O.F., 2009. Narcissistic personality disorders: Part 1. Psychiatr. Ann. 39, Ripoll, C., Salazar, J., Bobes, J., 2010. Validity of the Spanish version of the
105–167. http://dx.doi.org/10.3928/00485713-20090301-04. Hypersensitive Narcissism Scale (HSNS) in subjects attended at an Addiction
Kohut, H., 1971. The Analysis of the Self. A Systematic Approach to the Psychoanalytic Treatment Unit. Adicciones 22, 29–36.
Treatment of Narcissistic Personality Disorders. International University Press, New Ronningstam, E., 2011. Narcissistic personality disorder: a clinical perspective. J.
York. Psychiatr. Pract. 17, 89–99. http://dx.doi.org/10.1097/01.pra.0000396060.
Leon, A.C., Shear, M.K., Klerman, G.L., Portera, L., Rosenbaum, J.F., Goldenberg, I., 1993. 67150.40.
A comparison of symptom determinants of patient and clinician global ratings in Rosenfeld, H., 1987. Impasse and Interpretation. Tavistock, New York and London.
patients with panic disorder and depression. J. Clin. Psychopharmacol. 13, 327–331. Rossouw, T.I., 2015. The use of mentalization-based treatment for adolescents (MBT-A)
Levy, K.N., 2012. Subtypes, dimensions, levels, and mental states in narcissism and with a young woman with mixed personality disorder and tendencies to self-harm. J.
narcissistic personality disorder. J. Clin. Psychol. 68, 886–897. http://dx.doi.org/10. Clin. Psychol. 71, 178–187. http://dx.doi.org/10.1002/jclp.22153.
1002/jclp.21893. Rothschild, L., Zimmerman, M., 2002. Personality disorders and the duration of depres-
Marčinko, D., Jakšić, N., Ivezić, E., Skočić, M., Surányi, Z., Lončar, M., Franić, T., sive episode: a retrospective study. J. Personal. Disord. 16, 293–303.
Jakovljević, M., 2014. Pathological narcissism and depressive symptoms in psy- Stern, B., Yeomans, F., Diamond, D., Kernberg, O., 2013. Transference-focused psy-
chiatric outpatients: mediating role of dysfunctional attitudes. J. Clin. Psychol. 70, chotherapy for narcissistic personality disorder. In: Treating Pathological Narcissism.
341–352. http://dx.doi.org/10.1002/jclp.22033. American Psychological Association, Washington DC.
McCullough, J., 2000. Treatment for Chronic Depression: Cognitive Behavioral Analysis Tritt, S.M., Ryder, A.G., Ring, A.J., Pincus, A.L., 2010. Pathological narcissism and the
System of Psychotherapy. Guilford Press, New York. depressive temperament. J. Affect. Disord. 122, 280–284. http://dx.doi.org/10.
Miller, J.D., Lynam, D.R., Vize, C., Crowe, M., Sleep, C., Maples-Keller, J.L., Few, L.R., 1016/j.jad.2009.09.006.
Campbell, W.K., 2017. Vulnerable narcissism is (mostly) a disorder of neuroticism. J. Vázquez, C., Sanz, J., 1999. Fiabilidad y validez de la versión española del Inventario para
Pers. http://dx.doi.org/10.1111/jopy.12303. la Depresión de Beck de 1978 en pacientes con trastornos psicológicos. Clín. Salud 10,
Pincus, A.L., Lukowitsky, M.R., 2010. Pathological narcissism and narcissistic personality 59–81.
disorder. Annu. Rev. Clin. Psychol. 6, 421–446. http://dx.doi.org/10.1146/annurev. von Wolff, A., Hölzel, L.P., Westphal, A., Härter, M., Kriston, L., 2013. Selective serotonin
clinpsy.121208.131215. reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic
Pincus, A.L., Cain, N.M., Wright, A.G.C., 2014. Narcissistic grandiosity and narcissistic depression and dysthymia: a systematic review and meta-analysis. J. Affect. Disord.
vulnerability in psychotherapy. Personal. Disord. 5, 439–443. http://dx.doi.org/10. 144, 7–15. http://dx.doi.org/10.1016/j.jad.2012.06.007.
1037/per0000031. Yeomans, F.E., Clarkin, J.F., Kernberg, O.F., 2015. Transference-Focused Psychotherapy
Rhebergen, D., Beekman, A.T.F., de Graaf, R., Nolen, W.A., Spijker, J., Hoogendijk, W.J., for Borderline Personality Disorder. A Clinical Guide, 1st ed. American Psychiatric
Penninx, B.W.J.H., 2010. Trajectories of recovery of social and physical functioning Publishing, Arlington, VA.

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