Sexuality and attachment in patients with severe narcissistic personality disorders

This paper presents a model of severe narcissistic pathology that integrates contemporary object relations theory with attachment theory and research and the allied concept of mentalization. The focus is on the contribution of each theoretical perspective to understanding the difficulties in the sphere of sexuality and love relations that often bring these patients to treatment. The paper also discusses the oedipal configurations that characterize individuals with severe narcissistic disorders and how they stem in part from envy of an idealized parental couple leading to deficits in mentalization, or the capacity to take varied perspectives on the self in relation to others. The attachment classifications most frequently found in individuals with severe narcissistic disorders, including the dismissing, preoccupied and cannot classify categories are also reviewed as well as research which links these attachment classifications to aspects of sexual functioning. The paper then presents a brief overview of transference focused psychotherapy (TFP), a manualized psychoanalytic treatment designed for severe personality disorders, with a focus on the interpretive process in TFP and how it has been refined for treatment of individuals with severe narcissistic pathology. Case material is presented from a narcissistic personality disorder (NPD) patient in TFP with whose primary presenting problems were in the arena of sexuality and love relations. The ways in which conflicts around sexuality and love relations were lived out in the transference is delineated with a focus on the recapitulation and systematic interpretation first of devalued representations of others, and then of the idealized representations of self and others that comprise the compensatory grandiose self that defensively protects the individual from an underlying sense of vulnerability and imperfection.