Transference-focused psychotherapy for pathological narcissism in adolescents: a case report

This case report describes the treatment of an adolescent with pathological narcissism using transference-focused psychotherapy for adolescents (TFP-A). Sara, a 17-year-old girl, initially presented at age 14 with depressive symptoms, interpersonal difficulties, verbal outbursts, and impaired school functioning. Assessment using the Structured Interview of Personality Organization–Revised (STIPO-R) indicated pathological narcissism with a thick-skinned presentation at a middle borderline level of personality organization (middle BPO). Over 3 years of twice-weekly treatment, supplemented by periodic joint meetings with her parents, transference themes evolved from psychopathic and narcissistic to paranoid and subsequently depressive transference, with intermittent regressions. Reassessment with the STIPO-R indicated progression toward the border between high BPO and a neurotic level of personality organization, a range corresponding to higher level personality pathology. These findings suggest not only symptom improvement but also structural change in personality organization. Clinically, these changes manifested as greater stability in the sense of self and others, increased mentalization, reduced reliance on primitive defenses, and more reciprocal, emotionally meaningful relationships. School functioning also improved, alongside the emergence of a more integrated value system extending beyond immediate self-interest. This case highlights the potential of TFP-A to modify the pathological grandiose self in adolescents with narcissistic pathology.Footnote1