APA Citation
Diamond, D., Levy, K., Clarkin, J., Fischer-Kern, M., Cain, N., Doering, S., Horz, S., & Buchheim, A. (2014). Attachment and mentalization in female patients with comorbid narcissistic and borderline personality disorder. *Personality Disorders: Theory, Research, and Treatment*, 5(4), 428-433. https://doi.org/10.1037/per0000065
Summary
This groundbreaking study examines the attachment patterns and mentalization abilities of women diagnosed with both narcissistic and borderline personality disorders. The research reveals how these individuals struggle with understanding their own and others' mental states, while maintaining insecure attachment patterns rooted in early childhood experiences. The study provides crucial insights into the overlapping features of these personality disorders and their impact on emotional regulation and relationship functioning.
Why This Matters for Survivors
For survivors of narcissistic abuse, this research validates the complexity of healing from relationships with individuals who may have both narcissistic and borderline traits. Understanding mentalization deficits helps explain why abusers struggle to empathize or recognize others' emotional needs, while also illuminating survivors' own attachment wounds that may need healing through recovery work.
What This Research Establishes
Comorbid narcissistic and borderline personality features frequently co-occur, particularly in women, creating complex clinical presentations that challenge traditional diagnostic boundaries and treatment approaches.
Mentalization deficits are central to both disorders, with affected individuals showing impaired ability to understand their own and others’ mental states, contributing to relationship dysfunction and emotional dysregulation.
Insecure attachment patterns underlie both conditions, reflecting early childhood experiences that disrupted the development of healthy emotional regulation and interpersonal functioning.
Treatment requires specialized approaches that address both the grandiose aspects of narcissism and the emotional instability characteristic of borderline personality disorder through mentalization-based interventions.
Why This Matters for Survivors
This research validates what many survivors intuitively understand: that narcissistic abusers often display unpredictable, emotionally volatile behavior alongside their grandiosity and lack of empathy. The combination of narcissistic and borderline traits explains why your abuser might have seemed to lack basic understanding of your emotional experience while simultaneously being extremely reactive to perceived slights or abandonment.
Understanding mentalization deficits helps explain why rational conversations felt impossible with your abuser. Their inability to truly comprehend mental states—both their own and yours—meant they couldn’t engage in genuine empathy or emotional reciprocity, leaving you feeling unheard and invalidated.
The attachment patterns revealed in this research shed light on why you may have felt trapped in cycles of idealization and devaluation. Abusers with these comorbid features often recreate chaotic attachment dynamics from their own childhood, pulling you into patterns of trauma bonding and emotional confusion.
For your own healing, recognizing these complex presentations can help you understand that the abuse wasn’t about your inadequacy but about your abuser’s fundamental difficulties with emotional regulation and interpersonal connection. This knowledge can be both validating and liberating as you work toward recovery.
Clinical Implications
Clinicians working with survivors must recognize that many narcissistic abusers present with complex, comorbid personality features that create particularly damaging relationship dynamics. Traditional approaches focusing solely on either narcissistic or borderline presentations may miss the nuanced ways these conditions intersect and amplify each other.
Assessment of abuse survivors should include exploration of their partners’ mentalization abilities and attachment patterns. Understanding whether an abuser demonstrated both grandiose narcissistic traits and borderline emotional volatility can inform treatment planning and help survivors make sense of their confusing experiences.
Mentalization-based therapy approaches show promise for both treating individuals with these comorbid features and helping survivors develop better emotional awareness and relationship skills. Focusing on the capacity to understand mental states can break cycles of dysfunction and promote healthier interpersonal patterns.
Therapeutic work with survivors must address the particular trauma of being in relationship with someone who fundamentally cannot mentalize effectively. This type of emotional neglect and invalidation requires specialized intervention focusing on rebuilding trust in one’s own perceptions and emotional experiences.
How This Research Is Used in the Book
Chapter 8 explores the complex psychological presentations often found in narcissistic abusers, drawing on Diamond and colleagues’ research to help survivors understand the full scope of personality dysfunction they may have encountered. The mentalization framework provides crucial insight into why communication felt impossible and empathy seemed absent.
“When we understand that many narcissistic abusers also struggle with borderline-like emotional dysregulation and profound mentalization deficits, the seemingly contradictory behaviors—grandiosity mixed with emotional volatility—begin to make sense. Your abuser’s inability to truly comprehend your inner world wasn’t willful cruelty, though the impact was equally devastating. This research validates that you were dealing with someone fundamentally unable to engage in genuine emotional reciprocity, helping explain why your attempts at communication felt like speaking different languages.”
Historical Context
This 2014 study emerged during a period of growing recognition that personality disorder categories often overlap significantly, particularly narcissistic and borderline presentations. The research contributed to evolving clinical understanding that moved beyond rigid diagnostic categories toward dimensional approaches recognizing the complexity of personality dysfunction and its impact on relationships.
Further Reading
• Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization-based treatment. Oxford University Press.
• Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Jason Aronson.
• Levy, K. N., Johnson, B. N., Clouthier, T. L., Scala, J. W., & Temes, C. M. (2015). An attachment theoretical framework for personality disorders. Canadian Psychology, 56(2), 197-207.
About the Author
Diana Diamond is a clinical psychologist and psychoanalyst specializing in personality disorders and attachment theory at the City University of New York. Her research focuses on mentalization-based treatments for complex personality presentations.
Kenneth N. Levy is Professor of Psychology at Penn State University, renowned for his work on personality disorders, attachment, and psychotherapy research. He has authored over 200 publications on borderline and narcissistic personality disorders.
John F. Clarkin is Professor Emeritus at Weill Cornell Medical College and a leading expert in personality disorder treatment, particularly dialectical behavior therapy and mentalization-based approaches.
Historical Context
Published during a pivotal period in personality disorder research, this 2014 study emerged as clinicians began recognizing the frequent co-occurrence of narcissistic and borderline features, challenging traditional diagnostic boundaries and treatment approaches.
Frequently Asked Questions
Mentalization is the ability to understand mental states—thoughts, feelings, and intentions—in yourself and others. Narcissistic abusers often have impaired mentalization, making them unable to truly empathize with their victims' experiences.
Yes, research shows significant overlap between narcissistic and borderline personality disorders, with many individuals exhibiting features of both conditions, particularly around attachment difficulties and emotional regulation.
Insecure attachment patterns, often rooted in childhood trauma, can contribute to both narcissistic behaviors in abusers and trauma bonding in survivors, creating cycles of dysfunction in relationships.
Developing mentalization skills helps survivors better understand their own emotions, recognize manipulation tactics, and build healthier relationship patterns by improving emotional awareness.
Women with both narcissistic and borderline traits often struggle with intense emotional dysregulation and unstable relationships, making them both perpetrators and victims of abuse cycles.
Mentalization-based therapy focuses on developing the capacity to understand mental states, improving emotional regulation, and building more secure attachment patterns through therapeutic relationships.
The combination of narcissistic and borderline features creates complex presentation patterns that require specialized therapeutic approaches addressing both attachment trauma and emotional regulation.
This research reveals that many abusers have complex psychological presentations involving both grandiosity and emotional instability, helping explain the unpredictable nature of narcissistic abuse.