Treatment of narcissistic personality disorder
- Eve Caligor, MD
Eve Caligor, MD
- Clinical Professor of Psychiatry
- Columbia University College of Physicians and Surgeons
- Mark J Petrini, MD
Mark J Petrini, MD
- Assistant Clinical Professor of Medicine and Psychiatry
- Columbia University Medical Center
Narcissistic personality disorder (NPD) is characterized by grandiosity, which may be overt or covert, an urgent need for attention and praise, superficial interpersonal relationships, and a lack of empathy .
One of the least studied personality disorders, NPD appears to be prevalent, highly comorbid with other psychiatric disorders, and associated with significant impairment and psychosocial disability. NPD presents several challenges to clinicians. It has a variable presentation. There is disagreement over how to define the boundaries of the disorder, leading to lack of clarity with regard to its diagnostic criteria, epidemiology, and course. NPD is difficult to treat and complicates the treatment of commonly co-occurring disorders.
The treatment of NPD is described here. The epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis of narcissistic personality disorder are described separately. The epidemiology, clinical manifestation, assessment, diagnosis, and treatment of other personality disorders are also described separately. (See "Narcissistic personality disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Overview of personality disorders" and "Borderline personality disorder: Epidemiology, clinical features, course, assessment, and diagnosis" and "Treatment of borderline personality disorder" and "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis" and "Treatment of antisocial personality disorder".)
APPROACH TO TREATMENT
Psychotherapies and medication treatments for narcissistic personality disorder (NPD) are still in early stages of development and testing, with a lack of clinical practice guidelines with specific treatment recommendations . Based on anecdotal reports, psychotherapeutic approaches and medications used in practice appear to vary widely.
For patients with NPD, we suggest first-line treatment with psychotherapy rather than medication. Research data are not adequate to inform selection of a particular type of psychotherapy. In our clinical experience, a psychotherapeutic approach based on the objectives and techniques of supportive psychotherapy and applied to the needs of NPD patients may be most helpful.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Caligor E, Levy KN, Yeomans FE. Narcissistic personality disorder: diagnostic and clinical challenges. Am J Psychiatry 2015; 172:415.
- Levy KN, Chauhan P, Clarkin JF, et al. Narcissistic pathology: empirical approaches. Psychiatr Ann 2009; 39:203.
- Nosè M, Cipriani A, Biancosino B, et al. Efficacy of pharmacotherapy against core traits of borderline personality disorder: meta-analysis of randomized controlled trials. Int Clin Psychopharmacol 2006; 21:345.
- Ingenhoven T, Lafay P, Rinne T, et al. Effectiveness of pharmacotherapy for severe personality disorders: meta-analyses of randomized controlled trials. J Clin Psychiatry 2010; 71:14.
- Lieb K, Völlm B, Rücker G, et al. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry 2010; 196:4.
- Gunderson JG, Links PS. Handbook of Good Psychiatric Management, 1st ed, American Psychiatric Publishing, Washington DC 2014. p.70.
- Lequesne ER, Hersh RG. Disclosure of a diagnosis of borderline personality disorder. J Psychiatr Pract 2004; 10:170.
- Paris J. Why Psychiatrists are Reluctant to Diagnose: Borderline Personality Disorder. Psychiatry (Edgmont) 2007; 4:35.
- Ronningstam E. Narcissistic personality disorder: a clinical perspective. J Psychiatr Pract 2011; 17:89.
- Pincus AL, Cain NM, Wright AG. Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personal Disord 2014; 5:439.
- Kernberg OF. The almost untreatable narcissistic patient. J Am Psychoanal Assoc 2007; 55:503.
- Winston A, Rosenthal R, Pinsker H. Supportive Psychotherapy, American Psychiatric Publishing, Washington DC 2012.
- Bateman AW, Fonagy P. Mentalization-based treatment for borderline personality disorder: a practical guide, Oxford University Press, Oxford 2006.
- Diamond D, Yeomans FE, Levy KN. Psychodynamic psychotherapy for narcissistic personality. In: The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments, 1st ed, Campbell WK, Miller JD (Eds), Wiley, Hoboken 2011. p.423.
- Kernberg OF. An overview of the treatment of severe narcissistic pathology. Int J Psychoanal 2014; 95:865.
- Young JE. Cognitive therapy for personality disorders: A schema-focused approach, 3rd ed, Professional Resource, Sarasota 1999.
- Diamond D, Levy KN, Clarkin JF, et al. Attachment and mentalization in female patients with comorbid narcissistic and borderline personality disorder. Personal Disord 2014; 5:428.
- Yeomans FE, Clarkin, JF, Kernberg OF. Transference focused psychotherapy for borderline personality disorder. A clinical guide, 2nd ed, American Psychiatric Association, Washington DC 2015.
- The Oxford Handbook of Personality Disorders (Oxford Library of Psychology), Widiger TA. (Ed), Oxford University Press, New York 2012. p.534.
- Levy KN, Meehan, KB, et al. An Update and Overview of the Empirical Evidence for Transference-Focused Psychotherapy and Other Psychotherapies for Borderline Personality Disorder. In: Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence, Levy RA, Ablon JS, Kächele H (Eds), Humana Press, New York 2006. p.144.
- Campbell WK, Miller JD. The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments, Wiley, New York 2011. p.451.
- Reed-Knight B, Fischer S. Treatment of narcissistic personality disorder symptoms in a dialectical behavior therapy framework. In: The Handbook of Narcissism and Narcissistic Personality Disorder: Theoretical Approaches, Empirical Findings, and Treatments, 1st ed, Campbell WK, Miller JD (Eds), Wiley, Hoboken 2011. p.466.
- Linehan MM, Korslund KE, Harned MS, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry 2015; 72:475.
- Becker DF, Grilo CM, Edell WS, McGlashan TH. Comorbidity of borderline personality disorder with other personality disorders in hospitalized adolescents and adults. Am J Psychiatry 2000; 157:2011.
- Silk KR. Management and effectiveness of psychopharmacology in emotionally unstable and borderline personality disorder. J Clin Psychiatry 2015; 76:e524.
- Zerbo E, Cohen S, Bielska W, Caligor E. Transference-focused psychotherapy in the general psychiatry residency: a useful and applicable model for residents in acute clinical settings. Psychodyn Psychiatry 2013; 41:163.
- Soeteman DI, Hakkaart-van Roijen L, Verheul R, Busschbach JJ. The economic burden of personality disorders in mental health care. J Clin Psychiatry 2008; 69:259.
- APPROACH TO TREATMENT
- GENERAL PRINCIPLES
- Discussing the diagnosis
- Forming an alliance
- Supportive psychotherapy
- Structured psychotherapies
- - Mentalization-based therapy
- - Transference-focused psychotherapy
- - Schema-focused psychotherapy
- - Dialectical behavioral therapy
- Severe NPD with safety risks
- Co-occurring disorders
- MANAGING NPD IN MEDICAL CARE
- Making a contract
- SUMMARY AND RECOMMENDATIONS