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 "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.
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- 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