Narcissistic personality disorder: Treatment overview

INTRODUCTION — 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 [1].

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 has a variable presentation. In the past, controversy over how to define the boundaries of the disorder led to lack of clarity with regard to diagnostic criteria, epidemiology and course. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) focuses on a more aggressive grandiose subtype of NPD while alternative models are also proposed [2].

The treatment of NPD is described here. The epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis of NPD are described separately. Pharmacotherapy and psychosocial interventions for personality disorders, in general, are also reviewed separately.

●(See "Narcissistic personality disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

●(See "Overview of personality disorders".)

●(See "Personality disorders: Overview of pharmacotherapy".)

●(See "Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis".)

●(See "Borderline personality disorder: Psychotherapy".)

●(See "Antisocial personality disorder: Epidemiology, clinical manifestations, course, and diagnosis".)

●(See "Antisocial personality disorder: Treatment overview".)

●(See "Dimensional-categorical approach to assessing personality disorder pathology".)

OPTIMIZING THE THERAPEUTIC RELATIONSHIP — Narcissistic behaviors can disrupt medical care, exhaust medical practitioner and staff, and consume time and other resources. We use the following general principles to enhance the therapeutic alliance and overall clinical management of patients with narcissistic personality disorder (NPD) [3-5].

Forming an alliance — From early in the treatment, we communicate empathy while focusing on specific treatment goals that can help foster the development of an alliance. Patients with NPD typically show reluctance to begin treatment and resistance to engaging in treatment. Additionally, high rates of patient drop out are reported [6]. The grandiosity and defensiveness that characterize NPD make engagement in any form of psychotherapy difficult. Individuals with NPD often resist meaningful involvement with others, including therapists, and treatment can remain superficial for long periods and may never advance [7].

To enhance the therapeutic relationship we do the following during treatment:

●We maintain a nonjudgmental and inquisitive stance. Our experience tells us that patients are more likely to engage in treatment if their perceptions of the world and of others, including of the clinician themselves, are approached with curiosity and tolerance. We are cautious not to respond defensively or aggressively to the person with NPD, as confrontation of the patient’s grandiosity is likely to be unproductive. However, we are also vigilant not to collude with patients by minimizing or denying their pathology.

●We use the patient’s words whenever possible, and preface interventions with comments such as, “As you said earlier,” to help patients with NPD more readily accept the clinician’s comments and recommendations.

●We often “go with” the patient’s initial construction of the treatment relationship rather than attempting to correct the patient’s distortions. We avoid confronting gross idealization or devaluation, and allow some patients to construct a relationship between “buddies.” This will often help the individual with NPD to tolerate the “humiliation” of coming for help. This may allow the individual with NPD to settle more smoothly into treatment.

Once the initial hurdle of establishing treatment has been overcome, we gently and incrementally address negative feelings that the patient may have about the treatment and the clinician. This may lead to exploration of motivations for the patient’s negative responses to others and, ultimately, to themselves.

Clinician reaction to patients with NPD may be powerful and typically negative. Individuals with NPD often experience help and even positive change as humiliating dependence and weakness, which can confuse and unsettle practitioners inexperienced with NPD pathology [8]. (See "Approaches to the therapeutic relationship in patients with personality disorders".)

Discussing the diagnosis — We discuss the patient’s symptoms, symptoms of personality disorders, in general, treatment options, and expectations for improvement at the beginning of the therapy. We often do this without naming the term “narcissistic personality disorder” until the patient is more likely to accept the named diagnosis.

Our approach to sharing diagnostic impression is to:

●Focus on the core dysfunctions that characterize personality disorders as a group (eg, suspiciousness, detachment, social discomfort, unstable interpersonal relations, excessive emotionality, grandiosity, difficulty empathizing). (See "Overview of personality disorders", section on 'Clinical manifestations'.)

●Address the characteristics associated specifically with NPD: problems with self-esteem regulation, difficulty with intimacy, feelings of emptiness. This can be done without introducing the term “narcissistic personality disorder.”

●Have a neutral discussion of NPD, its effects, and its treatment. For many this may be a first step in developing a treatment alliance.

●With patients who do not ask for more information, it may be helpful to downplay or even avoid the term “narcissistic personality disorder” until the patient expresses curiosity or until the treatment has advanced to a stable alliance.

In our clinical experience many patients with a personality disorder are relieved to learn that they do not have, for example, a refractory mood disorder, but instead have a characterologic diagnosis that is well defined, and for which there exists potentially effective treatment. With a comprehensive diagnosis, we can present the patient with a rational treatment frame and realistic expectations. This often offers genuine hope of symptom reduction and lasting personality change. Without it, patients may be vulnerable to multiple courses of ineffective psychotherapies or polypharmacy that accumulates while chasing refractory symptoms [1,9-11].

However, disclosing to patients that they meet criteria for NPD has been much debated. Some patients experience the diagnosis as a humiliating label of an untreatable illness with little hope of recovery. Patients increasingly come to us aware of the diagnosis, often from internet searches or from other clinicians. These individuals are typically reassured by a clinician’s thoughtful, empathic explanation and discussion of the diagnosis.

Making a contract — We make a verbal treatment contract to set treatment boundaries and expectations of the treatment. We do this through an ongoing dialogue that outlines goals for the relationship rather than a list of demands or rules. The treatment contract can be considered a “third party,” that can neutralize the antagonistic dyads narcissistic patients create between themselves and others. The treatment contract typically needs to be reiterated throughout the treatment. The following example illustrates how a contract might work:

●Mr. X, a 56-year-old patient with Crohn disease, has frequently missed appointments, demands treatment he finds on the internet instead of the medications prescribed by his clinicians, and pays his bills late. When confronted with these behaviors, he shouts: “I miss appointments because you’re useless, you’re even worse than my last two doctors! I read about all these new treatments, why aren’t I getting them? You doctors make a fortune; why should I give you my money?”

While there are several problems the clinician might address here, in this example we would begin by addressing the patient’s affect. As an example:

●“I hear that you worry I can’t help you, and we need to talk about that. But before we discuss that we should talk about the way you communicate with me. It’s a real struggle for me to think when you’re shouting at me. I lose focus, and I can’t give your problems my full attention when I feel intimidated. Since we both want the same thing, can we agree that you won’t shout at me when you come to your appointments?”

The verbal contract may deflect patients anger from the caregiver toward the agreement:

●“I hear that you’re frustrated, but do you remember our agreement? Last time, we had an understanding that shouting prevents me from thinking clearly and distracts us both from concentrating on your medical concerns. I think you really got how important that was. Can we go back to that agreement to help us work together?”

“But I’m really angry; nothing you’re doing is making any difference! Of course I’m shouting!”

“Yes, I know, this treatment hasn’t worked as we’d hoped. We need to have a plan, but right now we need to work together to follow our agreement, and communicate in a way that can help us work together and allow me to be at my best for you."

Documentation — When events or circumstances have interfered with clinical care in an individual with NPD, we recommend documenting this in the patient chart using clear, standardized wording. A standard template documenting how symptoms have interfered with the treatment is a useful means of accurately communicating the problem and may limit potential telegraphing of negative feelings in the medical chart.

●“I am treating Mr. X for Crohn Disease. He has been combative, has missed appointments, and has been nonadherent with medication and preventive care. He devalues my treatment suggestions and claims to have more knowledge of his medical conditions than I have. He missed his colonoscopy this month and attributes his missed appointment to my shortcomings and the shortcomings of his family. This pattern of behavior in Mr. X is most consistent with a personality disorder; personality disorders are generally known to interfere with medical care, as they have for Mr. X in this case. It is likely that his behavior will continue to compromise his treatment for Crohn disease if his behavior remains unchanged.”

Many practitioners can be especially reluctant to “label” patients with personality disorders in medical records. This may be particularly true in individuals with NPD. Anecdotally, caregivers cite concerns that their notes will convey their own frustration and anger toward these difficult patients, whose aggression, devaluation, and nonadherence to medical treatments or advice can activate strong negative reactions in treatment providers. As it is well documented that individuals with personality disorders consume inordinate time and resources and cause potentially dangerous disruptions in medical care, we believe it is essential to document these systemic threats to care in patient records [12].

PSYCHOTHERAPY AS FIRST-LINE TREATMENT — For most patients with narcissistic personality disorder (NPD), we suggest first-line treatment with a manualized psychotherapy rather than other forms of psychotherapy (eg, supportive psychotherapy) or medication management. However, manualized forms of psychotherapy may be less available as they require training of clinicians in specific techniques. When manualized psychotherapy is not available, supportive psychotherapy is an appropriate alternative. Research data are not adequate to inform selection of one treatment over another.

There are minimal empirical data consistently supporting psychotherapy, medication management, or their combination in the treatment of NPD [3,4,7,8,13-19]. Our preference for treatment is based on the efficacy of psychotherapy in the treatment of personality disorders in general, our clinical experience, and the availability of treatment. (See "Personality disorders: Overview of pharmacotherapy", section on 'Symptom-domain-focused treatment' and "Borderline personality disorder: Psychotherapy", section on 'Specific psychotherapies' and "Approaches to the therapeutic relationship in patients with personality disorders", section on 'Cluster B'.)

Manualized psychotherapy — Manualized psychotherapies are treatments that follow a manual and require specialized training to deliver. While they have not been rigorously tested in the treatment of patients with NPD, they appear to be effective in reducing hospitalization and suicide attempts and enhancing psychosocial functioning of individuals with borderline personality disorders and are being adapted for NPD [9,15-17,20]. Our choice of manualized therapy is typically dependent on the availability of trained clinicians. When more than one form is available, we typically choose them in the order discussed below. Further discussion of these psychotherapies can be found elsewhere. (See "Borderline personality disorder: Psychotherapy", section on 'Specific psychotherapies'.)

Transference-focused psychotherapy — Transference-focused psychotherapy is an individual psychodynamic treatment whose core principles have been adapted to treat a wider range of pathologies, including NPD [15,21]. In our clinical experience, transference-focused psychotherapy typically has the best clinical effect in the treatment of NPD; however, availability is limited.

Individuals with “cluster B’ personality disorders tend to have cognitive distortions and highly charged affective experiences. Transference-based psychotherapy involves exploration, confrontation, and interpretation of emotionally charged issues that may arise between the patient and the therapist. The aim is to correct the patient’s tendency to perceive significant others in a distorted manner. Acknowledging and focusing on these distortions provides an opportunity to address grandiosity, antagonism, and fears of humiliation in a protected setting of the therapeutic relationship. (See "Borderline personality disorder: Psychotherapy", section on 'Transference-focused therapy'.)

Good psychiatric management — This is a form of manualized psychotherapy that can be practiced by primary care practitioners, nurse practitioners, and other mental health professionals who are not therapists [9]. Good psychiatric management therapists focus on hypersensitivity to relationship stressors and incorporate practical problem solving and realistic goal setting. The approach involves less of a distinct conceptual model and less psychotherapeutic techniques with greater focus on avoiding pitfalls that may occur in the treatment of disorders. (See "Borderline personality disorder: Psychotherapy", section on 'Good psychiatric management'.)

Mentalization-based therapy — Mentalization-based therapy is primarily a psychodynamic psychotherapy that also incorporates cognitive techniques. Patients in mentalization-based therapy are first taught to improve their capacity to self-reflect, and then to use self-reflection to assess and alter their subjective experience of self and others [20]. Mentalization is the ability to accurately experience mental states in oneself and in others and to recognize how mental states determine behavior. Given narcissistic patients’ impoverished capacity for self-reflection and attachment to others, mentalization-based therapy is a promising adaptation for NPD. (See "Borderline personality disorder: Psychotherapy", section on 'Mentalization-based therapy'.)

Dialectical behavioral therapy — Dialectical behavioral therapy (DBT), a form of cognitive-behavioral therapy (CBT) that combines individual therapy with group treatment, has core principles of acceptance (“radical acceptance”) and change.

While the efficacy of DBT has been established in treatment of borderline personality disorder, the skills and techniques may also address affective regulation association with NPD. Additionally, DBT has been useful to manage self-destructive behavior in patients with comorbid borderline personality disorder and NPD [19,22,23]. (See "Borderline personality disorder: Psychotherapy", section on 'Dialectical behavior therapy'.)

Schema-focused psychotherapy — Schema-focused psychotherapy combines aspects of CBT, attachment theory, and psychodynamic therapy to treat maladaptive schemas. Maladaptive schemas are pervasive negative perceptions of self, of others, and of one’s place in the world that are embedded in early life [17]. In patients with NPD, schema-focused psychotherapy addresses core schemas of narcissism: emotional depravation, defectiveness, and entitlement [24]. In schema-focused therapy, therapists enact a limited “reparenting” to replace maladaptive schemas with healthy behavioral and cognitive models [18,25]. (See "Borderline personality disorder: Psychotherapy", section on 'Schema-focused therapy'.)

Schema-focused therapy may be well suited for patients with NPD, who generally have difficulty tolerating psychotherapy and remaining in treatment. While minimal data support the use of schema-focused therapy in individuals with NPD, a clinical trial in patients with borderline personality disorder suggested that schema-focused therapy may have a lower dropout rate compared with other approaches [25].

Supportive psychotherapy — We suggest using supportive-based therapy when the options above are unavailable or have been ineffective. In our clinical experience, a psychotherapeutic approach based on the objectives and techniques of supportive psychotherapy and applied to the needs of patients with NPD may be helpful in the treatment.

Supportive psychotherapy is a pragmatic approach that, as most commonly practiced, makes use of both psychodynamic and cognitive-behavioral techniques, and it is often combined with psychopharmacologic management. Supportive psychotherapy can be structured as a short-term intervention to manage acute crises and/or deterioration in functioning, or as an ongoing maintenance treatment [26]. Supportive psychotherapy focuses on establishing and maintaining a treatment alliance, providing the patient with an understanding of their diagnosis, helping the patient to develop a more complete awareness of maladaptive behaviors, and working with the patient to identify realistic, attainable treatment goals and attain the highest possible level of functioning. The therapist establishes a collaborative, collegial relationship with the patient, in which the therapist provides encouragement, reassurance, advice, and coaching, while modeling adaptive behavior.

Supportive psychotherapy frequently involves skills training, often focusing on affect regulation and managing destructive impulses, development of social skills, and managing negative cognitions. Meeting with the patient’s family and/or significant others is frequently integrated into the treatment. (See "Overview of psychotherapies", section on 'Supportive psychotherapy'.)

Subsequent treatment — For individuals with a good response to treatment with psychotherapy (eg, improvement in psychosocial functioning, relationships, emotional dysregulation), we prefer long term treatment. Typically, this is measured in years.

For those with a poor response to management with psychotherapy we address specific symptom domains with medications. (See 'Pharmacotherapy for severe/persistent symptoms' below.)

PHARMACOTHERAPY FOR SEVERE/PERSISTENT SYMPTOMS — For individuals with severe or persistent symptoms (eg, severe affective dysregulation, aggression or other symptoms that may pose a safety risk to themselves or others, we prefer combining psychotherapy with a symptom-targeted approach to pharmacotherapy. These are reviewed below and discussed further elsewhere. (See "Personality disorders: Overview of pharmacotherapy", section on 'Targeted symptom domains'.)

●Affective dysregulation – We use mood stabilizers as our first choice for affective dysregulation in individuals with personality disorders, including narcissistic personality disorder (NPD) [14]. Low doses of a second-generation antipsychotic medications are an alternative choice. (See "Personality disorders: Overview of pharmacotherapy", section on 'Affective dysregulation'.)

●Impulsivity or behavior dyscontrol/aggression – For individuals with NPD with persistent impulsivity or behavior dyscontrol, we typically treat with a mood stabilizing medications, such as lamotrigine [14]. While minimal data support their use in the treatment of NPD, some trials support their use for behavior dyscontrol in individuals with borderline personality disorder [27,28]. (See "Personality disorders: Overview of pharmacotherapy", section on 'Impulsivity or behavioral dyscontrol'.)

●Cognitive-perceptual disturbances – Medications for these symptoms have not been studied in patients with NPD. Our preference is for treatment with a low dose of a second-generation antipsychotic medication. While minimal data support their use in this population, some studies have been found them to be more effective than antidepressants or mood stabilizer for the treatment of disruptive stress-related cognitive-perceptual experiences in patients with borderline personality disorder [14,29,30]. (See "Borderline personality disorder: Treatment overview" and "Personality disorders: Overview of pharmacotherapy", section on 'Cognitive-perceptual disturbances'.)

We typically suggest a taper of medication of effective medication after one year. However, this is dependent on patient preference, presence of side effects and our clinical judgment. In individuals with severe symptoms (eg, prominent psychosocial disability, difficulty stabilizing symptoms, suicidal thoughts) we often prefer to continue medications for a longer period of time (eg, up to 24 months).

MANAGING COMORBID DISORDERS — We prefer to address comorbid psychiatric conditions such as depression or anxiety, simultaneously with the treatment of narcissistic personality disorder (NPD). The co-occurrence of NPD with depression or anxiety may complicate treatment and make it more difficult to establish and maintain a therapeutic alliance. This may lead to higher drop-out rates or poor response to treatment.

Our preference is to combine psychotherapy with the preferred choice of medication for the anxiety or depressive disorder. As there are no clinical trials of medication efficacy in the treatment of NPD, our choice of medication is based on our clinical experience and the efficacy of medications in the treatment of the co-occurring disorder [14,29,31]. Choice of medication for depression and anxiety disorders is discussed elsewhere. (See "Major depressive disorder in adults: Approach to initial management" and "Generalized anxiety disorder in adults: Management".)

Unnecessary medication use or polypharmacy can easily occur in the treatment of NPD, because the aggression and distress characteristic of some patients with NPD can induce anxiety and desperation in clinicians. Patients with NPD are also at risk of undertreatment; they often experience the suggestion of medication as a narcissistic injury and may reject it. To avoid conflict, clinicians may unconsciously avoid recommending medication, even to patients with NPD and a highly symptomatic, treatable co-occurring disorder.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Personality disorders".)

SUMMARY AND RECOMMENDATIONS

●Optimizing the therapeutic relationship – Narcissistic behaviors can disrupt medical care, exhaust medical practitioner and staff, and consume time and other resources. We use the following principles to enhance the therapeutic alliance and improve overall clinical management of patients with narcissistic personality disorder (NPD).

•Forming an alliance – From early in the treatment, we communicate empathy while focusing on specific treatment goals that can help foster the development of an alliance.

•Discussing the diagnosis – We discuss the patient’s symptoms, symptoms of personality disorders in general, treatment options, and expectations for improvement, as part of our informed consent to treat. We often do this without naming the term “narcissistic personality disorder” until the patient is more likely to accept the named diagnosis.

•Verbal treatment contracts – We make a treatment contract to set treatment boundaries and expectations of the treatment. We do this through ongoing dialogue that outlines goals for the relationship rather than a list of demands or rules.

•Documentation – When events or circumstances have interfered with clinical care in an individual with NPD, we recommend using a standardized template for documentation.

●Psychotherapy as first line – For patients with NPD, we suggest first-line treatment with a manualized form of psychotherapy rather than other forms of psychotherapy or medication (Grade 2C). (See 'Psychotherapy as first-line treatment' above.)

•Manualized psychotherapy – Manualized psychotherapies are treatments that require specialized training to deliver. Minimal data support one manualized therapy versus another. However, in our clinical experience, transference-focused psychotherapy typically has the best clinical effect. (See 'Manualized psychotherapy' above.)

•Supportive psychotherapy – In cases where manualized psychotherapy is unavailable, supportive psychotherapy is a reasonable alternative option. While minimal data support any form of psychotherapy over another, in our clinical experience, a psychotherapeutic approach based on the objectives and techniques of supportive psychotherapy and applied to the needs of patients with NPD may helpful. (See 'Supportive psychotherapy' above.)

●Pharmacotherapy for severe or persistent symptoms – For individuals with severe or persistent symptoms that pose a risk of safety to self or others, we suggest adjunctive pharmacotherapy targeted to symptoms in combination with psychotherapy (Grade 2C). (See 'Pharmacotherapy for severe/persistent symptoms' above.)

The choice of medication is targeted to specific symptoms. (See "Personality disorders: Overview of pharmacotherapy", section on 'Symptom-domain-focused treatment'.)

●Managing comorbid disorders – We prefer to address comorbid psychiatric conditions such as depression or anxiety, simultaneously with the treatment of NPD. The co-occurrence of NPD with depression or anxiety may complicate treatment and make it more difficult to establish and maintain a therapeutic alliance. This may lead to higher drop-out rates or poor response to treatment. (See 'Managing comorbid disorders' above.)