Medscape is available in 5 Language Editions – Choose your Edition here.


Narcissistic Personality Disorder Treatment & Management

  • Author: Sheenie Ambardar, MD; Chief Editor: David Bienenfeld, MD  more...
Updated: May 09, 2016

Approach Considerations

Long-term, consistent outpatient care is the approach of choice in the treatment of narcissistic personality disorder (NPD). This usually involves a combination of psychotherapy and medication management.

The mainstay of treatment is individual psychotherapy—specifically, psychoanalytic psychotherapy. Other therapeutic modalities used to treat the disorder include group, family, and couples therapy, as well as cognitive-behavioral therapy (CBT) and short-term objective-focused psychotherapy.[14] Psychotropic medications are not specifically used to treat NPD but are often used to treat concomitant anxiety, depression, impulsivity, or other mood disturbances.

If the patient acutely decompensates or becomes a danger to self or others, inpatient treatment is warranted. As a rule, shorter hospital stays are best for patients with NPD; prolonged time in the hospital will do little to change the underlying severity of the illness. Hospitalization should only be used as a temporizing measure to allow stabilization of environmental stressors, adjustment of medication dosages, or both.[15]



Whereas individual psychoanalytic psychotherapy is the method of choice for the treatment of NPD, there has been much debate as to exactly what constitutes optimal treatment. The 2 main schools of thought in this regard are Otto Kernberg’s object-relations approach and Heinz Kohut’s self-psychology approach, which offer different and seemingly contradictory ways of approaching the narcissistic patient.[14]

In Kernberg’s approach, the job of the therapist is to actively interpret the patient’s narcissistic defenses while at the same time illuminating the patient’s negative transferences. Kernberg believed that the end goal of therapy was to eradicate or diminish the patient’s pathologic grandiose self through direct confrontation.[14]

By contrast, Kohut advocated a more empathic approach, with the therapist actually encouraging the patient’s grandiosity and promoting the development of idealization in the transference. Kohut’s end goal was to bolster the patient’s inherently deficient self-structure.[14]

No definitive studies have strongly favored one therapeutic stance over another. Currently, most clinicians embrace a style that fuses elements of both. The general preference is for a flexible and moderate approach that combines an empathic understanding of the patient’s need for narcissistic defenses with a thorough exploration of those defenses.

In line with such an approach, the therapist should recognize the self-preserving role that narcissism plays in the patient’s daily life and should be cautious about tearing down narcissistic defenses too quickly. At the same time, the therapist should strive to help the patient gain a realistic understanding of his or her own behavioral deficiencies.[14]

Besides individual psychoanalytic psychotherapy, group therapy and CBT have also been used to treat NPD. Group therapy was initially thought to be unsuitable for patients with narcissism because clinicians assumed that these patients would be unable to handle the requisite give-and-take inherent in the group process.

This initial assumption about the unsuitability of group therapy was reasonable, in that group processes usually require empathy, patience, and the ability to relate and connect to others—traits are deficient in narcissistic individuals. Nevertheless, studies[21] have suggested that long-term group therapy can benefit patients with narcissism by providing them with a safe haven in which they can explore boundaries, receive and accept feedback, develop trust, and increase self-awareness.[21, 22]

CBT also has the potential to benefit narcissistic patients.[23] There is a specific form of CBT, known as schema-focused therapy, that centers on repairing narcissistic schemas and the defective moods and coping styles associated with them.[24] This highly active and work-intensive form of treatment encourages patients to confront narcissistic cognitive distortions (eg, black-and-white thinking and perfectionism) and has yielded some promising results in the treatment of NPD.[14]


Pharmacologic Therapy

No psychiatric medications are tailored specifically toward the treatment of NPD. Nevertheless, patients with this disorder often benefit from the use of psychiatric medications to help alleviate certain symptoms associated with the disorder (eg, depression, anxiety, transient psychosis, mood lability, and poor impulse control). In addition, many patients with NPD have concomitant axis I diagnoses for which they are receiving regular psychiatric pharmacotherapy. Agents that may be indicated in the treatment of NPD patients include the following:

  • Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class (eg, citalopram)
  • Antipsychotics (eg, risperidone)
  • Mood stabilizers (eg, lamotrigine)

Long-Term Monitoring

Clinicians cannot always easily gauge the potential for suicide in patients with NPD, because these patients can become suicidal unexpectedly, even when they are not overtly depressed. Patients with narcissism can react brashly and dangerously to acute narcissistic injuries, which strike at the core of their low self-esteem.[25]

Accordingly, it is important for the clinician to monitor the NPD patient consistently, paying close attention to any unexpected life events that may catch the patient off guard. In addition, the patient’s access to potential means of suicide (eg, firearms and pills) should be limited.[26] As in any therapeutic relationship, the clinician should thoroughly document every aspect of the patient’s course of treatment, both to benefit the patient and to protect the clinician against any potential legal action.

Contributor Information and Disclosures

Sheenie Ambardar, MD Adult Psychiatrist, Private Practice

Sheenie Ambardar, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.


Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment


Dr. Ambardar would like to thank Dr. Donald C. Fidler, Farnsworth Endowed Chair of Psychiatric Education at West Virginia University, for generously granting permission to use his video clip in the multimedia section of this article.

  1. American Psychiatric Association. Personality disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013.

  2. American Psychiatric Association. Alternative DSM-5 model for personality disorders. Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013. 761-81.

  3. Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. 1982 Jan. 139(1):12-20. [Medline].

  4. Torgersen, S. Epidemiology. Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing; 2005. 129-141.

  5. de Ruiter C, Greeven PG. Personality disorders in a Dutch forensic psychiatric sample: convergence of interview and self-report measures. J Pers Disord. 2000 Summer. 14(2):162-70. [Medline].

  6. Ronningstam E. Narcissistic Personality Disorder: Facing DSM-V. Psychiatric Annals. 2009 Mar. 39:111-121.

  7. Crosby RM, Hall MJ. Psychiatric evaluation of self-referred and non-self-referred active duty military members. Mil Med. 1992 May. 157(5):224-9. [Medline].

  8. Bourgeois JA, Hall MJ, Crosby RM, Drexler KG. An examination of narcissistic personality traits as seen in a military population. Mil Med. 1993 Mar. 158(3):170-4. [Medline].

  9. Maffei C, Fossati A, Lingiardi V, Madeddu F, Borellini C, Petrachi M. Personality maladjustment, defenses and psychopathological symptoms in non-clinical subjects. J Pers Disord. 1995 Apr. 9:330-345.

  10. Rebecca J. Frey, Ph.D. Narcissistic Personality Disorder. Encyclopedia of Mental Disorders. Available at Accessed: September 8, 2008.

  11. Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry. 1995 Feb. 152(2):253-7. [Medline].

  12. Waller G, Sines J, Meyer C, et al. Narcissism and narcissistic defences in the eating disorders. Int J Eat Disord. 2007 Mar. 40(2):143-8. [Medline].

  13. Ronningstam E. Pathological narcissism and narcissistic personality disorder in Axis I disorders. Harv Rev Psychiatry. 1996 Mar-Apr. 3(6):326-40. [Medline].

  14. Ronningstam EF, Maltsberger JT. Part X: Personality Disorders. Gabbard GO. Gabbard's Treatments of Psychiatric Disorders. Fourth Edition. Washington DC: American Psychiatric Publishing; 2007. Chapter 52: Narcissistic Personality Disorder, pages 791-804.

  15. David Bienenfeld, MD. Personality Disorders. Medscape Reference. Available at Accessed: July 1, 2008.

  16. Simon RI. Outpatients. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington DC: American Psychiatric Publishing; 2004. 89-90.

  17. Holdwick DJ Jr, Hilsenroth MJ, Castlebury FD, et al. Identifying the unique and common characteristics among the DSM-IV antisocial, borderline, and narcissistic personality disorders. Compr Psychiatry. 1998 Sep-Oct. 39(5):277-86. [Medline].

  18. Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Personal Disord. 2001 Apr. 15(2):103-9. [Medline].

  19. Stormberg D, Ronningstam E, Gunderson J, et al. Brief communication: pathological narcissism in bipolar disorder patients. J Personal Disord. 1998. 12(2):179-85. [Medline].

  20. Clarkin JF, Howieson DB, McClough J. The Role of Psychiatric Measures in Assessment and Treatment. Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing Textbook of Psychiatry. 5th Edition. Arlington, VA: American Psychiatric Publishing; 2008. Chapter 3.

  21. Roth BE. Narcissistic patients in group therapy: containing affects in the early group. Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998. 221-238.

  22. Alonso A. The shattered mirror: treatment of a group of narcissistic patients. Group. 1992 Dec. 16:210-219.

  23. Young J, Flanagan C. Schema-focused therapy for narcissistic patients. Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998. 239-268.

  24. Young J, Klosko JS, Weishaar ME. Schema Therapy. A Practitioner's Guide. New York: Guilford; 2003.

  25. Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry. 2003 Jun. 48(5):301-10. [Medline].

  26. Links PS, Kolla N. Assessing and Managing Suicide Risk. Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook Of Personality Disorders. Washington DC: American Psychiatric Publishing; 2005. 459.

This is an actor portrayal of a patient with narcissistic personality disorder. This video clip was provided courtesy of Donald C. Fidler, MD, FRCP-I.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.