Medication Summary
Although no psychiatric medications are specifically approved for the treatment of narcissistic personality disorder (NPD), patients often benefit from the use of such medications to help alleviate certain symptoms associated with this disorder or to manage concomitant axis I diagnoses. Medications that may be considered include antidepressants (specifically, selective serotonin reuptake inhibitors [SSRIs]), antipsychotics, and mood stabilizers.
Selective Serotonin Reuptake Inhibitors
Class Summary
SSRIs such as citalopram may be used to treat depressive symptoms in adult patients with NPD. They are the antidepressants of choice because of their minimal anticholinergic effects. All are equally efficacious; selection depends on adverse effects and drug interactions. Determining whether the patient with NPD has a formal axis I diagnosis of major depression or depressive symptoms related to narcissistic pathology is important; this determination will influence the length and course of treatment.
Citalopram (Celexa)
Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs exist, though on the basis of metabolism and adverse effects, citalopram is considered the SSRI of choice for patients with head injury.
Escitalopram (Lexapro)
This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may occur after 1-2 weeks, which is faster than the relief obtained from other antidepressants.
Fluoxetine (Prozac)
Fluoxetine it selectively inhibits presynaptic serotonin reuptake with minimal or no effect on the reuptake of norepinephrine or dopamine.
Fluoxetine may cause more gastrointestinal adverse effects than other SSRIs now currently available. The drug may be administered in 1 dose or in divided doses. The presence of food does not appreciably alter levels of the medication. Fluoxetine may take up to 4-6 weeks to achieve steady state levels, as it has the longest half-life (72 h).
Fluoxetine's long half-life is an advantage and a drawback. If fluoxetine works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time. The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.
Fluvoxamine (Luvox CR)
Fluvoxamine enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than do tricyclic antidepressants.
Fluvoxamine has been shown to reduce repetitive thoughts, maladaptive behaviors, and aggression and to increase social relatedness and language use.
Sertraline (Zoloft)
Zoloft selectively inhibits presynaptic serotonin reuptake. It is indicated for obsessive-compulsive disorder in children aged 6-17 years.
Paroxetine (Paxil, Pexeva)
This would be unlabeled use. Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake.
For maintenance dosing, make dosage adjustments to maintain patient on lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.
Antipsychotic Agent
Class Summary
Atypical antipsychotic agents such as risperidone may be used in adult patients with NPD to treat transient psychosis, mood lability, and poor impulse control. The response to antipsychotics is less dramatic than that seen in in true psychotic axis I disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may be reduced. Antipsychotics are typically used for a short time while the symptoms are active.
Risperidone (Risperdal, Risperdal Consta IM Injection, Risperdal M-Tab)
Risperidone binds to dopamine D2 receptors with a 20 times lower affinity than that for serotonin 5-HT2 receptors. It mitigates negative symptoms of psychoses and reduces the incidence of extrapyramidal adverse effects.
Mood Stabilizers
Class Summary
Mood stabilizers such as lamotrigine may be used in adult patients with NPD to help with affect regulation and impulse control. The literature also contains some mention of the use of medications such as valproic acid and Lithium as mood stabilizers.
Lamotrigine (Lamictal)
Lamotrigine is an anticonvulsant that appears to be effective in the treatment of the depressed phase in bipolar disorders.
Valproic acid, divalproex sodium (Depakote, Depakene, Depacon, Stavzor)
Valproic acid is the most widely used agent in its class. It is modestly effective and generally well tolerated. It is chemically unrelated to other drugs that treat seizure disorders. Although its mechanism of action is not established, its activity may be related to increased brain levels of gamma-aminobutyric acid (GABA) or enhanced GABA action. It also may potentiate postsynaptic GABA responses, affect potassium channels, or have a direct membrane-stabilizing effect.
Lithium (Lithobid)
Lithium is indicated to treat bipolar disorder. The specific mechanism of action is unknown, but the drug alters sodium transport in nerve and muscle cells and influences reuptake of serotonin, norepinephrine, or both at cell membranes.
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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.
