Narcissistic Personality Disorder Treatment & Management

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 narcissistic personality disorder (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]

No psychiatric medications are tailored specifically toward the treatment of narcissistic personality disorder (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)

Clinicians cannot always easily gauge the potential for suicide in patients with narcissistic personality disorder (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.