Narcissistic Personality Disorder

Narcissistic Personality Disorder as described by the DSM-IV is a pervasive pattern of grandiosity in fantasy or behavior as well as a need for admiration and a lack of empathy that begins in early adulthood. This occurs in a variety of contexts and has at least five indicators out of the nine that are listed in the DSM. These individuals tend to devalue others for their imperfections. At times, they may idealize others whom they feel meets their criteria for perfection only to be disappointed when the idealized figure ultimately fails or lets them down in some way. Grandiosity is the most useful feature in differentiating Narcissistic personality from Histrionic, Antisocial, or Borderline Personality. Excessive pride, a lack of emotional expression may distinguish Narcissistic form Histrionic personality. A fairly stable sense of self, lack of self destructive and impulsive behavior, and abandonment concerns may distinguish Narcissistic from Borderline personality.

These individuals are often extremely vulnerable to fluctuations in self-esteem, rage and depression if slighted or if they feel that they have been rejected of defeated in some way. Depression is often the reason for seeking clinical assistance after some such disappointment has occurred. While individuals with Narcissistic Personality Disorder may be quite arrogant, others may hide their sense of superiority behind humility and self-sacrifice.

The theoretical approaches applied with this disorder are cognitive-behavioral, interpersonal and psychodynamic psychotherapy. For deeper changes, a more dynamic and longer-term approach is useful.

The goals for CBT treatment should be to find new ways to maintain self-esteem, increased sensitivity toward others, improved problem solving and increased self-awareness. Psychodynamic psychotherapy is considered in some circles (usually psychodynamic circles) to be the treatment of choice for these individuals. Self Psychology, originally developed by Heinz Kohut seeks to empathize with the individual’s hurts and disappointments. This mirroring and allows the development of an “idealizing” transference. “Empathic breaks” or failures in empathy are inevitable and provide an opportunity for reparation of these breaks. The pattern of disappointment and repair allows the patient to become aware of his or her sensitivity to disappointment and to internalize the imperfect but sensitive other of the therapist.

Interpersonal therapy is a short-term approach to help the individual to gain deeper understanding of the issues that prevent deeper intimacy in relationships. The approach allows the patient to gain more empathy for others and gain a more realistic view of relationships, thereby improving social support.

The clinician must be cautious, whatever the approach, not to confront interpersonal deficiencies or lack of empathy too soon. The individual may have come to therapy because of depression that resulted from disappointment and feelings of defeat. One must be cautious to “rebuild” the individuals self esteem and develop a working alliance before confronting the deficits that create their interpersonal problems. Further, mirroring behavior on the part of the therapist will undoubtedly bring out the arrogant behavior that is their pattern. One must be careful in their own response to the interpersonal defects that create difficulties in most other relationships, while still maintaining a broad perspective.

Conduct an assessment and address any safety issues. You will also need to establish a therapeutic relationship with the patient so you can motivate them for treatment. A thorough clinical history and psychosocial will be needed. A personality assessment may be useful.