para>Exacerbated by aging due to the inability to adapt to the physical, mental, and occupational restrictions age imposes, leading to depression. ‚
TREATMENT
GENERAL MEASURES
- Individual and group psychotherapy is offered for NPD, with only anecdotal reports of success. Regardless of the modality, the goals should be to engage the patient, establish methods of crisis stabilization, and solidify the importance of long-term counselling. The different forms of therapy available are the following:
- Psychodynamic therapy: to increase reflective capacity and emotional and interpersonal understanding
- Cognitive-behavioral therapy: designed to alter dysfunctional core beliefs
- Dialectical behavioral therapy
- Therapeutic community: used to affect attitudinal and behavioral change
- Cognitive-analytic therapy: designed to achieve greater self-understanding
- Behavioral therapy: designed to improve maladaptive behaviors
- Schema therapy is a form of integrative psychotherapy that has been shown to be more effective in NPD than other forms of psychotherapy (8)[A].
- Individuals with NPD usually come for therapy with presenting issues other than the aforementioned diagnostic features " ”most often for depression and anxiety.
- They often see the difficulties that they have with others as external and independent of their behavior. Their depression is often precipitated by situations that challenge the narcissistic grandiosity and reflects the discrepancy between NPD expectations or fantasies and reality.
- Individuals with NPD may have trouble entering treatment because they associate needing help as demeaning and unacceptable.
- If the situation becomes sufficiently severe, however, they will seek treatment to reestablish feelings of superiority and achievement.
- Therapy is often complicated by narcissists ' view of themselves. Their past, their current situation, and what they need from treatment all will be distorted by their need for acknowledgment of their superiority. They will resist feedback and may reject treatment if they are not sufficiently affirmed.
- NPDs chronically devalue those around them and demonstrate little empathy, thereby setting up potential countertransference situations with health care providers.
- The return to comfort for individuals with NPD may be all they are seeking, and they will leave treatment prematurely.
- Treatment also can be complicated by concomitant depression.
- Treatment can fail in terms of psychotherapy when consideration of possible substance abuse is ignored.
MEDICATION
- Evidence for pharmacologic treatment is limited to anecdotal reports and case series and only limited number of randomized controlled trials (2)[B].
- No FDA-approved treatments for NPD.
First Line
Antidepressant medication may be needed. ‚
- SSRIs have been used off-label to reduce target symptoms of interpersonal reactivity.
Second Line
Mood stabilizers may be needed. ‚
- In particular lithium, which is effective for labile mood; also used are carbamazepines, valproate, and lamotrigine. Atypical antipsychotics, such as quetiapine and olanzapine, can be used to reduce impulsive and aggressive behaviors.
ISSUES FOR REFERRAL
- Refer for individual or group therapy if the patient is willing.
- May need a psychiatrist for associated severe depression
ONGOING CARE
PATIENT EDUCATION
The National Institute of Mental Health (NIMH) at www.nimh.nih.gov ‚
PROGNOSIS
Prognosis for an adult with NPD is poor, although the person 's adaptation to situations and relationships can improve with treatment. ‚
COMPLICATIONS
- Family and relationship dysfunction
- Alcohol and other substance abuse. No single pattern of substance use or abuse can be identified for NPD; however, cocaine, as a high-status drug, is particularly common.
- Major depressive disorder
- Dysthymia
- Obsessive-compulsive behaviors
- Eating disorders
REFERENCES
11 Caligor ‚ E, Levy ‚ KN, Yeomans ‚ FE. Narcissistic personality disorder: diagnostic and clinical challenges. Am J Psychiatry. 2015;172(5):415 " “422.22 Dhawan ‚ N, Kunik ‚ ME, Oldham ‚ J, et al. Prevalence and treatment of narcissistic personality disorder in the community: a systematic review. Compr Psychiatry. 2010;51(4):333 " “339.33 Cooper ‚ LD, Balsis ‚ S, Oltmanns ‚ TF. Self- and informant-reported perspectives on symptoms of narcissistic personality disorder. Personal Disord. 2012;3(2):140 " “154.44 Twenge ‚ JM, Konrath ‚ S, Foster ‚ JD, et al. Egos inflating over time: a cross-temporal meta-analysis of the Narcissistic Personality Inventory. J Pers. 2008;76(4):875 " “902.55 Wright ‚ AG, Pincus ‚ AL, Thomas ‚ KM, et al. Conceptions of narcissism and the DSM-5 pathological personality traits. Assessment. 2013;20(3):339 " “352.66 Roepke ‚ S, Vater ‚ A. Narcissistic personality disorder: an integrative review of recent empirical data and current definitions. Curr Psychiatry Rep. 2014;16(5):445.77 Ronningstam ‚ E. Beyond the diagnostic traits: a collaborative exploratory diagnostic process for dimensions and underpinnings of narcissistic personality disorder. Personal Disord. 2014;5(4):434 " “438.88 Bamelis ‚ LL, Evers ‚ SM, Spinhoven ‚ P, et al. Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Am J Psychiatry. 2014;171(3):305 " “322.
ADDITIONAL READING
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Hopwood ‚ CJ, Donnellan ‚ MB, Ackerman ‚ RA, et al. The validity of the Personality Diagnostic Questionaire-4 Narcissistic Personality Disorder scale for assessing pathological grandiosity. J Pers Assess. 2013;95(3):274 " “283.
- Ronningstam ‚ E. An update on narcissistic personality disorder. Curr Opin Psychiatry. 2013;26(1):102 " “106.
CODES
ICD10
F60.81 Narcissistic personality disorder ‚
ICD9
301.81 Narcissistic personality disorder ‚
SNOMED
Narcissistic personality disorder ‚
CLINICAL PEARLS
- Current DSM-5 definition supports pathologic central grandiosity, with core dysfunction rooted in managing needs for validation and admiration.
- Must meet at least 5 of 9 diagnostic criteria as listed in section II of the DSM-5.
- The relative stability of self-image, as well as the lack of self-destructiveness, impulsivity, and abandonment concerns helps to distinguish NPD from borderline PD.
- Borderline, histrionic, and NPD patients all require attention; however, NPD individuals require that attention to be admiring.
- Individuals with NPD and obsessive-compulsive PD have a goal of perfectionism and believe that others cannot do things as well as they can, but NPD individuals often believe that they have achieved perfection.
- Individuals with NPD are vulnerable to severe depression, particularly when their superiority is challenged or with maladaptation to the effects of aging. Antidepressant medications, such as SSRIs, may be useful.
- Clinicians should set clear boundaries with patients with NPD and carefully manage the patient 's feelings of entitlement.