Individuals with narcissistic personality disorder (NPD) have a grandiose sense of identity, lack empathy, and need constant admiration. They believe they’re special or unique and have fantasies of unlimited power and success. They may exaggerate their accomplishments and talents.
They have unreasonable expectations of others and often make disparaging remarks. Yet, they have trouble handling any kind of criticism and can react with rage.
According to an article in BJPsych Advances, there may be two subtypes of NPD: grandiose or overt narcissism and vulnerable or covert narcissism: “People with the former subtype may appear arrogant, pretentious, dominant, self-assured, exhibitionist, or aggressive, whereas people with the latter may present as overly sensitive, insecure, defensive and anxious about an underlying sense of shame and inadequacy.”
Whatever the specific presentation, both types of individuals “share a preoccupation with satisfying their own needs at the expense of the consideration of others.”
NPD often co-occurs with antisocial personality disorder, borderline personality disorder, substance use disorder, mood disorder, and anxiety disorders.
NPD can be difficult to treat because individuals with the disorder don’t think they have a problem and tend to blame everyone else for everything. Still, treatment can help. The first-line (and best) treatment for NPD is psychotherapy. In severe cases, medication may be prescribed for NPD symptoms, but is usually used for co-occurring conditions.
The research on specific psychotherapeutic interventions for narcissistic personality disorder (NPD) is scarce. Some treatments for NPD have been adapted from treatments for borderline personality disorder, and require therapists to have specialized training. These include:
- Transference-focused psychotherapy (TFP) is a psychodynamic treatment that starts with a verbal treatment contract, which defines the roles and responsibilities of both client and clinician. Individuals with NPD identify their goals, which treatment focuses on. TFP also emphasizes the relationship between client and clinician, because this is where the individual’s symptoms play out and can be worked through. According to a chapter in Contemporary Psychodynamic Psychotherapy, “The therapist attends closely to the patient’s moment-to-moment experience and behavior in therapy sessions, with special attention to disturbed interpersonal behaviors, both in relation to the therapist and in the patient’s current relationships.”
- Schema-focused therapy (SFT) combines psychodynamic psychotherapy with cognitive behavioral therapy, and helps individuals with NPD to replace unhealthy schemas. These are pervasive, persistent negative perceptions of the self and others. In NPD, these schemas include defectiveness and entitlement.
- Mentalization-based therapy (MBT) is a psychodynamic treatment that helps individuals with NPD to accurately self-reflect and reflect on others’ thoughts and feelings—and to see the connection between these mental states and behavior.
- Dialectical behavior therapy (DBT), a form of cognitive behavioral therapy, focuses on mindfulness, emotional regulation, distress tolerance, and relationship skills. For example, as one expert noted, DBT “helps the client recognize his own thinking and accept the need for excessive attention. But it also helps the person recognize that there are times when it’s not all about him or her.”
Metacognitive interpersonal therapy (MIT) was specifically developed to treat NPD. It consists of two stages: stage setting and change promoting:
- Stage setting includes gaining a deeper understanding of the person’s interpersonal relationships by exploring different situations, memories, and recurrent patterns. For example, according to a 2012 article in the Journal of Clinical Psychology, “They also need to realize how expectations that others will be hostile or hamper their goals are largely schema driven and use this knowledge to form strategies for changing.” Plus, individuals with NPD learn to identify their feelings and understand their underlying emotional triggers.
- Change promoting includes showing individuals “that their ideas do not necessarily mirror reality and that situations can be understood differently when seen from another angle,” along with building new and healthier ways of thinking, feeling, and behaving (according to the previously mentioned article).
Supportive psychotherapy is another intervention that can be used with NPD. In fact, according to UpToDate.com, “In our clinical experience, a psychotherapeutic approach based on the objectives and techniques of supportive psychotherapy and applied to the needs of NPD patients may be most helpful.”
Supportive psychotherapy combines psychodynamic and cognitive behavioral treatments, along with medication (when appropriate). The goals include: making sure the person is stabilized; addressing co-occurring conditions (e.g., depression); and helping the person “attain the highest possible level of functioning given the constraints of the patient’s personality pathology.”
Supportive psychotherapy often includes teaching affect regulation and social skills, and managing destructive impulses and distorted thoughts. It also often involves the person’s family and/or partners.
No medication has been approved by the U.S. Food and Drug Administration (FDA) to treat narcissistic personality disorder (NPD). According to UpToDate.com, medication may be used when individuals with NPD have severe symptoms that compromise their safety.
This includes prescribing a mood stabilizer or antidepressant for significant affective instability; a mood stabilizer or antipsychotic for impulsive anger and aggression; or an antipsychotic for cognitive-perceptual disturbances (e.g., paranoid thoughts, hallucination-like symptoms, depersonalization.).
Medication may be prescribed to treat co-occurring conditions, such as mood disorders and anxiety disorders.
Individuals with NPD tend to report being extra sensitive to side effects, which can cause them to stop taking their medication. It’s critical for individuals with NPD to discuss their concerns with their doctor, and together, identify how to best minimize or effectively navigate bothersome effects.
Having a loved one who has narcissistic personality disorder (NPD) can be frustrating, overwhelming, and confusing. The severity of NPD symptoms varies among individuals. Some individuals may be entitled and selfish, while others are downright abusive. Which means that in some cases setting boundaries is enough, and in other cases, ending the relationship is critical.
Set boundaries. It’s critical to set limits, stand up for yourself, and express what is and isn’t acceptable. The key is to be clear, specific, and firm with your boundaries. This also means setting consequences if the person doesn’t respect your request (or outright bulldozes over your boundary)—and making sure to follow through with those consequences.
It’s likely that the person with NPD will try to cross your boundaries, especially if this is the first time you’re setting them. They might try to make you feel guilty or to manipulate the situation. Which is why it’s critical to be confident and assertive.
Practice self-care. Dealing with someone with NPD can be incredibly stressful and taxing. Make sure you’re taking compassionate care of yourself. Get enough rest and sleep. Engage in enjoyable activities. Meditate. Move your body. Surround yourself with supportive people who know how to foster healthy relationships.
Seek help for yourself. Another way to care for yourself is to work with a therapist. Doing so can help you learn to set and maintain boundaries, and effectively navigate stress. It can help you to feel validated and know you’re absolutely not alone. And it can help you leave the relationship, if you decide that’s what you need to do.
End the relationship. While some relationships with narcissistic individuals can be salvaged and improved, some cannot (particularly if there’s abuse). Be honest with yourself, and consider your emotional well-being. Walking away just might be the right choice for you. This article and this Psych Central piece offer insights into how to leave a narcissist.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Caligor, E., Clarkin, J.F., Yeomans, F.E. (2019). Transference-focused psychotherapy for borderline and narcissistic personality disorders. In David Kealy and John S. Ogrodniczuk (Eds.), Contemporary Psychodynamic Psychotherapy (pp.149-161). Cambridge, MA: Academic Press. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00010-6.
Caligor, E., Petrini, M.J. (2018, May 17). Treatment of narcissistic personality disorder. UpToDate.com. Retrieved from https://www.uptodate.com/contents/treatment-of-narcissistic-personality-disorder.
DiMaggio, G., Attina, G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of Clinical Psychology, 68, 8, 922-934. DOI: 10.1002/jclp.21896.
Ronningstam, E. (2016). Narcissistic personality disorder. In Howard S. Friedman (Ed.), Encyclopedia of Mental Health, Second Edition (pp. 182-185). Waltham, MA: Academic Press. DOI: 10.1016/B978-0-12-397045-9.00089-6.
Yakeley, J. (2018). Current understanding of narcissism and narcissistic personality disorder. BJPsych Advances, 24, 305-315. DOI: https://doi.org/10.1192/bja.2018.20.