Personality disorders are typically some of the most challenging mental disorders to treat, since they are, by definition, an integral part of what defines an individual and their self-perceptions. Treatment most often focuses on increasing coping skills and interpersonal relationship skills through psychotherapy.
Narcissistic Personality Disorder
Narcissistic patients try to sustain an image of perfection and personal invincibility for themselves and attempt to project that impression to others as well. Those with narcissistic personality disorder project an inflated sense of self because underneath that image of grandiosity is really an insecure person with very low self-esteem. The grandiose image is a way to protect themselves from fearing that others will find out that they have weaknesses and imperfections just like everyone else.
The DSM IV diagnosis of narcissistic personality tends to be more common in men than women. Because of their inflated sense of self importance, narcissists tend to be driven to achieve high levels of accomplishments. It is common to find narcissistic personalities amongst politicians, wealthy businessmen, movie producers, surgeons, and trial attorneys. The illusion of "greatness" they project to others is most commonly shattered by some substantial threat to their ego such as a physical illness, loss of a job, loss of a relationship, or depression when sensing that their lives are actually quite empty even though they may have acquired much material success. This loss precipitates a panicky sensation that "my world is falling to pieces," and the patient feels that his/her life is unraveling.
Most psychiatrists will, as a practical matter, treat most of their severely narcissistic patients for symptoms related to crises and relatively external Axis I diagnoses, rather than in an effort to address the personality disorder itself. The therapist must be aware of the importance of narcissism in helping to sustain the patient's self image, of refraining from confronting the need for self-aggrandizement, and of helping the patient use his or her narcissistic characteristics to develop a self-image based upon genuine positive self esteem rather than out of fears of inadequacy. Those patients who do not terminate treatment after symptom relief has been obtained may wish to receive help for some of the problems related to their personality disorder, such as interpersonal difficulties or depression.
If possible, long-term individual psychotherapy is the treatment of choice for those with narcissistic personality disorder because it helps to establish a strong therapeutic alliance between therapist and patient. Yet, even within this framework, expectations should focus on small changes in personality traits as opposed to expecting large changes as being possible.
Goals in therapy should focus on helping the patient develop some empathy for others by learning to appreciate other's feelings and points of view, acknowledging his/her "specialness" while helping the patient learn how to put it into perspective, and helping the patient learn how to appropriately handle slights and rejections from others without feeling one's sense of self as being extremely threatened. These goals can all be developed within the safety of a strong therapy relationship between therapist and patient so that when the patient's vulnerabilities are exposed, the therapist can help the patient feel okay about these vulnerabilities while gently putting the patient's exaggerated sense of self-importance back in perspective.
Group therapy for those with narcissistic personality disorder tends to be ineffectual. Usually in a therapy group, narcissists will tend to dominate the group or tire other group members with their list of accomplishments and grandeur. Because they do not respond well to critical feedback, narcissists are likely to drop out of group therapy once others start providing feedback about their behavior. Or, on the other hand, the other group members might drop out of the group because they get tired of the narcissists dominating the therapy.
The hospitalization of patients with severe Narcissistic Personality occurs frequently. For some, such as those who are quite impulsive or self-destructive, or who have poor reality-testing, this is the result of Axis I symptoms that are overlaid upon the personality disorder. Hospitalizations should be brief, and the treatment specific to the particular symptom involved.
Another group of patients for whom hospitalization is indicated, provided long-term residential treatment is available, are those who have poor motivation for outpatient treatment, chronic destructive acting out, and chaotic life-styles. An inpatient program can offer an intensive milieu, which includes individual psychotherapy, family involvement, and a specialized residential environment. The structure is physically and emotionally secure enough to sustain the patient with severe ego weakness throughout the course of expressive, conflict-solving psychotherapy. The ultimate goals are of affecting a more integrated, cohesive self-concept that is less vulnerable to slights, criticisms, rejections, or general blows to self-esteem.
Portions are from Internet Mental Health, Copyright © 1995-1996 by Phillip W. Long, M.D.