Narcissistic Personality Disorder: Re-Imagining Treatment

Background:

I have been a consumer of mental health services for a litany of diagnoses including but not limited to NPD. With this said, this presentation is intended to explore existing definitions of NPD and offer additional insight into other possible treatment pathways for people seeking support and resources to battle this disorder. The definition for NPD is complex, and can be located in the United States as well as others countries which medicalize pathology in the DSM-5 Diagnostic Manual for Mental Disorders.

As the article unfolds, I will suggest there may be different available options and treatment pathways for targeting the symptoms which consumers need relief from to be successful in their lives and live without having to live with this diagnostic label which only serves to propagate stigma and other biases around this and other personality disorders as well as for people carrying a mental health diagnosis. Ultimately, this article will hopefully set the stage for new conversations around personality disorders, their treatment, diagnosis, and language for people whom have been limited by their psychiatric label of NPD.

DSM-5 Definition and Criteria:

The DSM-5 offers a a diatribe cataloging the specific symptoms of NPD, which according to the manual, is indicated by five or more of the following symptoms:

• Exaggerates own importance

• Is preoccupied with fantasies of success, power, beauty, intelligence or ideal romance

• Believes he or she is special and can only be understood by other special people or institutions

• Requires constant attention and admiration from others

• Has unreasonable expectations of favorable treatment

• Takes advantage of others to reach his or her own goals

• Disregards the feelings of others, lacks empathy

• Is often envious of others or believes other people are envious of him or her

• Shows arrogant behaviors and attitudes

Treatment Approaches in Psychotherapy

Previous research suggests gathering “grandiosity and defensiveness” of people typically carrying this diagnosis creates complications for people undergoing treatment with psychotherapy. I am now suggesting a new approach which realizes these so-called symptoms for NPD and understands them as strengths for therapists to capitalize upon for treatment of the disorder.

Firstly, it must be said that people don’t come in through the therapy office door, by in large, requesting treatment for their NPD. NPD can contribute to other diagnoses and psychosocial & psychological problems for patients to manage on their own without treatment. For example, typically NPD patients present with depression or related anxiety because of various symptoms and unmet needs which drive these patients into treatment.

Based on this assumption, I would hazard to say that the primary focus of psychotherapy should not be on treating the NPD symptom but, instead, on its manifestation into other psychiatric and psychological problems, e.g. Depression, Anxiety, and other affective state regulators which become corrupted when the NPD symptom becomes active.

Thus, instead of re-inventing the wheel in psychotherapy, practitioners can focus on treating the real problem with the same sophistication as any other disorder that fits the treatment approach. This can be done in group therapy which has proven to be helpful for clients to gain the reflective lens necessary to cultivate personal insight into their interpersonal landscapes.

With the exception of “lacking empathy”, most if not all of the so-called indicators for NPD can be mobilized into strengths for consumers in NPD treatment. I will use the example of grandiosity and requiring excessive admiration from others to illustrate how this “deficit” can be flipped into a strength and even asset to the person carrying this label.

In as previous blog entry, I talked about a concept I term: Too Big too Fail. In short, this means it is in the interest of people carrying a diagnosis to mobilize all of their resources and support to meet their day-to-day challenges to reduce the likelihood of their opportunities turning up short of their expectations and hopes.

Simply put, there is never a reason not to be fully prepared in the day’s endeavors and be ready for anything. In a world where the unlikely is possible, and there is no definite, I can fully understand why people carrying this diagnosis are labeled as grandiose when it is really about being mindful and articulate about your needs as a consumer and what it will take for you to be successful in life.

Finally, it is not the therapists role to teach empathy unless that is the stuck point in the work which is keeping someone from realizing their missed opportunity for insight. Empathy, however, can be re-framed and posited as skill or technique for people to learn in psychotherapy to barter for their own goals without walking over the needs of others in his or her life.

Through bartering, people will be less inclined to feel envious because they are participating in a system that leaves room greater exchange of ideas and currency for people carrying this diagnosis. Instead of placing limitations and teaching restraint, people with this diagnosis are taught to reach for the upper limits of their personal success.

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised.

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

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