Clinical supervision gr | NURS 6650 – Psychotherapy With Groups and Families | Walden University

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Personality disorders refer to a group of mental illnesses that involve enduring patterns of thoughts, feelings, and behaviors that are not healthy which significantly and adversely affect how an individual functions in work, relationships, and various aspects of life.  According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), personality disorders fall into 10 distinct types: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive. The DSM-5 further divides PDs into three categories of clusters.  Cluster A: schizoid, schizotypal, paranoid the client may have odd or eccentric behaviors.  Cluster B borderline, histrionic, antisocial, narcissistic with dramatic behaviors.  Cluster C avoidant, dependent, obsessive-compulsive which includes anxious and fearful behaviors (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2013). 

This paper will discuss Narcissistic personality disorder a cluster B disorder.  A narcissistic personality disorder is characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. The client with NPD may experience significant psychological distress related to interpersonal conflict and functional impairment. Research has shown that core features of the NPD are associated with a poor prognosis in therapy, slow progress to behavioral change, premature patient-initiated termination, and negative therapeutic alliance (Dixon-Gordon et al., 2015).  A narcissistic personality disorder is prevalent, highly comorbid with other disorders, and associated with significant functional impairment and psychosocial disability.  NPD is a challenging clinical syndrome, variable presentation, difficult to treat, and often exists with co-occurring disorders which further complicates treatment.  

Therapeutic Approach

 Due to the complexity of identifying and treating NPD and the absence of expertise or resources for longer-term treatment of personality disorders, some specific approaches and techniques can be implemented to improve general clinical management of patients with the disorder.  There are no FDA-approved treatments for NPD, or any other personality disorder and clinicians use psychotherapy but the personality disorder is a challenging condition to treat (Dixon-Gordon et al., 2015).  Treatments for narcissistic personality disorder current treatment recommendations are based on clinical experience and theoretical formulations. Psychodynamic formulations have led to an increase in various treatment approaches, and case reports suggest that these treatments can be effective for some clients.  The recommended psychotherapies included: mentalization-based therapy, transference focused psychotherapy, and schema-focused psychotherapy. Each of these treatments targets psychological capacities thought to underlie and organize descriptive features of narcissistic personality disorder(Caligor et al., 2015).  However, medication may be used when clients with NPD have severe symptoms that compromise their safety. Medications include mood stabilizers or antidepressants for significant affective instability; mood stabilizer or antipsychotic for impulsive anger and aggression; or an antipsychotic for cognitive-perceptual disturbances such as paranoid thoughts, hallucination-like symptoms, depersonalization (Caligor et al., 2015).   Also, medication may be prescribed to treat co-occurring conditions, such as mood and anxiety disorders.  Clients with NPD tend to report being extra sensitive to side effects, which can cause them to stop taking their medication.  A strong therapeutic alliance has been linked to treatment success in clients with PDs. 

As the PMHNP providing care to a client with NPD, the diagnosis must be shared with the client.  This is an important part of informed consent.  In providing care for an NPD client it is imperative to discuss the etiology, clinical manifestations, course of illness, and treatment options.  Withholding diagnostic information may cause problems by focusing on comorbid conditions like depression or anxiety which the client may respond poorly to treatment.  Hence, if the narcissistic problems are not also addressed then the psychotherapies and medications to address depression and anxiety may be ineffective, lead to clinical worsening, and contribute to high drop out rates for NPD clients (Dixon-Gordon et al., 2011).      

In conclusion client with NPD are difficult to treat based on symptoms are closely linked to other psychosocial disorders and comorbid disorders. Also, treatment for NPD can be difficult for the client and therapist due to the frustration of the therapeutic progress.  NPD is an often misunderstood mental condition where a person acts arrogantly, lacks empathy, needs constant attention and admiration, and has an inflated sense of self.  There is still considerable research that needs to be done regarding the treatment of personality disorders. However, research suggests there is hope for the future in making significant changes in the psychosocial treatment for clients with personality disorders (Dixon-Gordon et al., 2011).  The PMHNP must be knowledgeable of available evidence-based practice, and well-trained to treat clients suffering from personality disorders.   Evidence has shown that PDs are treatable disorders.   The therapeutic alliance is an essential ingredient in all successful doctor-patient interactions, it is especially important when treating a narcissist. Patients with narcissistic traits commonly terminate treatment with medical providers after incidents that providers perceive as harmless misunderstandings.  Increased awareness of the clinician’s feelings when treating these patients will allow the clinician to better recognize the presence of narcissistic traits. This awareness, coupled with an improved understanding of what drives narcissistic behavior, will allow practitioners to manage these patients more effectively in a variety of medical settings.

  

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). (2013). American Psychiatric Association.

Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415–422. https://doi.org/10.1176/appi.ajp.2014.14060723

Dixon-Gordon, K. L., Turner, B. J., & Chapman, A. L. (2011). Psychotherapy for personality disorders. International Review of Psychiatry, 23(3), 282–302. https://doi.org/10.3109/09540261.2011.586992

Dixon-Gordon, K. L., Whalen, D. J., Layden, B. K., & Chapman, A. L. (2015). A systematic review of personality disorders and health outcomes. Canadian Psychology/Psychologie canadienne, 56(2), 168–190. https://doi.org/10.1037/cap0000024

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