Thread by @ScottMuirMD

How to manage narcissistic personality disorder in clinical practice, an experimental thread: #MedEd #psychtwitter

The drop out rate of patients with narcissistic personality disorder from Treatment is on the order of 60%

making the diagnosis matters, you're probably more afraid of it then the patient is.

When providing psychoeducation, start with curiosity: has anyone ever called you a narcissist?

"do you think they may have been onto something?"

The NPD-1 is a one question personality inventory for narcissistic personality disorder. It's one question is "are you a narcissist?"

It's more useful than the NPD 40 on average

NPD can be difficult for people, or they wouldn't be coming to see you in therapy. This is usually not the presenting complaint.

When I'm explaining this condition, are usually talk about vulnerability, and I like the metaphor of superman and kryptonite for those of that era. It's not that being super man is a Problem per se, is that it leaves you vulnerable to kryptonite.

In people suffering with NPD, they have a built-in vulnerability that comes with their super power--they believe in themselves, and that they can do amazing things, but when there is a crack in that accomplishment, and when people don't believe in them, it acts like kryptonite

So the disorder is really the distress they feel when people don't believe in them. Or when they don't believe in themselves.

Being remarkable means sometimes, either through mistakes or chance alone, sometimes things don't work out. People with NPD are particularly vulnerable to these defeats. The very same rocket fuel that helps them succeed, it can lead to being especially vulnerable

As guidance for clinicians: validation usually goes worse with this patient population than you think it will. A common response will be some thing like:
"You couldn't possibly understand"

This is an opportunity to validate that experience! "even for me, as a professional understander, I didn't get it! I imagine it's pretty lonely to be so misunderstood so much of the time?"

Don't be defensive. Don't assume your patient isn't great. Do lean into getting it wrong.

Validate the fact that it's hard to understand them.

Group Therapy is especially effective in this population, I am a particular fan of mentalization Based treatment, but I will know the group therapy goes better if the group has more npd individuals in it.

The Anna Freuw Center has some great guidance on this.

There is a relatively high rate of completed suicide in this population, so it can be a risky population to work with.

The heritability is very high, and the order of .71.

You are likely to be rejected.

It's worth working with this population, but it's even more worth understanding what this population looks like, so you know what to do.

Everyone deserves our respect, and has the right to good care. They don't have the right to good care with you specifically if there is a rupture in therapeutic trust which is by directional.

Thanks for reading this thread! Please feel free to share if it's helpful.