Narcissistic Personality Disorder

The family physician's reactions to the narcissistic patient are often difficult to manage. The superior, entitled, self-loving, arrogant attitude of these patients can be intimidating. They may elicit feelings of being devalued and inferior. The physician may have concerns about the patient's anger and criticism. Alternatively, the lack of empathy and interpersonal exploitation of these patients can readily provoke the physician to anger, a wish to retaliate with harsh criticism, or a desire to end the patient-physician relationship.

The core fears of narcissistic patients are the result of a fragile self-esteem and their need for constant approval and praise from others. They fear loss of admiration, potency, and power, and fear being exploited when vulnerable. Any perceived insult to their "grandiose self" (Kernberg, 1984, 1992) makes them feel rejected, deflated, and criticized and frequently results in feelings of rage, shame, or humiliation.

The narcissistic patient has generally intact reality testing, yet can undergo severe reality distortions when he perceives slights, rejection, or competition from others with talent. Those narcissistic patients who have paranoid and antisocial features (Kernberg, 1992) have a worse prognosis. They often have a fragile identity that can swing from the grandiose to the worthless. They rely heavily on splitting mechanisms to regulate their self-esteem. They portray themselves as grandiose and superior. This helps defend against feelings of extreme inadequacy and vulnerability. They can devalue, viciously attack, or degrade those around them when they act in a self-important way. Alternatively, as splitting operates, they may idealize or be envious of others who are, for the moment, seen as more powerful or successful. In this position, their self-esteem plummets, as evidenced by their sense of worthlessness and their reports of deprecating and degrading self-attacks.

Office management of the narcissistic patient, as well as many antisocial patients, requires that the physician not mistake the patient's superior and entitled manner for genuine confidence. When being verbally devaluing, it may help the physician to view the demeaning or verbally attacking patient as a wounded child having a "temper tantrum." This may prevent the physician from retaliating, by demeaning the patient, which only escalates a maladaptive interaction. Intervening in the face of a devaluing attack involves acknowledging that the patient feels hurt and that the patient also has a right to her opinions. If this patient can discuss these hurt feelings with a nonjudgmental and empathic physician, the problems generally resolve and a good physician-patient alliance can be restored. If this is not possible, offer the patient the right to seek another expert for consultation. This offer needs to be made without malice, defensiveness, or apology. This may help the patient calm down and reconsider his position.

In a long-term relationship with a narcissistic patient, the current splitting can be interpreted. This can be done by reminding patients that they previously praised the skill and abilities of the physician. Patients can be asked why they are now so critical and angry. When this is effective, it will allow patients to discuss their perception of insults to their self-esteem.

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