As a practicing physician, it's inevitable that you’ll encounter a narcissistic patient at some point.

Up to 6.2% of patients in community samples have narcissistic personality disorder (NPD), which according to the DSM-5 is in the Cluster B category (ie, “emotional, dramatic, and erratic”), according to a study published in Behavioral Medicine.

Kacel EL, Ennis N, Pereira DB. Narcissistic personality disorder in clinical health psychology practice: case studies of comorbid psychological distress and life-limiting illness. Behav Med. 2017;43(3):156–164.

 

Patients with NPD are more likely to utilize health care resources, which further increases your own chances of encountering them. Notably, they’re more likely to have not only psychiatric issues such as anxiety, depression, and suicidality, but also somatic pathology including heart and gastrointestinal disease.

 

Countertransference

Doctors traditionally adopt a maternal or paternal role with patients. With NPD patients, however, countertransference and associated entanglement can become an issue. A physician or other healthcare provider could adopt the grandiose, deficient self-appraisals of the narcissistic patient including feeling devalued, idealized, disregarded, and impatient.

Many clinicians experience these feelings while caring for narcissistic patients, and providers shouldn’t blame themselves or pass judgment.

“Rather than assess the rightness or wrongness of having these feelings when working with narcissists, practitioners should focus on deciphering why they feel the way they do and on how these feelings can be harnessed to better manage these patients,” wrote the authors of an article published in The Primary Care Companion for CNS Disorders.

Rose AB, Stern TA. Narcissistic patients: understanding and managing feelings and behaviors. Prim Care Companion CNS Disord. 2015 Aug 27;17(4):10.4088/PCC.15f01823.

 

 

Managing NPD cases

Various barriers present in patient interactions involving NPD, according to the authors of the Behavioral Medicine study. These patients could exhibit the following:

• Cognitive distortions

• Idealizing/devaluing clinicians

• Assistance-rejecting behaviors

• Poor boundaries

• Ambivalence regarding change

• Poor adherence

The authors wrote specifically about psychotherapy patients seen by psychologists, but their characterization of patient encounter challenges could apply more generally.

The authors of the article published in The Primary Care Companion for CNS Disorders provided more advice:

Realize that patients with NPD are likely to terminate a relationship due to the smallest perceived slight or ego assault that feels shaming. Consequently, sometimes the best you can do is extend the relationship for as long as possible.

Treating patients with NPD requires a physician to have insight into their condition.

By modeling emotions that narcissists typically find intolerable (eg, remorse, humility, gratitude), practitioners can generate a less threatening atmosphere and demonstrate non-pathologic coping skills to these patients.

 

Handling confrontations

In the immediate wake of an incident that the narcissistic patient feels is threatening, communicate remorse about what they found insulting or painful.

You can also admit your mistakes while projecting an upbeat image. This can make the patient feel that mistakes are acceptable and don’t necessarily attack their self-worth.

Expressing humility can also help model such behavior for the self-critical narcissistic patient. Combined, these strategies may help the patient open up to you about their problems and complaints.

Keep in mind that another challenge with NPD patients is that they may find direct conversations about pathology threatening, demeaning, or critical due to their extreme sensitivity to criticism. Discussing pathology may lead to a power struggle, so it’s important to engage in the aforementioned modeling behaviors.

McLean Hospital also provides some insightful guidance on how to manage patients with NPD.

Ronningstam E. Narcissistic personality disorder: a basic guide for providers. McLean Hospital.

Once again, this information is geared towards the mental-health professional, but much of it’s generally applicable. Here are some highlights:

 

• Treatment should be geared to the patient’s issues and functioning.

• Some patients may want to focus treatment on their own goals, and a flexible, collaborative, exploratory approach may be beneficial. Negotiating a mutual agreement may be a good idea.

• Focus first on the patient’s most urgent problems and glean their insight into these issues.

• Remain respectful, nonjudgmental, and on task at all times.