The Narcissistic Personality and Depression

Narcissistic people rarely come to therapy unless there is a level of suffering that becomes unbearable. Or, on rare occasions, if they become unbearable to others.  This  can perhaps be due to relationship change, role loss, grief - and depression. Mood disorders and personality disorders live in two diagnostically different categories. Depression is episodic, and personality disorders are complex and constant. Pathological narcissism can very much complicate the diagnosis and treatment of depression. When I say depression, I am referring to a ‘Major Depressive Episode’ - the kind where someone has an onset of mood and behavioural changes with a symptom array that is consistent for at least three weeks and that disrupts their daily routines.  This includes sleep and appetite changes, irritability, poor attention and concentration, negative thought patterns, and, most importantly, anhedonia. (Not deriving pleasure from life as one once did).  When I set out to research narcissism and depression, I honestly didn’t find much, so I will share here what I did find, as well as my own observations. 

As a general rule, narcissists have mood states that can swing from grandiosity to despair. This is about regulating the ego, the homeostasis of simply being in the world.  This tends to be fleeting in nature, and has a lot to do with how they need outside validation to feel good. I would propose that certain life changes, disappointments and losses can lead one to despair, which, without these regulating factors, can lead to depression. This could of course be described as narcissistic collapse - when the grandiosity no longer functions in the way it had been. This, however, is still different from a major depressive episode.  This is what I would most commonly see in the therapy space.  There is also a high co-morbidity of substance use which may be a risk factor for depression, as well. 

From the research I did, it is apparent that vulnerable narcissists are more prone to depression, and in fact are more likely to be diagnosed with depression - while the chronic, complex components of the personality disorder are missed. Vulnerable narcissists are somewhat more internalizing and maintain more of a victim mindset.  Grandiosity, or delusions of grandeur can be defence mechanisms against low mood. Those who are more grandiose in their presentation will have a tendency to externalize their frustrations, as well. That means that they take out their negative feelings on other people. Anyone who has ever lived with, or worked with a highly narcissistic person will know what I am referring to here. 

The complications for treatment are fairly predictable. Highly narcissistic people are not comfortable seeking help. They need to be seen in high regard by trained professionals - so they will let us know that they ‘know more than we do’. They become hyper-focused on being treated ‘like they are special’ rather than investing in a plan of change.  They lack the self-awareness that can lead to helpful inquiry and changing negative thought patterns. They don’t trust easily, are heavily defended and this makes therapeutic alliance quite challenging. I do think, however, that medication, and activational goals, such as changes to diet, exercise and sleep routines can be helpful. (Just as they would be to anyone). 

Stacey Sanderson