Borderline Personality Disorder with Narcissistic Features

Abstract

This case illustrates important principles of treating patients with BPD and narcissistic problems. Initial assessments should include evaluation and discussion of narcissistic and self-esteem problems, using language that is acceptable to patients. This allows treatment planning that considers evidence-based treatments for BPD, adapted for focusing on difficulties related to narcissism and self-esteem fluctuations. For general clinicians without specialty BPD training, the most useful treatment approach may be built on the model of interpersonal hypersensitivity in BPD. This simplified approach can be modified to address intrapersonal hypersensitivity, in which patients reject themselves (and others) when they fail to meet excessively high internal standards. This treatment builds on principles helpful for patients with BPD alone, including use of case management techniques, emphasis on collaboration, focus on work functioning initially, and examination of problems using the lens of interpersonal hypersensitivity. The concept of intrapersonal hypersensitivity provides guidance in difficult treatment situations that arise when patients elicit powerful reactions in their treating clinicians.