Psychotherapeutic Treatment of Depressive Symptoms in Patients with Narcissistic Disturbances: A Review

by Jane Fjermestad-Noll, Elsa Ronningstam, Bo Bach, Ole Jacob Storebø, Bent Rosenbaum & Erik Simonsen


This review sought to outline the common complicating and facilitating factors during treatment of depressive symptoms in patients with narcissistic pathology, including various specific treatment approaches. A systematic literature search was performed to identify literature describing the co-occurrence of depressive symptoms and narcissistic pathology along with psychotherapeutic considerations and methods used to treat depressive symptoms in such patients. Theory and research suggest that depressive symptoms often co-occur with narcissistic disturbances because depression may emerge when narcissistic defenses fail. Narcissistic disturbances are thought to oscillate between grandiose and vulnerable features, and patients often seek treatment when they are in the vulnerable state. Psychological factors that are frequently dysregulated in these patients are shame, perfectionism and aggression. These factors must therefore be recognized as a part of the narcissistic pathology, and should particularly be considered in order to build a psychotherapeutic alliance with the patient, to avoid premature termination of treatment, and to achieve a positive treatment response. Psychotherapy must primarily target the underlying narcissistic disturbance, and not the depressive symptoms per se. The review aims at outlining treatment approaches that may be useful for clinicians.

Journal of Contemporary Psychotherapy, 50, 21–28, March 2020.

Link to Online Publication [fulltext can be requested from the library].

Elsa Ronningstam, PhD is an Associate Professor of Psychology at Harvard Medical School and a Clinical Psychologist at McLean Hospital in Belmont, Massachusetts. She is a member of the faculty at the Boston Psychoanalytic Society and Institute and a member of the Boston Suicide Study Group. She has published and presented extensively nationally and internationally on topics related to studies and treatment of suicide and personality disorders. Her other recent publication Internal Processing in Patients with Pathological Narcissism or Narcissistic Personality Disorder: Implications for Alliance Building and Therapeutic Strategies appeared in the Special Issue of the Journal of Personality Disorders devoted to narcissism.

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