Jeffrey, a 52-year-old single New Yorker and former literary agent, has a history of treatment-resistant major depressive disorder (TRMDD) and generalized anxiety disorder (GAD). He was hospitalized for depression and suicidal ideation after losing his job (successful 20-year career) and partner of 15 years. He had controlled his depression and anxiety without psychiatric care, but his mental health deteriorated during COVID. He struggled to adapt to remote work and unfamiliar technology, unlike younger colleagues. His feeling of inadequacy contributed to worsening depression and anxiety.

Jeffrey “lost faith” in his healthcare when his symptoms worsened. A string of hospitalizations and various clinical trials for antidepressants, mood stabilizers, antipsychotics, ketamine, and electroconvulsive therapy (ECT) led to partial-to-no effect. His deteriorated occupational/social functioning, job and relationship losses, and worsened depression, anxiety, and hopelessness led him to plan suicide.

Admitted involuntarily to a hospital due to risk for self-harm, Jeffrey was given new drugs. Psychotherapy initially focused on his poor self-esteem and frustration, as he job searched. He tried cognitive behavioral therapy (CBT), including cognitive restructuring and exposure to new technologies.

Treatment initially helped with mood and reduced suicidal ideation, but Jeffrey was sad most days. He fixated on medication doses and adverse effects, demanding his regimen be changed. To his mother, he expressed hopelessness, frustration with his care, and feeling misunderstood by his team. He was put on a potent antidepressant that raised his energy, but didn’t improve his mood and anxiety. His team saw his anxiety coming from unrealistic expectations about how quickly his mood would improve and how easy it would be to find a job.

Jeffrey believed he’d be able to start his own literary agency and become a member of elite NYC social clubs. He envied ex-colleagues’ technological knowhow, but also criticized their inability to “read people” as well as he could. He resented their unwillingness to recognize this quality in him. In contrast, his ex-partner was an “angel,” supportive of his endeavors. He bemoaned finding another like them.

Jeffrey’s affect dramatically improved as an in-house patient, with less sleep disturbance, fatigue, concentration, and suicidality — but he still felt depressed, hopeless, and anxious. He was discharged to an acute care program. Despite frequent attendance, his depression relapsed relatively rapidly, resulting in another hospitalization.

The Vulnerable Narcissist

Jeffrey struggles with feelings of inferiority, self-doubt, and hypersensitivity, consistent with vulnerable narcissism, and depressive tendencies of poor self-definition/self-image. His grandiosity and fantasies of unlimited success and specialness — with unique interpersonal skills, special talents at work, unconditional admiration in personal relationships — are narcissistic defenses to protect this fragile self-image.

Stressors (job loss/breakup) can inflict narcissistic injuries—perceived threats to self-esteem—overwhelming his defenses, causing withdrawal, depression, self-accusation. He’s embarrassed and disappointed, envious of others, and feels misunderstood, mistreated, and powerless. His dependent character structure (over relying on his treatment team, needing his mother’s constant reassurance) reflects his self-doubt.

Jeffrey’s condition is consistent with research on the comorbidity of vulnerable narcissism and dependent personality disorder (DPD). His rapid affective changes reflect responses to treatment as well as his vacillating self-esteem.

Medication helps with Jeffrey’s depressive symptoms (sleep disturbance, decreased energy, poor concentration), but fail to sufficiently treat the guilt, worthlessness, social withdrawal, and depressed mood that reflects his underlying personality dysfunction.

His care is fragmented as he seeks new treatment teams, often oscillating between overdependence and devaluation. Jeffrey is therefore unable to engage in possibly the most effective treatment for him: a consistent psychopharmacologic regimen targeting symptoms, in combination with long-term, evidence-based psychotherapy.

Clinical Challenges

Jeffrey’s case shows the challenges in diagnosing MDD in individuals with NPD’s vulnerable traits. Overlapping symptoms make it difficult to attribute symptoms to the mood disorder or to the character pathology. There are also challenges with psychotherapy. Narcissists with exaggerated self-esteem don’t always recognize their problems and engage in treatment. The therapeutic alliance is challenged by therapists feeling coerced to find a panacea or feeling disparaged as incompetent.

Although treatment guidelines are scant, many of the recommended therapeutic approaches — mentalization-based therapy, transference-focused psychotherapy, schema-focused psychotherapy, and dialectical behavioral therapy — are adapted from the treatment of borderline personality disorder (BPD).

Treatment success requires a long-term relationship between patient and therapist, which is impractical in acute care. It’s not surprising that Jeffrey, with comorbid NPD and major depression, has a slower and less significant recovery.

Another difficulty is in identifying NPD when the prominent traits are not externally conspicuous behavior, but vulnerability. In terms of long-term psychotherapy, what’s needed is nonjudgmental, curious interventions that use the patient’s own words and recognize their vulnerability, ultimately challenging their self-criticism and encouraging interpersonal connections. Therapy should also set clear and achievable goals that are periodically reviewed with the patient.

Concluding Thoughts

NPD and MDD are common, and commonly comorbid, disorders, causing a significant level of distress and dysfunction. While individuals with NPD don’t often seek care, a major depressive episode may bring them to clinical attention, necessitating diagnosis and appropriate treatment of both conditions. Although the co-occurrence of NPD and MDD may add insult to injury for patients and compound challenges for clinicians, appropriately recognizing and addressing both may soften the blow. —Yaakov Green and Claire Holderness, “Adding Insult to Narcissistic Injury: Comorbidity of Narcissistic Personality Disorder and Major Depressive Disorder,” Psychiatric Times