A 45-year-old male is diagnosed with narcissistic personality disorder (NPD) comorbid with generalized anxiety disorder (GAD) and major depressive disorder (MDD). He has been treated with long-term psychodynamic psychotherapy on multiple occasions for 6 months to two years at a time. He has taken escitalopram 20 mg/d for 10 years. Sometimes, he has brief periods of depression lasting a few weeks at a time.
He has occasional suicidal ideation for the past 10 years. He has abused alcohol in the past, but has been sober for 5 years. He has never been hospitalized, overdosed, nor engaged in cutting behavior. His first cousin was diagnosed with bipolar disorder and did well on lithium. He was raised by an intact supportive family, became a lawyer, divorced twice, now lives alone, and never had childhood trauma.
He was seen as narcissistic because he has very high self-confidence, generally thinks he is smarter than others, and devalued his ex-wives. When asked about his failed marriages, he says: “They didn't appreciate me enough.” At work, colleagues see him as arrogant, and although he is productive, interpersonal tensions and disrespect for authority have limited his promotion in a corporate law firm.
On evaluation, when asked about his energy, sleep, mood, and activities, he reports constant mood swings, on an hourly basis, sometimes very happy for hours and sometimes irritable and down for hours. He usually only needs 4 hours of sleep nightly, and has a high energy and activity level compared to peers, and a very high libido all the time. He reports feeling anxious and having “nervous energy” most of the time. He is an active rock climber, bikes 20 miles each morning before going to work, and sees himself as a “workaholic.”