Can individuals with narcissistic personality disorder change?

Can Narcissists Change?

Yes, individuals with narcissistic personality disorder (NPD) can achieve meaningful change and even remission through long-term psychotherapy, typically requiring 2.5 to 5 years of treatment. 1, 2

Evidence for Change in NPD

The most compelling evidence comes from recent case series demonstrating that patients with NPD can improve substantially:

• All eight patients in a 2024 case series no longer met diagnostic criteria for NPD after 2.5 to 5 years of psychotherapy, with large effect sizes for symptomatic improvement 2
• A 2023 qualitative study of eight patients showed significant improvement in personality functioning, work/education engagement, and long-term relationships, with complete remission of NPD diagnosis 1
• Systematic improvement was observed across content, process, and relationship levels during therapy, with patient in-session improvement directly correlating with treatment outcomes 3

Timeline and Nature of Change

Change in NPD follows a specific pattern that clinicians should anticipate:

• The process of change is gradual rather than sudden, with noticeable improvements often occurring first in specific life contexts 1
• Treatment duration of 2.5 to 5 years is typically required for remission of diagnostic criteria 2
• Early improvements include enhanced motivation for therapy, increased reflective ability, better emotion regulation, stronger sense of agency, and improved interpersonal engagement 1

Therapeutic Approaches That Facilitate Change

While no single approach has been definitively proven superior, evidence-based psychotherapeutic interventions include:

• Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Mentalization-Based Treatment, Schema Therapy, and Transference-Focused Psychotherapy are recommended evidence-based approaches for personality disorders 4
• Clarification-oriented psychotherapy showed systematic relationships between patient improvement across three levels (content, process, relationship) and treatment outcomes in 161 NPD patients 3

Common Pitfalls and Clinical Challenges

Clinicians must navigate specific obstacles inherent to treating NPD:

• Core features of NPD are associated with poor prognosis markers including slow progress to behavioral change, premature patient-initiated termination, and negative therapeutic alliance 5
• Resistance to psychotherapeutic change, inconsistent adherence to medical recommendations, and volatile relationships with providers characterize the treatment experience 5
• Lack of insight is a core feature of personality disorders and should be expected rather than viewed as exclusionary for diagnosis or treatment 4
• Assessment should rely on structured interviews and multiple informants rather than self-report questionnaires, as patients with personality disorders have impaired insight 6, 4

Factors Predicting Successful Change

Specific patient characteristics and therapeutic processes indicate potential for improvement:

• Patient motivation and commitment to psychotherapy, reflective ability, emotion regulation capacity, sense of agency, and interpersonal/social engagement are key indicators contributing to change 1
• Improvement in patient processes during sessions (not just therapist processes) systematically relates to treatment outcomes 3
• The therapeutic alliance quality and patient's ability to engage in the relationship level of therapy predict success 3

Diagnostic Framework Considerations

The evolving understanding of personality disorders supports a more nuanced view of change:

• The ICD-11 replaced discrete personality disorder categories with a single dimensional diagnosis differentiated by severity (mild, moderate, severe) and optional trait specification 6, 4
• This dimensional approach allows for recognition of partial improvement and severity reduction, rather than requiring complete categorical remission 6
• Personality disorders arise from complex interactions of genetic predisposition, environmental factors, and adverse childhood experiences, suggesting multiple potential intervention points 4

Practical Treatment Principles

Based on expert case analyses, successful treatment incorporates:

• Long-term commitment to therapy (minimum 2.5 years) with consistent attendance and engagement 2
• Focus on developing reflective capacity and emotional regulation before addressing interpersonal patterns 1
• Gradual building of therapeutic alliance while managing inevitable ruptures and resistance 5, 3
• Coordination with other healthcare providers when medical comorbidities exist, as NPD affects illness experience and healthcare utilization 5