NURS 753 Week 7 Case Analysis Evaluation 3 on Depression With Narcissistic Personality Disorder Example

Passed Over After the Merger: A Case Analysis of Depression in a 47-Year-Old Sales Director With Narcissistic Personality Disorder and a Psychotherapy Plan Built Around the Alliance

Case Presentation

Mr. K., a 47-year-old regional sales director, came at the urging of his primary care nurse practitioner after four months of low mood, irritability, poor sleep and fatigue. The problems began when his company merged with a competitor and he was passed over for vice president in favor of a younger colleague from the other company, then moved to a smaller territory. He describes the decision as "a joke" made by people "who have no idea what I built," and spends hours each evening replaying meetings and composing emails he does not send. He has stopped going to the gym, sleeps poorly, has lost interest in golf and feels "flat and furious at the same time." His wife told him that if he did not get help she would move out; he says he came "to prove I'm fine." Twice, after being corrected in a team meeting, the thought came that his family and team might do better if he were gone; these faded within a day.

He has no previous psychiatric treatment, drinks two glasses of wine most nights, more since the merger, and has no history of mania or substance use disorder. His wife describes a long pattern of needing to be the most accomplished person in the room, difficulty hearing criticism, expecting special treatment from staff and family, and little patience for others' problems, alongside generosity when he is admired and real devotion to their two teenage children.

Assessment

Interview and Measures

The first interview required care. Mr. K. began by listing his achievements and questioning whether a nurse practitioner was qualified to treat him. Rather than defend my credentials, I reflected how painful it must be to have built something and feel it taken away, which changed the tone of the conversation. He scored 17 on the PHQ-9, which falls in the moderately severe band. He met criteria for depressed mood and anhedonia for more than two weeks, with insomnia, fatigue, poor concentration and feelings of worthlessness that he expressed as rage at others rather than self-blame. His AUDIT-C score was 4, indicating drinking to monitor.

Suicide Risk

He reported passive thoughts of death on two occasions, each triggered by a humiliation at work and resolving within a day, with no plan, intent or past attempts. He owns no firearms. Risk factors include middle-aged male sex, recent occupational loss, increased drinking and a pattern of shame-triggered ideation; protective factors include his children, his marriage and his wish to "come back." This pattern matters: in a comparison of 61 outpatients with narcissistic personality disorder and depressive symptoms and 56 depressed patients without personality disorder, the narcissistic group showed reactive, fluctuating depression with hostile, accusatory rumination toward others and suicidal ideation triggered by external events, rather than melancholic features (Fjermestad-Noll et al., 2019). We completed a safety plan with his wife's participation.

Personality Assessment

Over two sessions and with his wife's account, I reviewed personality features against DSM-5 criteria. He described and demonstrated a grandiose sense of self-importance, preoccupation with success, a belief that he should associate only with high-status people, a need for admiration, entitlement, limited empathy and arrogance, seven of the nine criteria, present since early adulthood and across work and family settings.

Diagnosis

Mr. K. meets DSM-5 criteria for major depressive disorder, single episode, moderate, and for narcissistic personality disorder (American Psychiatric Association, 2013). The personality diagnosis was not shared in the first session; it was discussed later in terms of patterns he recognized, such as how criticism affects him, consistent with concern about stigma and how diagnosis disclosure is handled in this population (Dimaggio et al., 2026).

Therapeutic Intervention

Formulation

Mr. K.'s self-esteem has rested on achievement and admiration. The demotion removed both, exposing a vulnerable sense of worth beneath the grandiose surface. He defends against shame with anger at others and rumination about injustice, which keeps the injury alive, while withdrawal from the gym, golf and friends removes sources of reward and deepens the depression (Wheeler, 2014). Any clinician who questions or corrects him risks becoming the next person who has humiliated him.

The State of the Evidence

Treatment of the depression rests on strong evidence for cognitive behavioral approaches and antidepressants. Treatment of narcissistic personality disorder does not. An international group of personality disorder experts concluded in 2026 that the field urgently needs empirically supported treatments and cautioned against treating a recent trial as a benchmark because of serious methodological concerns (Dimaggio et al., 2026). Early work is encouraging: in a feasibility study of a group psychoeducation program for 25 patients with pathological narcissism, attendance averaged 83% with one dropout, satisfaction was high and self-reported grandiosity decreased, although participants reported strong emotional activation and a need for individual support, and the design could not show causation (Blay et al., 2026). The plan therefore treats the depression with established methods and adapts them to his personality.

Alliance First

The first target is the relationship. In sessions 1 to 3 I will acknowledge his competence and losses, collaborate on goals he values, return to work at the level he wants, a calmer home and better sleep, and agree on how we will handle moments when he feels criticized by me. Ruptures will be named and repaired openly: when he dismisses a suggestion or becomes angry, I will ask what felt wrong and acknowledge my part. With this patient, the moment he feels insulted by the therapist is not a detour from treatment; it is the treatment.

Sixteen-Session Plan

Sessions 4 to 8 use behavioral activation: scheduling the gym, golf with a friend and time with his children, with weekly monitoring of activity and mood. Sessions 6 to 12 add cognitive work focused on rumination and on the belief that his worth depends on rank, using thought records about specific meetings and behavioral experiments such as asking a colleague's opinion in a meeting and noting the outcome. Sessions 9 to 14 address interpersonal patterns at work and home: what happens when he feels slighted, how others respond and what he might do differently, using examples from his week and from our sessions. Two couples sessions, at sessions 7 and 13, give his wife a role and address how his anger affects the family. Sessions 15 and 16 focus on relapse prevention, including plans for future setbacks at work. If he is interested after the depression lifts, I will offer referral to a group psychoeducation program or longer-term therapy focused on personality patterns.

A Sample Rupture and Repair

In session 5, Mr. K. arrived angry that I had suggested in the previous session that his colleagues might not have been trying to humiliate him. "You sound like HR," he said. I acknowledged the impact first: "It sounds like you felt I was taking their side, and that I missed how much that meeting hurt." He agreed. I asked what I could have done differently, and he said that he needed me to understand before I questioned anything. We agreed that when I offer another view, I will first say what I understand about his experience. He then said, more quietly, that the meeting had made him feel "like nothing." That statement, made only after the repair, opened the most productive work of the session on the shame beneath his anger.

Strengths and Barriers

His strengths include intelligence, persistence, a long record of achievement, love for his children and a wife who has not given up on him. Barriers include his discomfort with being a patient, his tendency to leave when he feels criticized and a work schedule full of travel. We arranged telehealth sessions on travel weeks and agreed that he can tell me directly when a session feels like criticism, rather than canceling the next one.

Medication

Given moderately severe depression, I recommended a selective serotonin reuptake inhibitor alongside therapy. He was initially reluctant to "need a pill," which we reframed as a tool athletes and executives use to recover. He agreed, along with reducing wine to no more than one glass on weeknights, since alcohol worsens sleep and mood.

Treatment Plan and Evaluation

Goals are a PHQ-9 below 10 by week 12 and below 5 by week 16, return of sleep and interest in activities, resumption of full work functioning and fewer evening arguments, measured by a weekly log he and his wife complete together. The PHQ-9 and suicide screening are repeated at every visit, the AUDIT-C monthly and the safety plan reviewed after any humiliating event at work. Medication response is assessed at four and eight weeks. If he drops out, which is common, a letter will invite him back without blame. At week 8, we will review together whether the plan is helping, using his log and scores, so that he has a voice in any change of course rather than experiencing it as a verdict.

Conclusion

Mr. K. has major depressive disorder triggered by a professional loss and shaped by narcissistic personality disorder, with angry rumination and shame-triggered suicidal thoughts. The plan treats the depression with behavioral activation, cognitive work and an SSRI, places the alliance and its repair at the center because of his personality, involves his wife and is honest that treatment for narcissistic personality disorder itself remains without established evidence.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Blay, M., Benmakhlouf, I., Speranza, M., Duarte, M., & Ronningstam, E. (2026). Feasibility and acceptability of a group psychoeducation program for patients with pathological narcissism with or without a diagnosis of narcissistic personality disorder. Journal of Psychiatric Practice, 32(4), 166-173. https://doi.org/10.1097/PRA.0000000000000940

Dimaggio, G., Inchausti, F., Bateman, A., Bo, S., Choi-Kain, L., Lind, M., Luyten, P., MacBeth, A., Juul, S., Kealy, D., Sharp, C., & Weinberg, I. (2026). Can all oxygen molecules accumulate in one corner of the room? Treating pathological narcissism requires high standard randomized clinical trials: A commentary on the trial by Mohajerin et al. Clinical Psychology & Psychotherapy, 33(4), Article e70319. https://doi.org/10.1002/cpp.70319

Fjermestad-Noll, J., Ronningstam, E., Bach, B., Rosenbaum, B., & Simonsen, E. (2019). Characterological depression in patients with narcissistic personality disorder. Nordic Journal of Psychiatry, 73(8), 539-545. https://doi.org/10.1080/08039488.2019.1664630

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing.