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Depression in Narcissistic PD — MRCPsych Paper B MCQ

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ModeratePersonality DisordersDepression in Narcissistic PDMRCPsych Paper B

A 35-year-old man with an established diagnosis of narcissistic personality disorder develops 6 weeks of persistent low mood, anhedonia, early-morning waking, impaired concentration and marked occupational impairment after a relationship breakdown. Assessment confirms a moderate depressive episode, without psychotic symptoms, mania or current substance misuse. During interviews he is demanding and becomes angry when limits are set. Which option most closely reflects the specific recommendation in NICE NG222 for depression coexisting with a personality disorder?

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Correct answer: B — Consider antidepressant medication plus psychological treatment, delivered with structured multidisciplinary support

Explanation lettering: E = shown as D · D = shown as E

B is correct. NICE NG222 states that treatment for depression should not be withheld because of a coexisting personality disorder. It recommends considering combined antidepressant medication and a psychological treatment, with support to maintain engagement and delivery in a structured multidisciplinary setting. His demanding behaviour requires consistent, collaborative management and clear boundaries rather than exclusion from care. Personality-focused treatment or referral to a specialist personality disorder programme may also be considered, but it should not replace treatment of the depressive episode, so A is insufficient. C omits the specifically recommended combined approach. Antipsychotics are not indicated simply to modify narcissistic traits, excluding D. The psychosocial precipitant does not negate a moderate depressive episode with marked impairment, making active monitoring alone in E inappropriate.

Reference: National Institute for Health and Care Excellence. Depression in adults: treatment and management (NG222), section 1.11, Depression in people with a diagnosis of personality disorder. 2022; reviewed 2026. https://www.nice.org.uk/guidance/ng222/chapter/recommendations