Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is a personality disorder. The narcissist is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity. Narcissistic personality disorder is closely linked to self-centeredness.

 

Causes

The cause of this disorder is unknown, according to Groopman and Cooper. However, they list the following factors identified by various researchers as possibilities.

• An oversensitive temperament at birth is the main symptomatic chronic form
• Being praised for perceived exceptional looks or talents by adults
• Excessive admiration that is never balanced with realistic feedback
• Excessive praise for good behaviors or excessive criticism for poor behaviors in childhood
• Overindulgence and overvaluation by parents
• Severe emotional abuse in childhood
• Unpredictable or unreliable caregiving from parents
• Valued by parents as a means to regulate their own self-esteem

Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood, they may intensify to the point where NPD is diagnosed. Some psychotherapists believe that the etiology of the disorder is, in Freudian terms, the result of fixation to early childhood development. If a child does not receive sufficient recognition for their talents during about ages 3–7 they will never mature and continue to be in the narcissistic early development stage.

A 1994 study by Gabbard and Twemlow reports that histories of incest, especially mother-son incest, are associated with NPD in some male patients.

 

Theories

Pathological narcissism occurs in a spectrum of severity. In its more extreme forms, it is narcissistic personality disorder (NPD). NPD is considered to result from a person’s belief that they are flawed in a way that makes them fundamentally unacceptable to others. This belief is held below the person’s conscious awareness; such a person would, if questioned, typically deny thinking such a thing. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognised their (perceived) defective nature, such people make strong attempts to control others’ views of them and behavior towards them.

Pathological narcissism can develop from an impairment in the quality of the person’s relationship with their primary caregivers, usually their parents, in that the parents were unable to form a healthy and empathic attachment to them. This results in the child’s perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.

Narcissistic personality disorder is isolating, disenfranchising, painful, and formidable for those living with it and often those who are in a relationship with them. Distinctions need to be made among those who have NPD because not every person with NPD is the same. Even with similar core issues, the way in which one’s individual narcissism manifests itself in his or her relationships varies.

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others’ needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen.

People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight criticism, real or imagined. To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility. In cases where the narcissistic personality-disordered individual feels a lack of admiration, adulation, attention and affirmation, he/she may also manifest wishes to be feared and to be notorious (narcissistic supply).

Although individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements. With narcissistic personality disorder, the individual’s self-perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.

The exploitativeness, sense of entitlement, lack of empathy, disregard for others, and constant need for attention inherent in NPD adversely affect interpersonal relationships.

 

Splitting

People who are diagnosed with narcissistic personality disorder use splitting (black and white thinking) as a central defense mechanism. They do this to preserve their self-esteem, by seeing the self as purely good and the others as purely bad. The use of splitting also implies the use of other defense mechanisms, namely devaluation, idealization and denial.

 

Relationship to shame

It has been suggested that narcissistic personality disorder may be related to defenses against shame.

Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes. He saw the “oblivious” subtype as being grandiose, arrogant, and thick-skinned and the “hypervigilant” subtype as being easily hurt, oversensitive, and ashamed. In his view, the oblivious subtype presents for admiration, envy, and appreciation a powerful, grandiose self that is the antithesis of a weak internalized self, which hides in shame, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers.

Dr. Jeffrey Young, who coined the term “Schema Therapy”, a technique originally developed by psychiatrist Aaron T. Beck (1979), also links NPD and shame. He sees the so-called Defectiveness Schema as a core schema of NPD, along with the Emotional Deprivation and Entitlement Schemas.

 

Diagnosis

DSM-IV-TR 301.81

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines narcissistic personality disorder (in Axis II Cluster B) as:

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• Requires excessive admiration
• Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
• Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
• Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
• Is often envious of others or believes others are envious of him or her
• Shows arrogant, haughty behaviors or attitudes

It is also a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

 

Proposed removal from DSM-5

The Personality and Personality Work Group has proposed the elimination of NPD as a distinct disorder in DSM-5 as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains, raising objections from some clinicians who characterize the new diagnostic system as an “unwieldy conglomeration of disparate models that cannot happily coexist” and may have limited usefulness in clinical practice.

 

ICD-10

The World Health Organization’s ICD-10 lists narcissistic personality disorder under (F60.8) Other specific personality disorders.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

 

Millon’s subtypes

Theodore Millon identified five subtypes of narcissist. Any individual narcissist may exhibit none or one of the following:

• Unprincipled narcissist – including antisocial features. A charlatan – is a fraudulent, exploitative, deceptive and unscrupulous individual.
• Amorous narcissist – including histrionic features. The Don Juan or Casanova of our times – is erotic, exhibitionist.
• Compensatory narcissist – including negativistic (passive-aggressive), avoidant features.
• Elitist narcissist – variant of pure pattern. Corresponds to Wilhelm Reich’s “phallic narcissistic” personality type.
• Fanatic narcissist – including paranoid features. An individual whose self-esteem was severely arrested during childhood, who usually displays major paranoid tendencies, and who holds on to an illusion of omnipotence. These people are fighting delusions of insignificance and lost value, and trying to re-establish their self-esteem through grandiose fantasies and self-reinforcement. When unable to gain recognition or support from others, they take on the role of a heroic or worshipped person with a grandiose mission.

Alexander Lowen has also specified five major subtypes from Phallic (“Skirtchasing”) to Sociopathic (i.e., dissociative, capable of mayhem and murder) as outlined in his famous book, “Narcissism: Denial of the True Self”.

 

Treatment

Prominent clinical strategies are outlined by Heinz Kohut, Stephen M. Johnson and James F. Masterson, while Johns discusses a continuum of severity and the kinds of therapy most effective in different cases.

Schema Therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD. It is unusual for people to seek therapy for NPD. Subconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes. Pharmacotherapy is rarely effective.

 

Epidemiology

Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.

 

History

The history of narcissism predates the discovery of narcissistic personality disorder. The term “narcissistic personality structure” was introduced by Kernberg in 1967 and “narcissistic personality disorder” first proposed by Heinz Kohut in 1968.
Cultural depictions

In the film To Die For, Nicole Kidman’s character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she “was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder… had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder.”

Robin Quivers, the longtime on-air companion to radio personality Howard Stern, was tested on a narcissism scale by Dr. Drew Pinsky and was scored a 34, which Pinsky noted was the highest he had ever recorded. Quivers denied that she was a narcissist, and Pinsky replied that such a denial is typical of a person scoring so high on the narcissism scale.

 

Narcissistic Personality Disorder: Summarized

Narcissistic Personality Disorder

Narcissistic Personality Disorder is characterized by a long-standing pattern of grandiosity (either in fantasy or actual behavior), an overwhelming need for admiration, and usually a complete lack of empathy toward others. People with this disorder often believe they are of primary importance in everybody’s life or to anyone they meet. While this pattern of behavior may be appropriate for a king in 16th Century England, it is generally considered inappropriate for most ordinary people today.

People with narcissistic personality disorder often display snobbish, disdainful, or patronizing attitudes. For example, an individual with this disorder may complain about a clumsy waiter’s “rudeness” or “stupidity” or conclude a medical evaluation with a condescending evaluation of the physician.

In laypeople terms, someone with this disorder may be described simply as a “narcissist” or as someone with “narcissism.” Both of these terms generally refer to someone with narcissistic personality disorder.

 

Symptoms of Narcissistic Personality Disorder

In order for a person to be diagnosed with narcissistic personality disorder (NPD) they must meet five or more of the following symptoms:

• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• Requires excessive admiration
• Has a very strong sense of entitlement, e.g., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
• Is exploitative of others, e.g., takes advantage of others to achieve his or her own ends
• Lacks empathy, e.g., is unwilling to recognize or identify with the feelings and needs of others
• Is often envious of others or believes that others are envious of him or her
• Regularly shows arrogant, haughty behaviors or attitudes

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Narcissistic personality disorder is more prevalent in males than females, and is thought to occur in less than 1 percent in the general population.

Like most personality disorders, narcissistic personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

Learn more about the symptoms and characteristics of someone with narcissitic personality disorder.

 

How is Narcissistic Personality Disorder Diagnosed?

Personality disorders such as narcissistic personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose personality disorder.

Many people with narcissistic personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for narcissistic personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

 

Causes of Narcissistic Personality Disorder

Researchers today don’t know what causes narcissistic personality disorder. There are many theories, however, about the possible causes of narcissistic personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

Narcissistic Personality Disorder Treatment

Medical Treatment

Hospitalization

The hospitalization of patients with severe Narcissistic Personality occurs frequently. For some, such as those who are quite impulsive or self-destructive, or who have poor reality-testing, this is the result of Axis I symptoms which are overlaid upon the personality disorder. Hospitalizations should be brief, and the treatment specific to the particular symptom involved.

Another group of patients for whom hospitalization is indicated, provided long-term residential treatment is available, are those who have poor motivation for outpatient treatment, fragile object relationships, chronic destructive acting out, and chaotic life-styles. An inpatient program can offer an intensive milieu which includes individual psychotherapy, family involvement, and a specialized residential environment. The structure is physically and emotionally secure enough to sustain the patient with severe ego weakness throughout the course of expressive, conflict-solving psychotherapy.

Small staff-patient groups within the wards, as well as large community meetings, at which feelings are shared and patients’ comments taken seriously by staff, and constructive work assignments, recreational activities, and opportunities to sublimate painfully conflictual impulses make the hospital a “holding” environment rather than merely a containing one. The ultimate goals are of effecting a better integrated internal world, more cohesive and modulated self-object representation, and a self-concept less vulnerable to narcissistic injury.

 

Psychosocial Treatment

Basic Principles

Narcissistic patients try to sustain an image of perfection and personal invincibility for themselves and attempt to project that impression to others as well. Physical illness may shatter this illusion, and a patient may lose the feeling of safety inherent in a cohesive sense of self. This loss precipitates a panicky sensation that “my world is falling to pieces,” and the patient feels a sense of personal fragmentation.

The histrionic patient’s idealization of the physician stands in contrast to the narcissistic patient’s frequent contemptuous disregard for the physician, who is denigrated in a defensive effort to maintain a sense of superiority and mastery over illness. Only the most senior physician in a prestigious institution is deemed worthy of respect as the frightened patient seeks an external reflection of his or her own fragile grandeur in the doctor. More junior members of the health care team may be the targets of derision as the patient seeks to establish hierarchical dominance in order to counter the shame and fear triggered by illness.

Health care professionals must convey a feeling of respect and acknowledge the patient’s sense of self-importance so that the patient can reestablish a coherent sense of self, but they must at the same time avoid reinforcing either pathologic grandiosity (which may contribute to denial of illness) or weakness (which frightens the patient). An initial approach of support followed by step-by-step confrontation of the patient’s vulnerabilities may enable the patient to deal with the implications of illness with feelings of greater subjective strength. The increased self-confidence may reduce the patient’s need to attack the health care team in a misguided effort at psychologic self-preservation and eases the pressure to provide perfect care, since the patient’s antagonistic feeling of entitlement (defined by DSM-III as an “expectation of special favors without assuming reciprocal responsibilities”) is reduced.

Many of the treatment principles and approaches discussed for this disorder apply as well to Borderline Personality Disorder.

The individual with narcissistic and related personality disorders is likely to present with Axis I symptoms and disorders at various times in his or her life. These should be treated as described elsewhere. Caution should be observed, however, not to overdiagnose psychotic decompensation as Schizophrenia unless all DSM-III criteria are apparent. The same caveat applies to the pharmacologic treatment of depressive symptoms in the absence of clinical signs of Major Affective Disorder. When treating presenting symptoms and Axis I disorders in patients with Narcissistic Personality Disorder and other similar conditions, attention should be paid to the consequences of removing symptoms in a patient whose underlying character is primitive and or fragile.

Some clinicians, suggest that the grandiosity and tendency to idealize and devalue should be interpreted as defensive maneuvers when aspects of early conflictual relationships are played out in adult life. Other clinicians, posit that the emergence of the patient’s grandiosity and tendency to idealize the therapist should initially be viewed supportively. To help the individual develop stronger self-esteem regulation, the therapist then gradually points out the realistic limitations of patient and therapist alike while also offering an empathic ambience to cushion patients in their efforts to accept and integrate these experiences. Unfortunately, much research will be required to validate the description and course of narcissistic personality disorder before further research can answer which techniques bring about a better response to treatment.

 

Individual Psychotherapy

Most psychiatrists will, as a practical matter, treat most of their severely narcissistic patients for symptoms related to crises and relatively external Axis I diagnoses, rather than in an effort to address the personality disorder itself. The therapist must be aware of the importance of narcissism to the contiguity of the patient’s psyche, refrain from confronting the need for self-aggrandizement, and help the patient use his or her narcissistic characteristics to reconstitute an intact self-image. Positive transference and therapeutic alliance should not be relied upon, since the patient may not be able to acknowledge the real humanness of the therapist but may have to see him/her as either superhuman or devalued.

Those patients who do not terminate treatment after symptom relief has been obtained may wish help for some of the problems related to their personality disorder, such as interpersonal difficulties or depression. The therapist must have a good understanding of the principles of the narcissistic personality style, both for interpretation to the patient and for use in combating countertransference. Goals for ordinary psychotherapy should not be too great, since the source of these patients’ difficulties lies deep in pathological development.

 

Group Therapy

The goals are to help the patient develop a healthy individuality (rather than a resilient narcissism) so that he or she can acknowledge others as separate persons, and to decrease the need for self-defeating coping mechanisms. The first step toward developing a working alliance is empathy with the surprise and hurt that the patient experiences as a result of confrontations within the group. The external structuring group therapy provides can control destructive behavior in spite of ego weakness. In groups, the therapist is less authoritative (and less threatening to the patient’s grandiosity); intensity of emotional experience is lessened; and regression is more controlled, creating a better setting for confrontation and clarification.

Outpatient analytic-expressive group therapy requires a concomitant individual relationship for most patients, which should be somewhat supportive. The need for this additional support, the likelihood of the patient’s leaving the group at the first sign of psychic insult, and proneness to disorganized thinking are all found more often in the Borderline patient. The patient with a Narcissistic Personality Disorder does not appear so vulnerable to separation anxieties as the Borderline patient, but is instead involved in issues centered around maintaining a sense of self-worth.