Narcissistic personality disorder

Narcissistic personality disorder
Specialty	Psychiatry, clinical psychology

Narcissistic personality disorder (NPD), a term first used by Heinz Kohut in 1971, is a form of pathological narcissism acknowledged in the Diagnostic and Statistical Manual of Mental Disorders in 1980, in the edition known as DSM III-TR. Narcissistic Personality Disorder, is a maladaptive, rigid, and persistent condition that may cause significant distress and functional impairment. The onset usually begins by early adulthood as a failure to outgrow the normal narcissism inherent between infancy and adolescence.

Classification

DSM-IV divides personality disorders into three clusters based on symptom similarities:

• Cluster A (paranoid, schizoid, schizotypal): odd or eccentric disorders
• Cluster B (antisocial, borderline, histrionic, narcissistic): dramatic, emotional or erratic disorders
• Cluster C (avoidant, dependent, obsessive-compulsive): anxious or fearful disorders

Narcissistic personality disorder is a "cluster B" personality disorder.

The ICD-10 (International Classification of Mental and Behavioural Disorders, published by the World Health Organisation in Geneva 1992) regards narcissistic personality disorder (NPD) as "a personality disorder that fits none of the specific rubrics". It relegates it to the category known as "Other specific personality disorders", which also includes the eccentric, "haltlose", immature, passive-aggressive, and psychoneurotic personality disorders.

Diagnostic criteria

At least five of the following are necessary for a diagnosis:

• 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 other special or high-status people (or institutions, eg: Harvard and other Ivy League institutions)
• requires excessive admiration
• has a strong sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
• 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 or believes others are envious of him or her
• has arrogant affect, haughty behaviors or attitudes

(see also full list in DSM-IV-TR)

Prevalence, age & gender features

According to DSM IV-TR, the prevalence of NPD is less than one per cent of the general population, though it manifests itself in 2 to 16 per cent of psychiatric outpatients. Studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to NPD.

Narcissistic traits are common in adolescents, who typically grow out of this behavior. For others the narcissistic behavior continues into adulthood and intensifies to the point where NPD may be diagnosed. The disorder occurs equally in males and females, with latest epidemiological studies showing a shift to NPD affecting females at a greater rate in the general population (78% more frequent in females). It has been suggested that NPD may be exacerbated by the physical, mental, and occupational restrictions of aging.

According to Robert B. Millman, professor of psychiatry at New York Hospital, pathological narcissism can be induced in adulthood by celebrity, wealth, or fame. Billionaires, high profile business executives, movie or music stars, professional sportsmen, or politicians may develop a transient and reactive form of NPD, complete with grandiose perceptions of themselves, a lack of ability to empathise with others, enraged reactions to slights (whether real or imagined), as well as other traits typical of NPD. This condition is referred to as acquired situational narcissism.

Clinical experience

The onset of pathological narcissism occurs in infancy, childhood and early adolescence. It is commonly attributed to childhood abuse and trauma inflicted by parents, authority figures, or even peers. Pathological narcissism is a defense mechanism intended to deflect hurt and trauma from the victim's "True Self" into a "False Self" which is omnipotent, invulnerable and omniscient. The Narcissist uses this False Self to regulate his or her labile sense of self-worth by the extraction of attention, in both positive and negative connotations.

Patients with NPD feel injured, humiliated and empty when criticised. They often react with disdain (devaluation), rage, and defiance to any slight, real or imagined. To avoid such situations, some patients with NPD withdraw socially and may feign modesty or humility to mask their underlying grandiosity. Dysthymic and depressive disorders are common reactions to these conditions of isolation and the feelings of shame and inadequacy. There is a broad spectrum of narcissistic personalities, styles, and reactions -- from the very mild, reactive and transient, to the severe and inflexible narcissitic personality disorder.

Though individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism makes it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements. The narcissist's perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.

The interpersonal relationships of patients with NPD are typically impaired due to the individual's lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention. They frequently select as mates, and engender in their children, "co-narcissism," which is a term coined to refer to a co-dependent personality style similar to co-alcoholism and co-dependency . Co-narcissists organize themselves around the needs of others. They feel responsible for others, accept blame readily, are eager to please, defer to other's opinions, and fear being considered selfish if they act assertively.

Treatment & prognosis

The common treatment for patients with narcissistic personality disorder is "talk therapy" (mainly psychodynamic psychotherapy or cognitive-behavioural treatment modalities). Medication is sometimes prescribed to treat attendant conditions such as mood disorders or obsessive-compulsive disorders, usually with some success.

The prognosis for an adult suffering from NPD is poor, although his adaptation to life and to social relationships can improve with treatment.

Psychodynamic approach: An approach to personality originally derived from psychoanalytic theory that asserts that personality differences are based on unconscious (dynamic) conflicts within the individual.

Cognitive-behavioral approach: An approach that defines personality differences by the way in which different people act and think about their actions. It tends to emphasise situational determinants and prior learning in an effort to explain how such differences come about.

Comorbidity & differential diagnoses

Narcissistic personality disorder is often diagnosed concurrently with other mental health disorders (co-morbidity), such as mood disorders, eating disorders, and substance-related disorders. Patients with NPD are frequently abusive and prone to impulsive and reckless behaviours (dual diagnosis).

NPD is also commonly diagnosed with other personality disorders, namely the histrionic, borderline, paranoid, and antisocial disorders. The personal style of those suffering from NPD should be distinguished from those of patients with other "Cluster B" personality disorders: the Narcissist is grandiose, the histrionic coquettish, the antisocial (psychopath) callous, and the borderline needy.

As opposed to patients with borderline personality disorder, the self-image of the Narcissist is stable. The individual is less impulsive, less self-defeating or self-destructive, and less concerned with abandonment issues.

In contrast to the histrionic patient, the Narcissist is achievement-oriented and proud of his or her possessions and accomplishments. Narcissists also rarely display the outward emotions of histrionics, and they typically hold the sensitivities and needs of others in contempt.

Narcissists and patients with antisocial personality disorder are both considered to lack empathy and remorse, and to be deceitful and interpersonally exploitative. Narcissists are less impulsive, less aggressive and far more motivated by attention, appearances and recognition. In comparison to patients with antisocial personality disorder, fewer Narcissists are criminals.

Patients suffering from the range of obsessive-compulsive disorders (OCD) are committed to achieving perfection, but as they do not always believe that they are capable of attaining it, the result is constant behavioural adjustments and rituals. As opposed to Narcissists, individuals with OCD are self-critical and far more aware of their own deficiencies, flaws, and shortcomings. Often OCD sufferers feel the need to control their environment through perfectionism, given their perception that they have little control of the outside world.

Narcissistic wound

The term narcissistic wound (or injury) refers to the events or beliefs experienced by an individual with NPD, representing the internalised crux of their disorder. A therapist can provoke an individual with such a "wound" and thereby determine the causes of the disorder. Although this often results in an emotional outburst on the part of the patient, it may be a valuable diagnostic and therapeutic tool.

Additional references

• Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR), American Psychiatric Association, Washington, D.C., 2000.
• Robert C. Schwartz, Ph.D., DAPA and Shannon D. Smith, Ph.D., DAPA, "Psychotherapeutic Assessment and Treatment of Narcissistic Personality Disorder" (American Psychotherapy Association, Article #3004 Annals July/August 2002)
• Goldman, Howard H., Review of General Psychiatry, fourth edition, Prentice-Hall International, London, 1995.
• Gelder, Michael, Gath, Dennis, Mayou, Richard, Cowen, Philip (eds.), Oxford Textbook of Psychiatry, third edition, Oxford University Press, Oxford, 1996, (reprinted 2000).
• Millman, Robert B. et al, Substance Abuse: A Comprehensive Textbook, 2004
• Gabbard, Glen O (Ed); Beck, Judith S (Ed); Holmes, Jeremy (Ed). Oxford Textbook of Psychotherapy. (pp. 279-289). ix, 534 pp., 2005.
• Maccoby, Michael. The Productive Narcissist.
• Ronningstam, Elsa F. Identifying and Understand the Narcissistic Personality.

External links

• Narcissistic Personality Disorder at a Glance
• Open Site Narcissistic Personality Disorder
• DSM-IV-TR Narcissistic Personality Disorder Diagnostic Criteria
• How to Recognize a Narcissist
• Narcissistic Personality Disorder page on Mentalhealth.com
• Mental Health Matters Narcissistic Personality Disorder