Narcissistic personality disorder

Narcissistic personality disorder
Specialty	Psychiatry, clinical psychology

Narcissus, the mythical Greek youth, after whom narcissism is named, became obsessed with his own reflection. He might have been diagnosed as a classic, somatic narcissist.

Narcissistic personality disorder (NPD) is a form of pathological narcissism that first appeared as a mental health diagnosis in the DSM III-TR (Diagnostic and Statistical Manual) in 1980. As distinct from healthy narcissism, which all people possess to some extent, pathological narcissism is a maladaptive, rigid, and persisting condition that can cause significant distress and functional impairment. Narcissistic personality disorder itself is defined by the DSM (see DSM cautionary statement) as being characterized by an all-pervasive pattern of grandiosity (in fantasy or behavior), the need for excessive admiration or adulation, and a distinct lack of empathy, all present in a variety of possible contexts. Its onset usually begins by early adulthood with a failure to outgrow the normal narcissism inherent in 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 and types.

DSM-IV-TR diagnostic criteria

According to the DSM (DSM-IV-TR), five (or more) of the following criteria are considered necessary for the clinical diagnosis to be met:

DSM-IV-TR Narcissistic Personality Disorder Diagnostic Criteria

Prevalence and age and gender features

According to the DSM IV-TR, the prevalence of NPD is less than 1% of the general population, though it manifests in 2% to 16% of psychiatric outpatients. It also notes that studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to narcissistic personality disorder.

Narcissistic traits are common in adolescents, who mostly grow out of this behavior, while, for others, this narcissistic behavior continues into adulthood and intensifies to the point where they become diagnosed with NPD. This disorder occurs more frequently (between 50% and 75%) in men than in women. It has been suggested that NPD may be exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes.

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

Clinical experience

The onset of pathological narcissism is 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 the False Self to regulate his or her labile sense of self-worth by extracting from any form of attention, both positive and negative, his narcissistic supply. This narcissistic supply can be defined as a constant need or hunger for attention.

Patients with NPD feel injured, humiliated and empty when criticized. They often react with disdain (devaluation), rage, and defiance to any slight, real or imagined. To avoid such situations, some patients with NPD socially withdraw and feign false modesty and humility to mask their underlying grandiosity. Dysthymic and depressive disorders are common reactions to isolation and feelings of shame and inadequacy. There are a whole range of narcissistic reactions, styles, and personalities – from the mild, reactive and transient, to the permanent personality disorder.

The interpersonal relationships of patients with NPD are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (narcissistic supply).

Though often ambitious and capable, inability to tolerate setbacks, disagreement and criticism make it difficult for people with NPD to work with a team or to maintain long-term professional achievements. The narcissist's fantastic grandiosity, frequently coupled with a hypomanic mood, is typically incommensurate with his or her real accomplishments (the "grandiosity gap").

Patients with NPD are either "cerebral" (derive their narcissistic supply from their intelligence or academic achievements) or "somatic" (derive their narcissistic supply from their physique, exercise, physical or sexual prowess and romantic or physical "conquests"). They can also be either "classic" (meet five of the nine diagnostic criteria included in the DSM), or they are "compensatory" (their narcissism compensates for deep-set feelings of inferiority and lack of self-worth).

Some speculate that there are people with narcissistic defenses who are covert, or inverted narcissists. As co-dependents, they derive their narcissistic supply from their relationships with classic narcissists.

Treatment and prognosis

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

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

Comorbidity and differential diagnoses

Narcissistic personality disorder is often diagnosed 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 commonly diagnosed with other personality disorders, namely the histrionic, borderline, paranoid, and antisocial. The personal style of those suffering from NPD should be distinguished from the personal styles 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, he or she is less impulsive and less self-defeating or self-destructive and less concerned with abandonment issues.

Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt.

According to the DSM-IV-TR, both narcissists and psychopaths are "tough-minded, glib, superficial, exploitative, and unempathic". But narcissists are less impulsive, less aggressive, and less deceitful. Psychopaths rarely seek narcissistic supply. Compared to psychopaths, fewer narcissists are criminals.

Patients suffering from the range of obsessive-compulsive disorders are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical and far more aware of their own deficiencies, flaws, and shortcomings.

References

• Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR) 2000. American Psychiatric Association, Washington, DC.
• 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, 1995. Prentice-Hall International, London.
• Gelder, Michael, Gath, Dennis, Mayou, Richard, Cowen, Philip (eds.), Oxford Textbook of Psychiatry, third edition, 1996, reprinted 2000. Oxford University Press, Oxford.
• Millman Robert B. (MD) Substance Abuse: A Comprehensive Textbook.

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