Narcissistic personality disorder

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This article is about the personality disorder. For more information on clinical research and types of narcissism, see Narcissism.
Narcissistic personality disorder
Narcissus-Caravaggio (1594-96) edited.jpg
Narcissus by Caravaggio, gazing at his own reflection.
Classification and external resources
Specialty Psychiatry
ICD-10 F60.8
ICD-9-CM 301.81
MedlinePlus 000934
MeSH D010554
Personality disorders
Cluster A (odd)
Cluster B (dramatic)
Cluster C (anxious)
Not specified

Narcissistic personality disorder (NPD) is a personality disorder in which a person is excessively preoccupied with personal adequacy, power, prestige and vanity, mentally unable to see the destructive damage they are causing to themselves and others. It is a cluster B personality disorder.[1]

It is estimated that this condition affects one percent of the population, with rates greater for men. First formulated in 1968, NPD was historically called megalomania, and is a form of severe egocentrism.[2]

Signs and symptoms[edit]

People with narcissistic personality disorder are characterized by exaggerated feelings of self-importance. They have a sense of entitlement and demonstrate grandiosity in their beliefs and behavior. They have a strong need for admiration, but lack feelings of empathy.[3]

DSM-5[edit]

Symptoms of this disorder, as defined by the DSM-5, include:[4]

A. Significant impairments in personality functioning manifested by:

1. Impairments in self functioning (a or b):
a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others' experiences and predominance of a need for personal gain

B. Pathological personality traits in the following domain:

  1. Antagonism, characterized by:
a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

DSM-IV-TR[edit]

Symptoms of this disorder, as defined by the DSM-IV-TR, include:[1]

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. 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).
  4. Requires excessive admiration.
  5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
  6. Is inter-personally exploitative, i.e., takes advantage of others to achieve his or her own ends.
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

Other symptoms in addition to the ones defined by DSM-IV-TR include: Is inter-personally exploitative, i.e., takes advantage of others to achieve his or her own ends, has trouble keeping healthy relationships with others, easily hurt or rejected, appears unemotional, and exaggerating special achievements and talents, setting unrealistic goals for himself/herself.[5]

Narcissistic personality disorder is characterized by an over-inflated sense of self-importance, as well as dramatic, emotional behavior that is in the same category as antisocial and borderline personality disorders.[6]

In addition to these symptoms, the person may display arrogance, show superiority, and seek power.[7] The symptoms of narcissistic personality disorder can be similar to the traits of individuals with strong self-esteem and confidence; differentiation occurs when the underlying psychological structures of these traits are considered pathological. Narcissists have such an elevated sense of self-worth that they value themselves as inherently better than others, when in reality they have a fragile self-esteem, cannot handle criticism, and often try to compensate for this inner fragility by belittling or disparaging others in an attempt to validate their own self-worth. Comments and criticisms about others are vicious from sufferers of NPD, in an attempt to boost their own poor self-esteem.[8]

Another narcissist symptom is a lack of empathy. They are unable to relate, understand, and rationalize the feelings of others. Instead of behaving in a way that shows how they are feeling in the moment, they behave in the way that they feel they are expected to behave or that gives them the most attention.[5]

An extensive US survey found a high association with other disabilities, especially amongst men: mental disability, substance use, mood, anxiety disorders and other personality disorders, bipolar I disorder, post-traumatic stress disorder, and schizotypal and borderline personality disorders were among the associated disabilities.[9]

Eating disorders[edit]

The study of narcissism and the narcissistic defenses in the eating disorders was concerned with the correlation between eating pathology and narcissism. Two types of narcissism were observed: core narcissism, having extremely positive (high) self-esteem combined with delusions about the level and ability of achievement; and narcissistic defenses, defenses that are triggered when self-esteem is threatened. Such narcissists maintain self-esteem by seeing themselves as misunderstood and subject to intolerable demands.[10]

Two types of narcissistic defenses that were measured with eating pathology were "poisonous pedagogy" and "narcissistically abused". Poisonous pedagogy is one who places blame on others and is overly critical of others' inadequacies. The narcissistically abused are those who put others’ needs before theirs yet see themselves as being poorly treated. Two groups were measured: Clinical (83 women and one male with the mean age of 28.4) and Non-Clinical (70 women with a mean age of 23.2). The body mass index of the groups did not significantly vary. Participants filled out a questionnaire that was measured by eating characteristic and narcissism levels by the OMNI (O’Brien Multiphasic Narcissism Inventory) and the EDE-Q (Eating Disorder Examination Questionnaire). OMNI measures pathological narcissism of narcissistic personality, poisonous pedagogy, and narcissistically abused personality. EDE-Q measures the common eating disorders: restraint, eating concern, body shape concern, and body weight concern.[10]

The basic summaries of the questionnaire’s findings were that the poisonous pedagogy defenses was related to restrictive mind-set; the narcissistically abused defense related to restraint, eating concern, body shape concern, and body weight concern. The only main difference between the groups was the role of core narcissism in the clinical women’s levels of eating concerns. The authors concluded that further research is needed to better understand the relationship approaches in both groups.[10]

Professional attainment[edit]

In 2005, Board and Fritzon published the results of a study in which they interviewed senior business managers, assessing them for the presence of personality disorder.[11] Comparing their findings to three samples of psychiatric patients, they found that their senior business managers were as likely to demonstrate narcissistic traits as the patient population, although were less physically aggressive.

Causes[edit]

The cause of this disorder is unknown; however, Groopman and Cooper (2006) listed the following factors identified by various researchers as possibilities:[12]

  • An oversensitive temperament (personality traits) at birth.
  • Excessive admiration that is never balanced with realistic feedback.
  • Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood.
  • Overindulgence and overvaluation by parents, other family members, or peers.
  • Being praised for perceived exceptional looks or abilities by adults.
  • Severe emotional abuse in childhood.
  • Unpredictable or unreliable caregiving from parents.
  • Learning manipulative behaviors from parents or peers.
  • Valued by parents as a means to regulate their own self-esteem.

Some narcissistic traits are common with 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.[13]

Recent research has identified a structural abnormality in the brains of those with narcissistic personality disorder, specifically noting less volume of gray matter in the left anterior insula.[14][15] This brain region relates to empathy, compassion, emotional regulation, and cognitive functioning.[15]

Narcissism in children[edit]

In children, inflated self-views and grandiose feelings, which are characteristics of narcissism, are part of the normal self-development. Children typically cannot understand the difference between their actual and their ideal self, which causes an unrealistic perception of the self. After about age 8, views of the self, both positive and negative, begin to develop based on comparisons of peers, and become more realistic. Two factors that cause self-view to remain unrealistic are dysfunctional interactions with parents that can be either excessive attention[16] or a lack thereof. For example, but not limited to, the excessive attention and lack of attention go hand in hand when a child’s parents are divorced. Usually, one is overindulgent (typically the one seeing the child less) and the other shows less affection.[5] The child either compensates for lack of attention or acts in terms of unrealistic self-perception.[17]

Theories[edit]

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.[18] This belief is held below the person's conscious awareness; such a person would, if questioned, typically deny thinking such a thing. To protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognized 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 could not form a healthy and empathic attachment to them.[19] 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.[20]

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.[21]

Narcissistic individuals use various strategies to protect the self at the expense of others. They tend to devalue, derogate and blame others, and they respond to threatening feedback with anger and hostility.[22]

People who are 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.[23] 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, they may also manifest a desire to be feared and 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.[24] 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.

Splitting[edit]

Main article: Splitting (psychology)

People who are diagnosed with narcissistic personality disorder use splitting as a central defense mechanism. According to psychoanalyst Kernberg, "The normal tension between actual self on the one hand, and ideal object on the other, is eliminated by the building up of an inflated self-concept within which the actual self and the ideal self and ideal object are confused. At the same time, the remnants of the unacceptable images are repressed and projected onto external objects, or people, which are devalued."[25]

The merging of the "inflated self-concept" and the "actual self" is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defense mechanisms of devaluation, idealization and denial.[26] Other people are either manipulated as an extension of one's own self, who serve the sole role of giving "admiration and approval"[25] or they are seen as worthless (because they cannot collude with the narcissist's grandiosity).[25]

Relationship to shame[edit]

Main article: Shame

It has been suggested that narcissistic personality disorder may be related to defenses against shame.[27] Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes.[28] 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 of 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. 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.[29][better source needed]

Diagnosis[edit]

DSM-5[edit]

The formulation of narcissistic personality disorder in DSM-IV was criticised for failing to describe the range and complexity of the disorder. Critics say it focuses overly on "the narcissistic individual's external, symptomatic, or social interpersonal patterns—at the expense of ... internal complexity and individual suffering," which reduces its clinical utility.[30]

The Personality and Personality Disorders Work Group originally 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,[31][32] replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains.

Some clinicians objected to this, characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice.[33]

In July 2011, the Work Group came back with a major revision to their original proposal. In this revision, NPD was reinstated with dramatic changes to its definition.[34] The general move towards a dimensional (personality trait-based) view of the Personality Disorders has been maintained despite the reintroduction of NPD.

ICD-10[edit]

The World Health Organization's ICD-10 lists narcissistic personality disorder under (F60.8) Other specific personality disorders.[35]

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

Subtypes[edit]

Theodore Millon identifies four narcissist subtypes,[36][37] however, there are few pure variants of any subtype,[37] and the subtypes are not recognized in the DSM or ICD.

Subtype Description Personality Traits
Unprincipled narcissist Including antisocial features. A charlatan who is a fraudulent, exploitative, deceptive, and unscrupulous individual Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con man and charlatan; dominating, contemptuous, vindictive.
Amorous narcissist Including histrionic features. The Don Juan or Casanova of our times who is erotic, exhibitionist Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclines real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling.
Compensatory narcissist Including negativistic and avoidant features Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
Elitist narcissist Variant of “pure” pattern. Corresponds to Wilhelm Reich's "phallic narcissistic" personality type Feels privileged and empowered by virtue of special childhood status and pseudo achievements; entitled façade bears little relation to reality; seeks favored and good life; is upwardly mobile; cultivates special status and advantages by association.

Other theorists have identified two types of narcissism. Those narcissists who have been diagnosed with narcissistic grandiosity express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."[38] Another type of narcissism is narcissistic vulnerability. It entails (on a conscious level) "helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behavior as being socially avoidant in situations where their self-presentation is not possible so they withdraw, or the approval they need/expect is not being met."[38]

Treatment[edit]

People rarely seek therapy for NPD. This is partly because NPD sufferers deny they have a problem. Most cannot see the destructive damage they cause to themselves and to others and usually only seek treatment at the insistence of relatives and friends.[5]

Psychotherapy is used to treat NPD.[39] Clinical strategies are outlined by Heinz Kohut, Stephen M. Johnson and James F. Masterson, while Johns[20] 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.[40] Unconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes.[41][42] Pattern change strategies, over a long period of time, are for narcissists to work on increasing their ability to become more empathetic in everyday relationships. To help modify their sense of entitlement and self-centeredness schema, the strategy is to help them identify how to utilize their unique talents and to help others for reasons other than their own personal gain. This is not so much to change their self-perception of their "entitlement" feeling but more to help them empathize with others. Another type of treatment would be temperament change.[43]

Anger, rage, impulsivity and impatience can be worked on with skill training. Therapy is not one hundred percent effective because patients receive feedback poorly and defensively. Anxiety disorders and somatoma dysfunctions are prevalent but the most common would be depression. Medication has proven ineffective for treating narcissistic personality disorder, but psychoanalytic psychotherapy has a higher success rate. Therapists must recognize the patient’s traits and use caution in tearing down narcissistic defenses too quickly.

Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted, but group therapy can also contradict itself as the patient may show "demandingness, egocentrism, social isolation and withdrawal, and socially deviant behavior." Researchers originally thought group therapy among Narcissists would fail because it was believed that group therapy required empathy that NPD patients lack. However, studies show group therapy does hold value for patients because it lets them explore boundaries, develop trust, increase self-awareness, and accept feedback.[5] Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: "...effective expression, empathy, discussion and problem solving/conflict resolution."[5]

Marital/relationship therapy is most beneficial when both partners participate.[43]

Epidemiology[edit]

Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.[12][44]

In 2009, Twenge and Campbell conducted studies suggesting that the incidence of NPD had more than doubled in the US in the prior 10 years, and that 1 in 16 of the population have experienced NPD.[45]

"A nationwide study in the United States found that 7.7 percent of men and 4.8 percent of women could be diagnosed with narcissistic personality disorder (Stinson et al., 2008). These data also suggest that narcissistic personality disorder is more prevalent among younger adults, possibly supporting the impression that narcissistic personality disorder is on the rise as a result of social and economic conditions that support more extreme versions of self-focused individualism (Bender, 2012)."[46]

History[edit]

The use of the term "narcissism" to describe excessive vanity and self-centeredness predates by many years the modern medical classification of narcissistic personality disorder. The condition was named after Narcissus, a mythological Greek youth who became infatuated with his own reflection in a lake. He did not realize at first that it was his own reflection, but when he did, he died out of grief for having fallen in love with someone that did not exist outside of himself.

The term "narcissistic personality structure" was introduced by Kernberg in 1967[47] and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.[48]

Society and culture[edit]

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."[49]

Criticism[edit]

A Norwegian study concluded that narcissism should be conceived as personality dimensions pertinent to the whole range of PDs rather than as a distinct diagnostic category.[50] Alarcón and Sarabia concluded that narcissistic personality disorder shows such inconsistency that it should be considered as a trait domain instead of as a type of disorder.[51]

See also[edit]

Associated:

Case study:

References[edit]

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Further reading[edit]

Professional

  • Masterson, James F (1 June 1981). The Narcissistic and Borderline Disorders: An Integrated Developmental Approach (First ed.). London: Routledge. ISBN 978-0876302927. 

General public

  • Brown, Nina W (1 April 2008). Children of the Self-Absorbed (Second ed.). Oakland: New Harbinger Publications. ISBN 978-0743214285. 
  • Behary, Wendy (1 July 2013). Disarming the Narcissist (Second ed.). Oakland: New Harbinger Publications. ISBN 978-1608827602. 
  • Hotchkiss, Sandy (7 August 2003). Why Is It Always About You? (Reprint ed.). Florence: Free Press. ISBN 978-1572245617. 

External links[edit]
DSM-III-R only
DSM-IV only
Appendix B (proposed)
DSM-5
(Categorical
model)
DSM-5
Alternative hybrid categorical and dimensional model in Section III included to stimulate further research
Schizotypal
Specific
Other
Unspecified
Types
Characteristics
Defences
Cultural phenomena
Related articles
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