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Narcissistic personality disorder
Specialty	Psychiatry, clinical psychology

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 to others in the process. It is estimated that this condition affects one percent of the population. First formulated in 1968, NPD was historically called megalomania, and is a form of severe egocentrism.

Symptoms

Some people diagnosed with a 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.

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

• Expects to be recognized as superior and special, without superior accomplishments
• Expects constant attention, admiration and positive reinforcement from others
• Envies others and believes others envy him/her
• Is preoccupied with thoughts and fantasies of great success, enormous attractiveness, power, intelligence
• Lacks the ability to empathize with the feelings or desires of others
• Is arrogant in attitudes and behavior
• Has expectations of special treatment that are unrealistic

Other symptoms in addition to the ones defined by DSM-IV-TR include: Is interpersonally 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.

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.

In addition to these symptoms, the person may display arrogance, show superiority, and seek power. 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.

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 what gives them the most attention.

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 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. The child either compensates for lack of attention or acts in terms of unrealistic self-perception.

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.

Eating disorders

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 a subject to intolerable demands.

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 mean age of 23.2). BMI of groups did not significantly vary. They 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.

The basic summaries of the questionnaire’s findings were the poisonous pedagogy defenses was related to restrictive mind-set; 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. Further research is needed to better understand the relationship approaches in both groups.

Professional attainment

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. 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

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

• 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.
• 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.

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. This brain region relates to empathy, compassion, emotional regulation, and cognitive functioning.

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. 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. 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.

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.

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.

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. 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. 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

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, which are devalued."

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. Other people are either manipulated as an extension of one's own self, who serve the sole role of giving "admiration and approval" or they are seen as worthless (because they cannot collude with the narcissist's grandiosity).

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 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. 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-5

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.

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, 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.

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. The general move towards a dimensional (personality trait-based) view of the Personality Disorders has been maintained despite the reintroduction of NPD.

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.

Subtypes

Theodore Millon identified five narcissist subtypes, however, there are few pure variants of any subtype, and the subtypes are not recognized in the DSM or ICD.

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."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."

Treatment

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. This is partly due to the NPD sufferers’ not believing they have a problem. Most, if not all, are unable to see the destructive damage they are causing to themselves and to others and usually only seek treatment at the insistence of relatives and friends. Unconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes. 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.

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. Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: "...effective expression, empathy, discussion and problem solving/conflict resolution."

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

Epidemiology

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

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.

"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)."

History

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 and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.

Society and culture

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."

See also

• Malignant narcissism
• Narcissism
• Narcissistic leadership
• Narcissistic mortification
• Narcissistic neurosis
• Narcissistic parent
• Narcissistic Personality Inventory
• Narcissistic rage and narcissistic injury
• Narcissism of small differences
• Narcissistic supply

Associated:

• Egomania
• Egotism
• Hubris
• Megalomania
• Selfishness
• Superiority complex
• True self and false self

Case study:

• Brian Blackwell

References

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Further reading

• The Culture of Narcissism, C. Lasch, New York: Norton; Revised edition (May 1991). ISBN 978-0-393-30738-2
• How to Survive Working for a Narcissistic Leader (2011-05-19) BNet
• The Narcissism Epidemic, Jean M. Twenge, Ph.D. and W. Keith Campbell, Ph.D., New York, Free Press 2009 ISBN 978-1-4165-7625-9

S1

• DSM-IV-TR Narcissistic Personality Disorder Diagnostic Criteria
• Narcissistic personality disorder PubMed
• Narcissistic personality disorder Mayo Clinic
• Narcissistic Personality Disorder Cleveland Clinic

v t e Narcissism
Similar personality concepts	Egomania Egotism God complex Healthy narcissism Hubris Machiavellianism Messiah complex Narcissus (mythology) Superiority complex
In society	Collective narcissism Don Juanism In the workplace Leadership Me generation Parents
Pathological narcissism	Narcissistic personality disorder history Dark triad Malignant narcissism Manipulation (psychology) Narcissistic injury neurosis elation mortification supply withdrawal Narcissistic Personality Inventory
Related psychology concepts	Compensation Empathy Entitlement Grandiosity
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• Abnormal psychology
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