Narcissistic personality disorder

Signs and symptoms

People with narcissistic personality disorder are characterized by their persistent grandiosity, excessive need for admiration, and a disdain and lack of empathy for others. These individuals often display arrogance, a sense of superiority, and power-seeking behaviors. Narcissistic personality disorder is different from having a strong sense of self-confidence; people with NPD typically value themselves over others to the extent that they disregard the feelings and wishes of others and expect to be treated as superior regardless of their actual status or achievements. In addition, people with NPD may exhibit fragile egos, an inability to tolerate criticism, and a tendency to belittle others in an attempt to validate their own superiority.

According to the DSM-5, individuals with NPD have most or all of the following symptoms, typically without commensurate qualities or accomplishments:

1. Grandiosity with expectations of superior treatment from others
2. Fixated on fantasies of power, success, intelligence, attractiveness, etc.
3. Self-perception of being unique, superior and associated with high-status people and institutions
4. Needing constant admiration from others
5. Sense of entitlement to special treatment and to obedience from others
6. Exploitative of others to achieve personal gain
7. Unwilling to empathize with others' feelings, wishes, or needs
8. Intensely envious of others and the belief that others are equally envious of them
9. Pompous and arrogant demeanor

NPD usually develops by adolescence or early adulthood. It is not uncommon for children and teens to display some traits similar to NPD, but these are typically transient without meeting full criteria for the diagnosis. True NPD symptoms are pervasive, apparent in various situations, and rigid, remaining consistent over time. The symptoms must be severe enough that they significantly impair the individual's ability to develop meaningful relationships with others. Symptoms also generally impair an individual's ability to function at work, school, or in other important settings. According to the DSM-5, these traits must differ substantially from cultural norms in order to qualify as symptoms of NPD.

Associated features

People with NPD tend to exaggerate their skills and accomplishments as well as their level of intimacy with people they consider to be high-status. Their sense of superiority may cause them to monopolize conversations and to become impatient or disdainful when others talk about themselves. In the course of a conversation, they may purposefully or unknowingly disparage or devalue the other person by overemphasizing their own success. When they are aware that their statements have hurt someone else, they tend to react with contempt and to view it as a sign of weakness. When their own ego is wounded by a real or perceived criticism, their anger can be disproportionate to the situation, but typically, their actions and responses are deliberate and calculated. Despite occasional flare-ups of insecurity, their self-image is primarily stable (i.e., overinflated).

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others' views, unaware of others' needs, the effects of their behavior on others, and insist 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, insult, blame others and they often respond to threatening feedback with anger and hostility. Since the fragile ego of individuals with NPD is hypersensitive to perceived criticism or defeat, they are prone to feelings of shame, humiliation and worthlessness over minor or even imagined incidents. They usually mask these feelings from others with feigned humility, isolating socially or they may react with outbursts of rage, defiance, or by seeking revenge. 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 denial, idealization and devaluation.

According to the DSM-5, "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic personality disorder." Although overconfidence tends to make individuals with NPD ambitious, it does not necessarily lead to success and high achievement professionally. These individuals may be unwilling to compete or may refuse to take any risks in order to avoid appearing like a failure. In addition, their 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 relationships with superiors and colleagues.

Causes and mechanisms

The cause of this disorder is unknown. Experts tend to apply a biopsychosocial model of causation, meaning that a combination of environmental, social, genetic and neurobiological factors likely play a role.

Genetic

There is evidence that narcissistic personality disorder is heritable, and individuals are much more likely to develop NPD if they have a family history of the disorder. Studies on the occurrence of Personality disorders in twins determined that there is a moderate to high heritability for narcissistic personality disorder. However the specific genes and gene interactions that contribute to its etiology, and how they may influence the developmental and physiological processes underlying this condition, have yet to be determined.

Environment

Environmental and social factors are also thought to have a significant influence on the onset of NPD. In some people, pathological narcissism may develop from an impaired attachment to their primary caregivers, usually their parents. This can result 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. Overindulgent, permissive parenting as well as insensitive, over-controlling parenting, are believed to be contributing factors.

According to Groopman and Cooper (2006), the following factors have been identified by various researchers as possible factors that promote the development of NPD:

Cultural elements are believed to influence the prevalence of NPD as well since NPD traits have been found to be more common in modern societies than in traditional ones.

Neurobiology

There is little research into the neurological underpinnings of narcissistic personality disorder. Nevertheless, 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. Another study has associated the condition with reduced gray matter in the prefrontal cortex. The brain regions identified in these studies are associated with empathy, compassion, emotional regulation, and cognitive functioning. These findings suggest that narcissistic personality disorder is related to a compromised capacity for emotional empathy and emotional regulation.

DSM-5

The formulation of narcissistic personality disorder in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) was criticised for failing to describe the range and complexity of the disorder. Critics said it focuses overly on "the narcissistic individual's external, symptomatic, or social interpersonal patterns—at the expense of ... internal complexity and individual suffering," which they argued reduced 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. 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 (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) lists narcissistic personality disorder under 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

While the DSM-5 regards narcissistic personality disorder as a homogeneous syndrome, there is evidence for variations in its expression. Two major presentations of narcissism are typically identified, an "overt" or "grandiose" subtype, characterized by grandiosity, arrogance, and boldness, and a "covert" or "vulnerable" subtype characterized by defensiveness and hypersensitivity. Those with "narcissistic grandiosity" express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism." Psychiatrist Glen Gabbard described the subtype, which he referred to as the "oblivious" subtype as being grandiose, arrogant, and thick-skinned. The subtype of "narcissistic vulnerability" 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." Gabbard described this subtype, which he referred to as the "hypervigilant" subtype as being easily hurt, oversensitive, and ashamed. In addition, a "high-functioning" presentation, where there is less impairment in the areas of life where those with a more severe expression of the disorder typically have difficulties in, is suggested.

Other

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

Will Titshaw also identified three subtypes of narcissistic personality disorder which are not officially recognized in any editions of the DSM or the ICD.

Comorbidity

NPD has a high rate of comorbidity with other mental disorders. Individuals with NPD are prone to bouts of depression, often meeting criteria for co-occurring Depressive disorders. In addition, NPD is associated with bipolar disorder, anorexia, and substance use disorders, especially cocaine. As far as other personality disorders, NPD may be associated with histrionic, borderline, Antisocial, and Paranoid personality disorders.

Treatment

Narcissistic personality disorder is rarely the primary reason for people seeking mental health treatment. When people with NPD enter treatment, it is typically prompted by life difficulties or to seek relief from another disorder, such as major depressive disorder, substance use disorders, bipolar disorder, or eating disorders, or at the insistence of relatives and friends. This is partly because individuals with NPD generally have poor insight and fail to recognize their perception and behavior as inappropriate and problematic due to their very positive self-image.

Treatment for NPD is centered around psychotherapy. In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time by outlining clinical strategies for using psychoanalytic psychotherapy with clients with NPD that they claimed were effective in treating the disorder. Contemporary treatment modalities commonly involve transference-focused, metacognitive, and schema-focused therapies. Some improvement might be observed through the treatment of symptoms related to comorbid disorders with psychopharmaceuticals, but as of 2016. According to Elsa Ronningstam, psychologist at Harvard Medical School, "Alliance building and engaging the patient's sense of agency and reflective ability are essential for change in pathological narcissism."

Pattern change strategies, done over a long period of time, are used to increase the ability of those with NPD 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. Psychoanalytic psychotherapy may be effective in treating NPD, but therapists must recognize the patient's traits and use caution in tearing down narcissistic defenses too quickly. Anger, rage, impulsivity, and impatience can be worked on with skill training. Therapy may not be effective because patients may receive feedback poorly and defensively. Anxiety disorders and somatoform dysfunctions are prevalent but the most common would be depression.

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 patients with NPD 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 with NPD 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.

No medications are indicated for treating NPD, but may be used to treat co-occurring mental conditions or symptoms that may be associated with it such as depression, anxiety, and impulsiveness if present.

Prognosis

The effectiveness of psychotherapeutic and pharmacological interventions in the treatment of narcissistic personality disorder has yet to be systematically and empirically investigated. Clinical practice guidelines for the disorder have not yet been created, and current treatment recommendations are largely based on theoretical psychodynamic models of NPD and the experiences of clinicians with afflicted individuals in clinical settings.

The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates.

Epidemiology

Lifetime prevalence of NPD is estimated at 1% in the general population and 2% to 16% in clinical populations. A 2010 systematic review found the prevalence of NPD to be between 0% to 6% in community samples. There is a small gender difference, with men having a slightly higher incidence than in women.

According to a 2015 meta-analysis that looked at gender differences in NPD, there has recently been a debate about a perceived increase in the prevalence of NPD among younger generations and among women. However, the authors found that this was not reflected in the data and that the prevalence has remained relatively stable for both genders over the last 30 years (when data on the disorder were first collected).

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.

Early Freudianism

Sigmund Freud commented, regarding the adult neurotic's sense of omnipotence, that “this belief is a frank acknowledgement of a relic of the old megalomania of infancy”. He similarly concluded that “we can detect an element of megalomania in most other forms of paranoic disorder. We are justified in assuming that this megalomania is essentially of an infantile nature and that, as development proceeds, it is sacrificed to social considerations”.

Edmund Bergler also considered megalomania to be normal in the child, and for it to be reactivated in later life in gambling. Otto Fenichel states that, for those who react in later life to narcissistic hurt with denial, a similar regression to the megalomania of childhood is taking place.

Object relations

Whereas Freud saw megalomania as an obstacle to psychoanalysis, in the second half of the 20th century object relations theory, both in the United States and among British Kleinians, set about revaluing megalomania as a defence mechanism that offered potential access for therapy. Such an approach built on Heinz Kohut's view of narcissistic megalomania as an aspect of normal development, by contrast with Kernberg's consideration of such grandiosity as a pathological development distortion.

Society and culture

In popular culture, narcissistic personality disorder has been called megalomania.

Fiction

An article on the Victorian Web argues that Rosamond Vincy, in George Eliot’s Middlemarch (1871–72), is a full-blown narcissist as defined by the DSM.

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."

Other examples in popular fiction include television characters Adam Demamp (portrayed by Adam DeVine in Workaholics) and Dennis Reynolds (portrayed by Glenn Howerton in It's Always Sunny in Philadelphia).

Criticism

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. Alarcón and Sarabia in examining past literature on the disorder concluded that narcissistic personality disorder "shows nosological inconsistency and that its consideration as a trait domain with needed further research would be strongly beneficial to the field".