Narcissistic personality disorder

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}} Narcissistic personality disorder (NPD) is a form of pathological narcissism that first appeared as a disorder in the Diagnostic and Statistical Manual of Mental Disorders in 1980, in the edition known as DSM III-TR. As distinct from healthy narcissism, which all people possess to some extent, pathological narcissism is a maladaptive, rigid, and persistent condition that can cause significant distress and functional impairment. The disorder is defined by the DSM as 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 of which are present in a variety of contexts. Its onset usually begins by early adulthood, with a failure to outgrow the normal narcissism inherent in adolescence. [1]

1 Classification
2 Diagnostic criteria
3 Prevalence and age and gender features
4 Clinical experience
5 Treatment and prognosis
6 Comorbidity and differential diagnoses
7 Narcissistic wound
8 References
9 External links

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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.

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Diagnostic criteria

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

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 people
requires excessive admiration
strong sense of entitlement
takes advantage of others to achieve his or her own ends
lacks empathy
is often envious or believes others are envious of him or her
arrogant affect

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

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Prevalence and age and 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 two to 16 per cent of psychiatric outpatients. It also notes that studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to NPD.

Narcissistic traits are common in adolescents, who mostly grow out of this behavior. For others, the narcissistic behavior continues into adulthood and intensifies to the point where they become diagnosed with NPD. The 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 may develop a transient and reactive form of NPD 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.

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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.

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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.

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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.

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. Compared to patients with antisocial personality disorder, fewer narcissists are criminals.

Patients suffering from the range of obsessive-compulsive disorders are committed to perfection but do not always believe that they are capable of attaining it resulting in rituals and constant adjustments. Opposed to narcissists, sufferers of 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 versus what little control they have on the outside world.

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Narcissistic wound

The term narcissistic wound (or injury) refers to the event(s) and/or belief(s) experienced by an individual with NPD that are the internalized crux of their disorder. By probing this wound, a therapist can provoke an individual with the disorder and thereby determine the cause. Although this often results in an emotional outburst on the part of the patient, it is a valuable diagnostic and therapeutic tool.

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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., Substance Abuse: A Comprehensive Textbook

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