## History and Physical The presentation of NPD is highly variable. Persons with NPD generally speak from a place of self-importance and may demand or expect special treatment. In the clinical setting, amongst physicians, managers, and other high-ranking professionals, a patient with NPD may present as friendly while simultaneously presenting as cruel and bitter towards other staff not viewed as high-ranking. They may try to brag about their credentials and friends they view as having high status (ie, name-dropping). They are generally unable to handle criticism from peers or staff and frequently become enraged. [\[29\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) [\[30\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) The clinical history is likely to reveal tumultuous relationships. Often, these individuals become increasingly isolated as they grow older due to others having difficulty maintaining their friendships with those who suffer from severe NPD. Additionally, legal charges are often present in the clinical history, as individuals with NPD have difficulty following rules (or believing rules apply to them). [\[30\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Descriptions of empathy are limited when discussing failed relationships. Although many individuals with NPD deny feelings of depression or any signs of perceived weakness, they often suffer symptoms of depression due to an underlying fragile ego perpetuated by socio-occupational impairment from their maladaptive behaviors. [\[31\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) The mental status examination is completed in psychiatric evaluations and varies amongst each case of NPD. Still, the following areas should be carefully considered in the psychiatric evaluation of NPD. [\[32\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) - **Appearance:** The clinician should note the patient's general grooming and fashion choices. Clothing, accessories, hairstyles, or tattoos that are provoking may suggest NPD, as there is a sense of grandiosity and attention-seeking behavior characteristic of the disorder. - **Behavior:** The clinician should monitor for disinhibited behaviors, grandiose postures, smirking, and scoffing. The context of the patient's cooperation should be paid particular attention to, as it may vary greatly depending on who the individual interacts with (depending on their perceived status). - **Speech:** NPD may present with an increased amount of speech due to feelings of needing to prove oneself or brag about achievements and friendships, but there are no expected concerns with speech initiation, volume, or vocabulary. - **Affect:** Affect is highly variable but may fluctuate greatly depending on the conversation topic, particularly if the patient with NPD feels challenged or threatened by the interviewer. More lability is expected than usual, with more frequent irritability. - **Thought content:** It is essential to assess for delusions in patients with NPD. The level of grandiose thought may border between nondelusional grandiose thoughts and delusional (psychotic) grandiose thoughts. Although this distinction does not impact the treatment plan, it does help the clinician assess the severity of NPD. - **Thought process:** The thought process in NPD is generally concrete, with grandiosity being unchallengeable. Still, individuals with NPD have the capability for linear and logical thought, often used to achieve their initial accomplishments (higher education, careers, relationships of status). - **Cognition:** General cognition and orientation are not expected to be impaired in NPD but should be evaluated to rule out other psychiatric conditions. - **Insight:** NPD is an egosyntonic disorder; therefore, a patient's understanding of their NPD is generally poor. Accepting self-deficit is usually not congruent with NPD. - **Judgment:** The severity of NPD will impact a patient's judgment. This can often be assessed by inquiring of the patient's legal and relationship histories. - **Impulse control:** The underlying temperament of NPD is classic for high reward dependence and low harm avoidance behaviors, which generally results in poor impulse control. This can also be assessed by inquiring about past legal and relationship history. Go to: ## Evaluation Diagnosis of a personality disorder benefits from longitudinal observation of a patient's behaviors over various circumstances to give a broader understanding of long-term functioning. Because many personality disorder features overlap with symptoms during another acute psychiatric condition, personality disorders should generally be diagnosed when no acute psychiatric process is concurrently occurring. [\[33\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) However, this is not always possible or required, as in the cases of an underlying personality disorder contributing significantly to hospitalizations or relapse of another psychiatric condition (ie, major depressive episode). [\[34\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Still, it may take several visits with a patient to finally establish a firm diagnosis of NPD. Patients with cluster B personality disorders often display transference, which is a projection of their prior conflicts onto the clinician. Clinicians often develop counter-transference, which is when the clinician projects unresolved conflicts onto the patient. This frequently occurs due to the nature of the patient encounters for individuals who have personality disorders, as they may be aggressive, unreasonable to logic, or rude. [\[35\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Clinicians must recognize signs of counter-transference when they occur to remove any treatment bias that may impact the clinical care of a patient with NPD. [\[36\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Sublimation is a psychological defense mechanism that helps individuals transform unwanted or unhelpful impulses into less harmful or helpful ones. When clinicians begin to feel frustrated with patients who may be suffering from a personality disorder, it is useful (when possible) to sublimate the negative feelings of counter-transference and use those feelings instead as an evaluation tool to guide the differential diagnosis towards a personality disorder, which may ultimately direct the treatment plan. [\[37\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Various structured interviews and inventories have been developed to assist in evaluating NPD. Otto Kernberg's structured clinical interview, created in 1981, has continued to undergo revisions and restructuring as a structured clinical interview for personality disorders. The current version is a semistructured diagnostic interview with questions about personality organization, defenses, object relations, and coping skills. This interview focuses on interpersonal relationships. The Personality Institute at the Weill Cornell Institute copyrights the current version. The interview is based on psychodynamic principles and is expected to be used by persons with previous training in psychoanalytical work. [\[38\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Other instruments may measure the severity of NPD, such as the five-factor narcissism inventory that looks at the 5 aspects of general personality. There are about 148 questions on the measure. [\[39\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) Another measure that may be useful is the Narcissistic Personality Inventory. [\[40\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#) For formal diagnosis, the conglomerate of information provided by personal history, collateral information, mental status examination, and psychometric tools, individuals must meet the DSM-5-TR diagnostic criteria for NPD. **NPD DSM-5-TR Criteria** In interpersonal settings, there is a pervasive pattern of grandiosity, need for admiration, and lack of empathy. This pattern of behaviors onsets in early adulthood and persists through various contexts. Clinical features include at least 5 of the following: - Having a grandiose sense of self-importance, such as exaggerating achievements and talents, expecting to be recognized as superior even without commensurate achievements - Preoccupation with fantasies of success, power, beauty, and idealization - Belief in being "special" and that they can only be understood by or associated with other high-status people (or institutions) - Demanding excessive admiration - Sense of entitlement - Exploitation behaviors - Lack of empathy - Envy towards others or belief that others are envious of them - Arrogant, haughty behaviors and attitudes [\[1\]](https://www.ncbi.nlm.nih.gov/books/NBK556001/?utm_source=chatgpt.com#)