Narcissistic personality disorder

Note: Some of the symptoms listed below are actually symptoms of grandiosity. Narcissistic PD is separate and distinct from grandiosity but is often comorbid with it.

**Narcissistic personality disorder** (**NPD**) is a personality disorder caused by an intense bout of anger and characterized by a long-term pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a lack of empathy toward other people. People with NPD often spend much time thinking about achieving power and success, or on their appearance. Typically, they also take advantage of the people around them. Such narcissistic behavior typically begins by early adulthood, and occurs across a broad range of situations.

The causes of narcissistic personality disorder are unknown. The condition of NPD is included in the cluster B personality disorders in the *Diagnostic and Statistical Manual of Mental Disorders* (DSM). A diagnosis of NPD is made by a healthcare professional interviewing the person in question. The condition of NPD should be differentiated from mania and substance use disorder.

Treatments for narcissistic personality disorder have not been well studied. Therapy is difficult, because people with narcissistic personality disorder usually do not consider themselves to have a mental health problem. About one percent of people are believed to be affected with NPD at some point in their lives. It occurs more often in men than women, and typically affects younger as opposed to older people. The narcissistic personality was first described by the psychoanalyst Robert Waelder, in 1925; and the term *narcissistic personality disorder* (NPD) was coined by Heinz Kohut, in 1968.

## Signs and symptoms

People with narcissistic personality disorder (NPD) are characterized by the personality traits of persistent grandiosity, an excessive need for admiration, and a personal disdain and lack of empathy for other people. As such, the person with NPD usually displays arrogance and a distorted sense of personal superiority, and seeks to establish abusive power and control over others. Self-confidence (a strong sense of self) is a personality trait different from the traits of narcissistic personality disorder; thus, people with NPD typically value themselves over others, to the extent of openly disregarding the wishes and feelings of anyone else, and expect to be treated as superior, regardless of their actual status or achievements. Socially, the person with narcissistic personality disorder usually exhibits a fragile ego (self-concept), intolerance of criticism, and a tendency to belittle other people, in order to validate his or her own superiority.

The *Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition* (DSM-5, 2013) indicates that a person with NPD usually displays some or all of the following symptoms, typically without possessing the commensurate personal qualities or accomplishments for which they demand respect and status:

* Grandiosity with expectations of superior treatment from other people
	+ Self-perception of being unique, superior, and associated with high-status people and institutions
	+ Sense of entitlement to special treatment and to obedience from others
	+ Need for continual admiration from others
	+ Continually criticizing, bullying and belittling others
	+ Exploiting others to achieve personal gain
	+ Fixation on fantasies of power, success, intelligence, attractiveness, etc.
* Explosive temper, especially if handling criticism. Can get very angry if their directions are not followed by others.
* Lack of empathy for the negative impact they have on the feelings, wishes, and needs of other people
* Intense envy of others, and the belief that others are equally envious of them

Narcissistic personality disorder usually develops either in adolescence or in early adulthood; and it is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD. True symptoms of NPD are pervasive, apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person's mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person's psychological abilities to function as a social animal, either at work, or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptoms of NPD, the person's manifested personality traits must substantially differ from the cultural norms of society.

### Associated features

People with NPD exaggerate their skills and accomplishments, and their degree of intimacy with people they consider high-status. Such a sense of personal superiority may cause them to monopolize conversations, or to become impatient and disdainful when other persons talk about themselves. When wounded in the ego, either by a real or a perceived criticism, the narcissist's displays of anger can be disproportionate to the nature of the criticism suffered; but typically, the actions and responses of the NPD person are deliberate and calculated. Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.

To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed control freak who passes blame and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of his or her behaviors, whilst insisting that people see him or her as an ideal person. To protect their fragile self-concept, narcissists use psycho-social strategies, such as the tendency to devalue and derogate and to insult and blame other people, usually with anger and hostility towards people's responses to the narcissist's anti-social conduct. Because their fragile egos are hypersensitive to perceived criticism or defeat, people with NPD are prone to feelings of shame, humiliation, and worthlessness over minor incidents of daily life and imagined, personal slights, and usually mask such feelings from people, either by way of feigned humility, or by socially isolating themselves, or by responding with outbursts of rage and defiance, or by seeking revenge. The merging of the *inflated self-concept* and the *actual self* is evident in the grandiosity component of narcissistic personality disorder; also inherent to that psychological process are the defense mechanisms of idealization and devaluation and of denial.

The DSM-5 indicates that: "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." Given the high-function sociability associated with narcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives. Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they might be unwilling to compete, or refuse to take risks, in order to avoid failure or the appearance of failure. Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism, and their apathy towards other people, make it difficult for persons with NPD to work cooperatively or to maintain long-term, professional relationships with superiors and colleagues.

## Causes

The causes of narcissistic personality disorder are unknown. Researchers apply a biopsychosocial model of causation, whereby the occurrence and the expression of NPD — a pathological amplification of the traits of the narcissistic personality — are consequent to a combination of nature and nurture, of environmental and social, genetic and neurobiological factors.

### Genetic

Narcissistic personality disorder is an inheritable psychological condition; research evidence indicates that a person is more likely to develop NPD if said personality disorder occurs in the medical history of his or her family. The results reported in *A Twin Study of Personality Disorders* (2000) indicate that the rate of occurrence of personality disorders in twins determined that there is a moderate-to-high likelihood of the heritability of NPD; and the research of *The Genetic Epidemiology of Personality Disorders* (2010) indicates that specific genes and genetic interactions (epistasis) contribute to the formation of NPD, and to the development of a narcissistic personality, yet how genetics influence the developmental and the physiologic processes underlying NPD remains undetermined.

### Environment

Environmental and social factors also exert significant influence upon the onset of NPD in a person. In some people, pathological narcissism may develop from an impaired emotional attachment to the primary caregivers, usually the parents. That lack of psychological and emotional attachment to a parental figure can result in the child's perception of himself or herself as unimportant and unconnected to other people, usually family, community, and society. Typically, the child comes to believe that they have a personality defect that makes him or her an unvalued and unwanted person; in that vein, either overindulgent and permissive parenting or insensitive and over-controlling parenting are contributing factors towards the development of NPD in a child.

In *Gabbard's Treatments of Psychiatric Disorders* (2014), the following factors are identified as promoting the development of narcissistic personality disorder:

* An oversensitive temperament (individual differences of behavior) at birth.
* Excessive admiration that is never balanced with realistic criticism of the child.
* Excessive praise for good behaviors, or excessive criticism for bad behaviors in childhood.
* Overindulgence and overvaluation by parents, family, and peers.
* Being praised by adults for perceived exceptional physical appearance or abilities.
* Severe emotional abuse in childhood.
* Unpredictable or unreliable care-giving by the parents.
* Learning the behaviors of psychological manipulation from parents or peers.

Moreover, the research reported in "Modernity and Narcissistic Personality Disorders" (2014) indicates that cultural elements also influence the prevalence of NPD, because narcissistic personality traits more commonly occur in modern societies than in traditional societies.

## Pathophysiology

Studies of the occurrence of narcissistic personality disorder (NPD), such as *Gray Matter Abnormalities in Patients with Narcissistic Personality Disorder* (2013) and *Narcissists' Lack of Empathy Tied to Less Gray Matter* (2016) identified structural abnormalities in the brains of people afflicted with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex. The results of the study *Brain Structure in Narcissistic Personality Disorder: A VBM and DTI Pilot Study* (2015) associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex. The regions of the brain identified and studied — the insular cortex and the prefrontal cortex — are associated with the human emotions of empathy and compassion, and with the mental functions of cognition and emotional regulation. The neurologic findings of the studies indicate that narcissistic personality disorder is related to a compromised (damaged) capacity for emotional empathy and emotional regulation.

## Diagnosis

### DSM-5

The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the *Diagnostic and Statistical Manual of Mental Disorders*, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That the APA's formulation, description, and definition is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns — at the expense of . . . internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR.

In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the *Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed.* (DSM-5, 2013), and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains. Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice. Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.

### ICD-10

The *International Statistical Classification of Diseases and Related Health Problems*, 10th Edition (ICD-10), of the World Health Organization (WHO), lists narcissistic personality disorder (NPD) under the category of "Other specific personality disorders". The ICD-10 requires that any personality-disorder diagnosis also meet and satisfy the General diagnostic criteria 2 used for determining that a person has a diagnosable personality disorder.

### Subtypes of NPD

Although the DSM-5 indicates narcissistic personality disorder as a homogeneous syndrome, there is evidence of overt and covert subtypes in the expression of NPD. The study *Narcissistic Personality Disorder: Diagnostic and Clinical Challenges* (2015) indicates the existence of two subtypes of narcissism:

* Grandiose narcissism, characterized by the personality traits of grandiosity, arrogance, and boldness;
	+ The research indicates that people with grandiose narcissism express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."
* Vulnerable narcissism, characterized by the personality traits of defensiveness and hypersensitivity.

In an inventory of the types of NPD, the psychiatrist Glen Gabbard

* described the "oblivious" subtype of narcissist as being a grandiose, arrogant, and thick-skinned person;
* described the "narcissistic vulnerability" of the subtype of person who consciously exhibits the personality traits of helplessness and emotional emptiness, and of low self-esteem and shame, which usually are expressed as socially avoidant behavior in situations where the narcissist's self-presentation is impossible; therefore, they withdraw from situations wherein the needed or expected social approval is not given.

Gabbard also described the "hypervigilant" subtype of narcissist whose feelings are easily hurt, has an oversensitive temperament, and ashamed; and described the "high-functioning" subtype of narcissist as a person less functionally impaired in the areas of life where narcissists with a severe expression of NPD usually have difficulties in functioning as a normally-socialized person.

In the study *Disorders of Personality: DSM-IV-TM and Beyond* (1996), Theodore Millon suggested five subtypes of narcissist; however, there are few, pure subtypes of narcissist. Morever, Millon's five subtypes of narcissist are not recognized in either the *Diagnostic and Statistical Manual of Mental Disorders* or in the *International Statistical Classification of Diseases and Related Health Problems*.

 **Amorous narcissist** | Including histrionic features.
 **Compensatory narcissist** | Including negativistic and avoidant features
 **Elitist narcissist** | Variant of pure pattern
 **Normal narcissist** | Absent of the traits of the other four

### Comorbidity

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders. People with NPD are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder. Moreover, the occurrence of NPD is further associated with the occurrence of bipolar disorder, of anorexia, and of substance use disorders, especially cocaine use disorder.

In that vein, NPD also might be comorbid with the occurrence of other mental disorders, such as histrionic personality disorder, borderline personality disorder, antisocial personality disorder, or paranoid personality disorder.

## Treatment

Narcissistic personality disorder is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they usually are prompted by difficulties in their lives, or are seeking relief from some other disorder of their mental health, such as a major depressive disorder, a substance use disorder (drug addiction), a bipolar disorder (manic depression), or an eating disorder (anorexia nervosa, rumination disorder, bulimia nervosa). The reason for such an indirect path to psychotherapeutic treatment is partly because narcissists generally possess poor insight, and are unaware that their actions produced their mentally unhealthy circumstance, and so fail to recognize that their perceptions and behaviors are socially inappropriate and problematic, because of their very positive self-image (inflated self-concept).

In general, psychotherapy is the basis for treating narcissistic personality disorder. In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time with clinical strategies that applied psychoanalytic therapy to NPD clients, which, they claimed, effectively treated that personality disorder. Contemporary psychotherapy treatments include transference-focused therapy; metacognitive therapy; and schema therapy, to treat the client's particular subtype of NPD. Improvements to the mental health of patients with NPD are possible with psychopharmaceutical treatment of the symptoms of the comorbid disorders; despite such drug therapy, the psychologist Elsa Ronningstam said that "alliance-building and engaging the patient's sense of agency and reflective ability are essential for [achieving] change in pathological narcissism." Psychiatric medications usually are not indicated for treating NPD, but can be used to treat the co-occurring symptoms of psychological depression, anxiety, and impulsiveness, when present in the NPD client. In the field of relationship counseling mental health therapy is most beneficial when both partners participate in the treatments.

## 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

The lifetime rates of narcissistic personality disorder are estimated at 1% in the general population; and between 2% to 16% in the clinical population. A 2010 review found rates of NPD between 0% to 6% in community samples, and that the yearly number of new cases of NPD in men is slightly greater than in women. A 2015 review found that the rates of NPD have been relatively stable for men and women throughout the thirty-year period in which data were collected.