Narcissistic personality disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2], Haleigh Williams, B.S.

Synonyms and keywords: NPD; self-centered personality disorder; self-involved personality disorder; egotistic personality disorder; egotistitical personality disorder; narcissistic; narcissism; Narcissus; self-centered; self-involved; egotistic; egotistical; narcissistic personality

Overview

Narcissistic personality disorder (NPD) is a mental illness characterized by an extreme focus on oneself, chronic arrogance and feelings of superiority, a lack of empathy or consideration for others, and a longstanding need to be admired and respected. NPD is a maladaptive, rigid, and persistent condition that may cause significant distress and functional impairment. 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 in 1992, regards narcissistic personality disorder (NPD) as "a personality disorder that fits none of the specific rubrics," relegating it to the category known as "Other specific personality disorders." This category also includes the eccentric, "haltlose," immature, passive-aggressive, and psychoneurotic personality disorders. Men are more commonly afflicted with NPD than women. The primary consequences of NPD are social. Interpersonal relationships often suffer due to the patient’s sense of entitlement and disregard for the feelings of others, which may manifest as manipulation, infidelity, or violence. Disruptions to relationships may give rise to anxiety or depression in an NPD patient.

Historical Perspective

The term narcissistic personality disorder was first used by Heinz Kohut in 1971. In 1980, NPD became a diagnostic category as defined by the DSM. From the publication of the DSM-III to the DSM-IV, which was released in 1994, professional thought shifted from considering the primary characteristic of NPD an inability to empathize with others to an unwillingness to consider or try to understand others' feelings.

Classification

No formal classification scheme exists for NPD.

Pathophysiology

It has been suggested that certain neurological defects that are common in NPD patients (i.e., frontolimbic dysfunctions) may predispose sufferers to such neurodegenerative diseases as dementia. Additional longitudinal studies will be necessary to confirm this association.

Common Comorbid Conditions

NPD is found in individuals suffering from psychopathy in approximately 21% of cases; in BPD patients in 37-39% of cases; and in substance abuse disorder patients in 11.8% of cases. Mood disorders and PTSD are also commonly comorbid with NPD. Dysthymia is strongly negatively correlated with incidence of NPD.

Causes

The cause of NPD is unknown. Neurological and environmental factors may both play a role. Potentially relevant environmental factors may include:

• An oversensitive temperament at birth
• Overindulgence and overvaluation by parents
• Valued by parents as a means to regulate their own self-esteem
• Excessive admiration that is never balanced with realistic feedback
• Unpredictable or unreliable caregiving from parents
• Severe emotional abuse in childhood
• Being praised for perceived exceptional looks or talents by adults
• Learning manipulative behaviors from parents

Psychologists commonly believe that pathological narcissism results from an impairment in the quality of the person’s relationship with their primary caregivers, usually their parents, in that the parents were unable to form a healthy, empathic attachment to them. This results in the child conceiving of themselves as unimportant and unconnected to others. The child typically comes to believe that he or she has some defect of personality which makes them unvalued and unwanted.

Differential Diagnosis

NPD must be differentiated from other mental disorders which present with similar symptomology, including:

• Antisocial personality disorder
  • NPD patients are most effectively differentiated from ASPD patients by their grandiosity—the propensity to misrepresent themselves or their abilities as unique and superior to others.
  • NPD patients are more likely to have a steady job and less likely to be institutionalized/incarcerated, while ASPD patients are more likely to actively exploit or abuse other people.
  • Some experts suggest that ASPD would best be defined as a subgroup of NPD.
• Borderline personality disorder
  • Both NPD and BPD patients are hyper-sensitive and prone to overreact to criticism or perceived slights. They are also less likely to maintain healthy and fulfilling interpersonal relationships.
  • In BPD, anxiety and depression are endemic to the disorder, whereas in NPD, this type of distress may result as a secondary consequence of the personality disorder, resulting from defects in interpersonal functioning that define the symptomology of NPD.
• Psychopathy
  • Psychopathy and NPD are both associated with a sense of superiority to others and a lack of empathy. NPD patients are less likely to exhibit manipulative and duplicitous behavior.

Epidemiology and Demographics

Prevalence

The lifetime prevalence of narcissistic personality disorder is from 6,200 per 100,000 (6.2%) of the overall population.

Age

NPD most commonly presents in young adults, though it has been observed in patients in their later years as well.

Gender

Males are more commonly afflicted with NPD than females, though the extent of the disparity is unclear.

Race

NPD is most common among Black men and women and Hispanic women.

Risk Factors

Risk factors for the development of NPD include:

• Adolescence
• Male gender (50-75%)
• Genetic predisposition
• Being unmarried
• Excess admiration or neglect by parents
• Emotional abuse or manipulation

Screening

No formal screening recommendations exist for NPD.

Natural History, Complications, and Prognosis

Natural History

Current research aims to define the neurological underpinnings of the development of NPD. Certain neurological defects that are common in NPD patients (i.e., frontolimbic dysfunctions) may predispose them to neurodegenerative diseases later in life, particularly dementia.

Complications

The primary consequences of NPD are social. Interpersonal relationships often suffer due to the patient’s sense of entitlement and disregard for the feelings of others, which may manifest as manipulation, infidelity, or violence. Disruptions to relationships may give rise to anxiety or depression in an NPD patient. Similarly, the behavior and viewpoints of NPD patients may even cause mental health clinicians to harbor negative feelings toward them, which could impair treatment.

In some cases, questionable decision-making on the part of patients suffering from NPD may give rise to dire situations or life crises, under which circumstances a patient may require immediate medical attention. A lapse of this nature may also lead to suicide.

Prognosis

Narcissism is associated with a broad spectrum of intensity, ranging from socially acceptable and even healthy or professionally beneficial to pathological and destructive. The prognosis of NPD depends on the severity of its presentation in a given patient and the patient’s willingness to seek treatment. Since NPD patients often turn to healthcare to address psychological distress that occurs as a result of personal or academic/professional failures, sufferers who are able to circumvent such failures may be particularly unlikely to seek treatment.

Poor prognostic factors include:

• Vulnerability in self-esteem
• Intolerance to criticism
• Feelings of humiliation and self-criticism
• Histrionic, borderline, antisocial and/or paranoid personality disorders

Diagnosis

Diagnostic Criteria

DSM-V Diagnositic Criteria for Narcissistic Personality Disorder

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:

“

Significant impairments in personality functioning manifest by: Impairments in self functioning (A or B): A) Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem. B) Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations. Impairments in interpersonal functioning (A or B): A) Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others. B) Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain Pathological personality traits in the following domain: Antagonism, characterized by: Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

”

ICD-10 Criteria

While the ICD-10 does not specifically define the characteristics of this personality disorder, it is classified in the category "Other Specific Personality Disorders".

ICD-10 states that Narcissistic Personality Disorder is "a personality disorder that fits none of the specific rubrics F60.0-F60.7." That is, this personality disorder does not meet the diagnostic criteria for any of the following:

• F60.0 Paranoid Personality Disorder
• F60.1 Schizoid Personality Disorder
• F60.2 Dissocial (Antisocial) Personality Disorder
• F60.3 Emotionally unstable (borderline) Personality Disorder
• F60.4 Histrionic Personality Disorder
• F60.5 Anankastic (Obsessive-Compulsive) Personality Disorder
• F60.6 Anxious (Avoidant) Personality Disorder
• F60.7 Dependent Personality Disorder

History and Symptoms

Symptoms of narcissistic personality disorder include:

• Grandiosity
• Need for admiration
• Intense fear of rejection, isolation, and/or loss of admiration or respect
• Lack of empathy (coupled with a sense of entitlement that pervades interpersonal relationships)
  • Deficits in emotional empathy are generally stronger than those in cognitive empathy. Problems with cognitive empathy may be rooted in a lack of motivation rather than an actual inability.
  • This general lack of empathy in NPD patients may be particularly likely to manifest as racism.
• Tendency to exploit others, possibly subconsciously
• Arrogance
• Envy
• Interpersonal distancing and avoidance
• Insecurity and vulnerability
• Hypersensitivity
• Aggressiveness
• Proneness to shame

Physical Examination

The gold standard for diagnosing NPD is the Diagnostic Interview for Narcissism, which consists of 33 questions evaluating a patient's functional status in five areas: grandiosity, interpersonal relations, reactiveness, affects and moods, and social and moral adaptation. The questionnaire has good internal consistency and acceptable inter-rater reliability.

Laboratory Findings

No laboratory findings are considered diagnostic of NPD.

Imaging Findings

No imaging findings are currently considered diagnostic of NPD, though frontolimbic dysfunctions may be present, and may predispose sufferers to such neurodegenerative diseases as dementia.

Other Diagnostic Studies

Assessment modalities include self-reporting through the Personality Diagnostic Questionnaire-4 and Cloninger's Temperament and Character Inventory (TCI).

Treatment

Medical Therapy

The mainstay of treatment for NPD is psychotherapy, though suffering as a result of the disorder itself is rarely the reason a patient will seek treatment. Commonly, patients are urged to seek psychiatric counsel by family members or loved ones; they may also seek treatment for a different but related condition, such as major depressive disorder or an eating disorder. Treatment aims to help patients control their impulsivity and aggression while encouraging them to be more empathetic and less entitled. No specific medications have proven particularly effective in the treatment of NPD, though medication may be required to treat a co-occurring disorder.

Surgery

Surgery is not indicated for the treatment of NPD.

Prevention

Primary Prevention

Primary prevention of NPD involves the maintenance of a stable home life throughout childhood and the avoidance of excessive flattery or emotional manipulation by parents or caregivers.

Secondary Prevention

No strategies are indicated for the secondary prevention of NPD.

References

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