Narcissistic personality disorder
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Template:DiseaseDisorder infobox
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.[1] 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 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," which also includes the eccentric, "haltlose," immature, passive-aggressive, and psychoneurotic personality disorders. Men are more commonly afflicted with NPD than women.[2] 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.[3]
Historical Perspective
The term narcissistic personality disorder was first used by Heinz Kohut in 1971.[4] In 1980, NPD became a diagnostic category as defined by the DSM.[1] From the publication of the DSM-III to the DSM-IV, which was released in 1994, professional thought about the characteristics of NPD shifted from an inability to empathize with others to an unwillingness to consider or try to understand others' feelings.[5]
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.[6]
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.[5][7] Mood disorders and PTSD are also commonly comorbid with NPD.[7] Dysthymia is strongly negatively correlated with incidence of NPD.[7]
Causes
The cause of NPD is unknown. Neurological and environmental factors may both play a role. Potentially relevant environmental factors may include:[8]
- 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.[9]
Differential Diagnosis
NPD must be differentiated from other mental disorders which present with similar symptomology, including:[2][3][7]
- 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.[2]
- 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.[2]
- Some experts suggest that ASPD would best be defined as a subgroup of NPD.[10]
- 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.[5]
- 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.[3]
- 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.[5]
Epidemiology and Demographics
Prevalence
The lifetime prevalence of narcissistic personality disorder is from 6,200 per 100,000 (6.2%) of the overall population.[11]
Age
NPD most commonly presents in young adults, though it has been observed in patients in their later years as well.[12]
Gender
Males are more commonly afflicted with NPD than females, though the extent of the disparity is unclear.[2]
Race
NPD is most common among Black men and women and Hispanic women.[7]
Risk Factors
Risk factors for the development of NPD include:[11][13][7]
- 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.[1] Certain neurological defects that are common in NPD patients (i.e., frontolimbic dysfunctions) may predispose them to neurodegenerative disorders later in life, particularly dementia.[6]
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.[3] Similarly, the behavior and viewpoints of NPD patients may even cause mental health clinicians to harbor negative feelings toward them, which could impair treatment.[3]
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.[1]
Prognosis
Narcissism is associated with a broad spectrum of intensity, ranging from socially acceptable and even healthy or professionally beneficial to pathological and destructive.[1][5] 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.[3]
Poor prognostic factors include:[11]
- Vulnerability in self-esteem
- Intolerance to criticism
- Feelings of humiliation and self-criticism
- Histrionic, borderline, antisocial and paranoid personality
Diagnosis
Diagnostic Criteria
DSM-V Diagnositic Criteria for Narcissistic Personality Disorder
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A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:[11]
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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:[1][5][14]
- 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)
- 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.[15] The questionnaire has good internal consistency and acceptable inter-rater reliability.[2]
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.[6]
Other Diagnostic Studies
Assessment modalities include self-reporting through the Personality Diagnostic Questionnaire-4 and Cloninger's Temperament and Character Inventory (TCI).[16]
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
Clinical experience
Pathological narcissism occurs in a spectrum of severity [9]. In its more extreme forms, it is narcissistic personality disorder. NPD is considered to result from a person's belief that he or she is flawed in a way that makes the person fundamentally unacceptable to others [17]. This belief is held below the person’s conscious awareness; such a person would typically deny thinking such a thing, if questioned. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognised their supposedly defective nature, such people make strong attempts to control others’ view of them and behaviour towards them.
To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others' needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen. They may also demand certain behavior from their children because they see the children as extensions of themselves, and need the children to represent them in the world in ways that meet the parents’ emotional needs [18]. (For example, a narcissistic father who was a lawyer demanded that his son, who had always been treated as the "favorite" in the family, enter the legal profession as well. When the son chose another career, the father rejected and disparaged him.)
These traits will lead overly narcissistic parents to be very intrusive in some ways, and entirely neglectful in others. The children are punished if they do not respond adequately to the parents’ needs. This punishment may take a variety of forms, including physical abuse, angry outbursts, blame, attempts to instill guilt, emotional withdrawal, and criticism. Whatever form it takes, the purpose of the punishment is to enforce compliance with the parents' narcissistic needs[18].
People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight, real or imagined [19]. To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility.
There is a broad spectrum of pathologically narcissistic personalities, styles, and reactions -- from the very mild, reactive and transient, to the severe and inflexible narcissistic personality disorder.
Though individuals with NPD are often ambitious and capable, the 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 achievements [20]. With narcissistic personality disorder, the person's perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.
The exploitativeness, sense of entitlement, lack of empathy, disregard for others, and constant need for attention inherent in NPD, adversely affects interpersonal relationships. Individuals with NPD frequently select as mates, and engender in their children, "co-narcissism," which is a term coined to refer to a co-dependent personality style similar to co-alcoholism and co-dependency [18]. Co-narcissists organize themselves around the needs of others. They feel responsible for others, accept blame readily, are eager to please, defer to others’ opinions, and fear being considered selfish if they act assertively.
True Self, False Self
Alexander Lowen describes pathological narcissism, and narcissistic personality disorder, as "the denial of the true self"[21]
Masterson describes the creation of a false self as:
- when a young child fails to separate her own self-image from that of her mother. This happens roughly between the ages of two and three, often because of a parent’s own emotional problems. A mother’s encouragement of a child's self-assertion is vital. When the mother suffers from low self-esteem, she has difficulty encouraging her child’s emerging self. The child experiences this absence as a loss of self, creating feelings of abandonment that lead to depression. To deal with the depression, the child gives up efforts to support her emerging self. Instead, she relies on her mother’s approval to maintain the esteem of a "false self." [22]
Narcissistic Personality disorder and Shame
It has been suggested that Narcissistic personality disorder may be related to defenses against shame. [23]
Gabbard suggested NPD could be broken down into two subtypes[24]. He saw the "oblivious" subtype as being grandiose, arrogant and thick skinned and the "hypervigilant" subtype as easily hurt, oversensitive and ashamed.
He suggested that the oblivious subtype presents a large, powerful, grandiose self to be admired, envied and appreciated, which is the antithesis of the weakened and internalised self that hides in a generic state of shame, in order to fend off devaluation, whereas the hypervigilant subtype, far from fending off devaluation, is obsessed with it, neutralising devaluation by seeing others as unjust abusers.
Jeffrey Young, who developed Schema Therapy, also links shame to NPD. He sees the so-called Defectiveness Schema as a core schema of NPD, next to the Emotional Deprivation and Entitlement Schema's. [25]. The Defectiveness Schema is compensated with three Schema Modes (coping strategies):
- Surrender: Choose critical partners and significant others; puts him- or herself down.
- Avoidance: Avoids sharing "shameful" thoughts and feelings with partners and significant others due to fear of rejection.
- Overcompensation: Behaves in a critical or superior way toward others; tries to come across as perfect.
Note that an individual with this schema might not employ all three schema modes.
Treatment
Though there is controversy in the profession, most psychiatrists and psychologists regard NPD as a relatively stable condition when experienced as a primary disorder [18]. James F. Masterson's A Therapist's Guide to the Personality Disorders: The Masterson Approach outlines a prominent approach to healing NPD, while [9] discusses a continuum of severity and the kinds of therapy most effective in different cases. Typically, as narcissism is an ingrained personality trait, rather than a chemical imbalance, medication and therapy are not very effective in treating the disorder.
Schema Therapy, a form of therapy developed by Jeffrey E. Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD. [26]
It is unusual for people to seek therapy for NPD. Subconscious fears of exposure of inadequacy are often met with defensive disdain of therapeutic processes [27], [28]
Pharmacotherapy is rarely used, though there is one unofficially documented observation of therapeutic response with the atypical anti-depressant bupropion (Wellbutrin). [3]
Because NPD contributes to negative, stressful life experiences characterized by the mental health field as "clinically significant distress" or "impairment", co-existing conditions of depression and anxiety are typical, and can improve with pharmaceutical interventions.[citation needed] NPD sufferers are more likely to seek such treatment from primary care physicians for relief of immediate symptoms of distress / depression.[citation needed]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Ronningstam E, Baskin-Sommers AR (2013). "Fear and decision-making in narcissistic personality disorder-a link between psychoanalysis and neuroscience". Dialogues Clin Neurosci. 15 (2): 191–201. PMC 3811090. PMID 24174893.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Gunderson JG, Ronningstam E (2001). "Differentiating narcissistic and antisocial personality disorders". J Pers Disord. 15 (2): 103–9. PMID 11345846.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Miller JD, Campbell WK, Pilkonis PA (2007). "Narcissistic personality disorder: relations with distress and functional impairment". Compr Psychiatry. 48 (2): 170–7. doi:10.1016/j.comppsych.2006.10.003. PMC 1857317. PMID 17292708.
- ↑ Kohut, Heinz, The Analysis of the Self, 1971
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Baskin-Sommers A, Krusemark E, Ronningstam E (2014). "Empathy in narcissistic personality disorder: from clinical and empirical perspectives". Personal Disord. 5 (3): 323–33. doi:10.1037/per0000061. PMC 4415495. PMID 24512457.
- ↑ 6.0 6.1 6.2 Poletti M, Bonuccelli U (2011). "From narcissistic personality disorder to frontotemporal dementia: a case report". Behav Neurol. 24 (2): 173–6. doi:10.3233/BEN-2011-0326. PMID 21606578.
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM; et al. (2008). "Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions". J Clin Psychiatry. 69 (7): 1033–45. PMC 2669224. PMID 18557663.
- ↑ "Narcissistic Personality Disorder". Personality Disorders - Narcissistic Personality Disorder. Armenian Medical Network. 2006. Retrieved 2007-02-14.
- ↑ 9.0 9.1 9.2 Johnson, Stephen M PhD (1987). Humanizing the Narcissistic Style. New York: Norton, page 39
- ↑ Kernberg OF (1989). "The narcissistic personality disorder and the differential diagnosis of antisocial behavior". Psychiatr Clin North Am. 12 (3): 553–70. PMID 2678022.
- ↑ 11.0 11.1 11.2 11.3 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
- ↑ Balsis S, Eaton NR, Cooper LD, Oltmanns TF (2011). "The Presentation of Narcissistic Personality Disorder in an Octogenarian: Converging Evidence from Multiple Sources". Clin Gerontol. 34 (1): 71–87. doi:10.1080/07317115.2011.524821. PMC 3104277. PMID 21637723.
- ↑ Livesley, W.J., Jang, K.L., Jackson, D.N. and P.A. Vernon (1993). "Genetic and environmental contributions to dimensions of personality disorder". American Journal of Psychiatry 150, 1826-1831. Abstract online. Accessed June 18, 2006.
- ↑ 14.0 14.1 Bell CC (1980). "Racism: a symptom of the narcissistic personality disorder". J Natl Med Assoc. 72 (7): 661–5. PMC 2552506. PMID 7392083.
- ↑ Gunderson JG, Ronningstam E, Bodkin A (1990). "The diagnostic interview for narcissistic patients". Arch Gen Psychiatry. 47 (7): 676–80. PMID 2360861.
- ↑ Miller JD, Campbell WK, Pilkonis PA, Morse JQ (2008). "Assessment procedures for narcissistic personality disorder: a comparison of the personality diagnostic questionnaire-4 and best-estimate clinical judgments". Assessment. 15 (4): 483–92. doi:10.1177/1073191108319022. PMC 2841972. PMID 18550845.
- ↑ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 19-20
- ↑ 18.0 18.1 18.2 18.3 Rappoport, Alan, Ph. D.Co-Narcissism: How We Adapt to Narcissistic Parents. The Therapist, in press
- ↑ American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 659
- ↑ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 22
- ↑ Lowen, Alexander, M.D. (1997) Narcissism: Denial of the True Self Touchstone (New York), ISBN 0-7432-5543-7
- ↑ Masterson, J, M.D. The Hollow Self
- ↑ Wurmser L, Shame, the veiled companion of narcissism, in The Many Faces of Shame, edited by Nathanson DL. New York, Guilford, 1987, pp 64–92
- ↑ Gabbard GO, subtypes of narcissistic personality disorder. Bull Menninger Clin 1989; 53:527–532
- ↑ Young, Klosko, Weishaar: Schema Therapy - A Practitioner's Guide, 2003, Page 375
- ↑ Young, Klosko, Weishaar: Schema Therapy - A Practitioner's Guide, 2003, chapter 10, Pages 373-424
- ↑ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, page 23
- ↑ Kohut, Heinz, (1971). The Analysis of the Self.