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]
Causes
The etiology of this disorder is unknown, but, according to Groopman and Cooper, factors identified by researchers as possibly contributing to this disorder include:[6]
- 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 [7].
Differential Diagnosis
Epidemiology and Demographics
Prevalence
The prevalence of narcissistic personality disorder is from 0 to 6200 per 100,00 (0% to 6.2%) of the overall population.[8]
Gender
Approximately 50 to 75% of subjects with narcissistic personality disorder are men.[6]
Risk Factors
Natural History, Prognosis and Complications Section
Prognosis
Poor prognostic factors include:
- Vulnerability in self-esteem
- Intolerance to criticism
- Feelings of humiliation and self-criticism
- Histrionic, borderline, antisocial and paranoid personality[8]
Diagnostic Criteria
DSM-V Diagnositic Criteria for Narcissistic Personality Disorder[8]
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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:
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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
Clinical experience
Pathological narcissism occurs in a spectrum of severity [7]. 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 [10]. 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 [11]. (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[11].
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 [12]. 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 [13]. 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 [11]. 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"[14]
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." [15]
Narcissistic Personality disorder and Shame
It has been suggested that Narcissistic personality disorder may be related to defenses against shame. [16]
Gabbard suggested NPD could be broken down into two subtypes[17]. 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. [18]. 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 [11]. James F. Masterson's A Therapist's Guide to the Personality Disorders: The Masterson Approach outlines a prominent approach to healing NPD, while [7] 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. [19]
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 [20], [21]
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 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.
- ↑ Gunderson JG, Ronningstam E (2001). "Differentiating narcissistic and antisocial personality disorders". J Pers Disord. 15 (2): 103–9. PMID 11345846.
- ↑ 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
- ↑ 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 "Narcissistic Personality Disorder". Personality Disorders - Narcissistic Personality Disorder. Armenian Medical Network. 2006. Retrieved 2007-02-14.
- ↑ 7.0 7.1 7.2 Johnson, Stephen M PhD (1987). Humanizing the Narcissistic Style. New York: Norton, page 39
- ↑ 8.0 8.1 8.2 8.3 8.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
- ↑ 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.
- ↑ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 19-20
- ↑ 11.0 11.1 11.2 11.3 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.