Narcissistic Personality Disorder

Narcissistic Personality Disorder is a personality disorder where individuals have a grandiose sense of their own self-importance but are also extremely sensitive to criticism. They have little ability to empathize with others, and they are more concerned about appearance than substance. It is characterized by arrogance, grandiosity, a need for admiration, and a tendency to exploit others. Patients with this condition often have a sense of excessive entitlement and may demand special treatment.

Epidemiology
  • Prevalence estimates range between 0% to 6.2% in community samples.[1]
  • 50% to 75% of diagnoses are male.[2]
Prognosis
  • Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to “injury” from criticism or defeat.
  • Impairment can be severe, and may include marital problems and interpersonal relationships conflicts
  • Individuals may face occupational difficulties, and show an unwillingness to take risks in competitive or other situations in which defeat is possible.
  • Individuals with narcissistic personality disorder may have more difficulties to the aging process, especially when it comes to new physical and occupational limitations related to ageing (“mid-life crisis”).[3]
Comorbidity
  • Anorexia nervosa and substance use disorders (especially cocaine) are comorbid
  • Associated personality disorders include histrionic, borderline, antisocial, and paranoid personality disorders

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 5 (or more) of the following:

  1. Has a grandiose sense of self-importance (e.g. - exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
  4. Requires excessive admiration
  5. Has a sense of entitlement (i.e. - unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations)
  6. Is interpersonally exploitative (i.e. - takes advantage of others to achieve his or her own ends)
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
  8. Is often envious of others or believes that others are envious of him or her
  9. Shows arrogant, haughty behaviors or attitudes.

Narcissistic personality disorder can be broken into 3 concepts:[4]

  1. Overt: Grandiose, stereotypical loud
  2. Covert: More fragile, self effacing, overly aware of others
  3. Malignant: a combination of narcissistic personality disorder and antisocial personality disorder

Kohut believed narcissism is developmentally arrested at an early stage, when an individual needs a feedback environment to maintain their cohesive selves. He formulated that self-object transferences recreate the situation with parents that was not fully successful during childhood (mirroring, idealising). When a narcissist does not get response they need (i.e. - an empathic deficit), they are prone to fragmentation of the self (experience a narcissistic injury).

Kernberg viewed the narcissist’s grandiosity and exploitation as evidence of oral rage, which results from the emotional deprivation caused by an indifferent and spiteful parent. When this occurs, the child's sense of being special, provides an emotional escape from perceived threat/indifference by the parent. The grandiosity and entitlement that develops protects a split off the “real self.” Here, the “real self” contains strong, unconscious feelings of envy, deprivation, fear, and rage. Thus, the defensive structure in narcissistic personality disorder is remarkably similar to one with borderline personality.

  • High-achieving individuals
    • Many highly successful individuals can have 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.
    • A stable self-image and relative lack of self-destructiveness, impulsivity, and abandonment concerns help distinguish narcissistic personality disorder from BPD
    • Excessive pride in achievements, lack of emotional display, and disdain for others' sensitivities help distinguish narcissistic personality disorder from histrionic personality disorder.
    • Individuals with ASPD and narcissistic personality disorders share features such as tough-mindedness, glibness, superficialness, exploitation, and a lack of empathy. However, ASPD is characterized by impulsivity, aggression, and deceit. In addition, individuals with ASPD may not want the admiration and envy of others, and narcissistic personality disorder usually lacks the history of conduct disorder in childhood or criminal behavior in adulthood.
    • In both narcissistic personality disorder and OCPD, there may be perfectionism and the belief that others cannot do things as well. However, in OCPD, there is frequent self-criticism, while dose with individuals with narcissistic personality disorder are more likely to believe that they have already achieved perfection.
    • Suspiciousness and social withdrawal usually distinguish those with schizotypal or paranoid personality disorder from those with narcissistic personality disorder. When these qualities are present in individuals with narcissistic personality disorder, they are usually driven from fears of having any flaws or imperfections revealed.
    • Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder.
    • Narcissistic personality disorder should be distinguished from symptoms that may develop in association with persistent substance use (e.g. - stimulant induced mania)
  • Mentalization-based therapy, transference-focused psychotherapy, schema-focused psychotherapy, and dialectical behaviour therapy (DBT) for significant self-destructive behaviors.
  • Higher functioning narcissistic personalities may do well in psychodynamic (or psychoanalytic) psychotherapy, and supportive psychotherapy may also be useful.
  • Individual psychotherapy is viewed by many as the basic treatment of choice. Psychotherapy can be very challenging for therapists, and confrontation and mirroring techniques are suggested.

Personality Disorder Guidelines

Guideline Location Year PDF Website
World Federation of Societies of Biological Psychiatry (WFSBP) International 2009 - Link
For Patients
For Providers
Research
1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.