Narcissistic Personality Disorder

 Narcissistic personality disorder (NPD) is a personality disorder with a long-term pattern of abnormal behavior characterized by exaggerated feelings of self-importance, excessive need for admiration, and a lack of empathy. Those affected often spend a lot of time thinking about achieving power or success, or on their appearance. They often take advantage of the people around them. The behavior typically begins by early adulthood and occurs across a variety of social situations.

The cause of narcissistic personality disorder is unknown. It is a personality disorder classified within cluster B by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Diagnosis is made by a healthcare professional interviewing the person in question. The condition needs to be differentiated from mania and substance use disorder.

Treatments have not been well-studied. Therapy is often difficult as people with the disorder frequently do not consider themselves to have a problem. About one percent of people are believed to be affected at some point in their lives. It appears to occur more often in males than females and affects young people more than older people. The personality was first described in 1925 by Robert Waelder, and the term NPD came into use in 1968.

Signs and symptoms

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

The DSM-5 indicates that persons with NPD usually display some or all of the following symptoms, typically without the commensurate qualities or accomplishments:

1.            Grandiosity with expectations of superior treatment from other people

2.            Fixated on fantasies of power, success, intelligence, attractiveness, etc.

3.            Self-perception of being unique, superior, and associated with high-status people and institutions

4.            Needing continual admiration from others

5.            Sense of entitlement to special treatment and to obedience from others

6.            Exploitative of others to achieve personal gain

7.            Unwilling to empathize with the feelings, wishes, and needs of other people

8.            Intensely envious of others and the belief those others are equally envious of them

9.            Pompous and arrogant demeanor

Narcissistic personality disorder usually develops in adolescence or early adulthood. It is not uncommon for children and adolescents to display traits similar to those of NPD, but such occurrences are usually transient and below the criteria for a diagnosis of NPD. True symptoms of NPD are pervasive, apparent in varied situations, and rigid, remaining consistent over time. The NPD symptoms must be sufficiently severe that they significantly impair the person's capabilities to develop meaningful human relationships. Generally, the symptoms of NPD also impair the person's psychological abilities to function, either at work, school or in important social settings. The DSM-5 indicates that the traits manifested by the person must substantially differ from cultural norms, to qualify as symptoms of NPD.

Associated features

People with NPD tend to exaggerate their skills, accomplishments, and their level of intimacy with people they consider high-status. This sense of superiority may cause them to monopolize conversations or to become impatient or disdainful when others talk about themselves. When their own ego is wounded by a real or perceived criticism, their anger can be disproportionate to the situation, but typically, their actions and responses are deliberate and calculated. Despite occasional flare-ups of insecurity, their self-image is primarily stable (i.e., overinflated).

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others' views, unaware of others' needs and the effects of their behavior on others, and insist that others see them as they wish to be seen. Narcissistic individuals use various strategies to protect themselves at the expense of others. They tend to devalue, derogate, insult, and blame others, and they often respond to threatening feedback with anger and hostility. Since the fragile ego of individuals with NPD is hypersensitive to perceived criticism or defeat, they are prone to feelings of shame, humiliation, and worthlessness over minor or even imagined incidents. They usually mask these feelings from others with feigned humility or by isolating themselves socially, or they may react with outbursts of rage, defiance, or by seeking revenge. The merging of the "inflated self-concept" and the "actual self" is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defense mechanisms of denial, idealization, and devaluation.

According to the DSM-5: "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and because significant functional impairment or subjective distress do they constitute narcissistic personality disorder." Due to the high functionality associated with narcissism, some people may not view it as an impairment in their lives. Although overconfidence tends to make individuals with NPD ambitious, it does not necessarily lead to success and high achievement professionally. These individuals may be unwilling to compete or may refuse to take any risks to avoid appearing like a failure. In addition, their inability to tolerate setbacks, disagreements, or criticism, along with their lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional relationships with superiors and colleagues.

Causes

The causes of narcissistic personality disorder are unknown. Experts tend to apply a biopsychosocial model of causation, meaning that a combination of environmental, social, genetic, and neurobiological factors is likely to play a role in formulating a narcissistic personality.

Genetic

There is evidence that narcissistic personality disorder is heritable, and individuals are much more likely to develop NPD if they have a family history of the disorder. Studies on the occurrence of personality disorders in twins determined that there is a moderate to high heritability for narcissistic personality disorder.

However, the specific genes and gene interactions that contribute to its cause—and how they may influence the developmental and physiological processes underlying this condition—have yet to be determined.

Environment

Environmental and social factors are also thought to have a significant influence on the onset of NPD. In some people, pathological narcissism may develop from an impaired attachment to their primary caregivers, usually their parents. This can result in the child's perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted. Overindulgent, permissive parenting as well as insensitive, over-controlling parenting are believed to be contributing factors.

According to Leonard Groopman and Arnold Cooper, the following have been identified by various researchers as possible factors that promote the development of NPD:

•             An oversensitive temperament (personality traits) at birth.

•             Excessive admiration that is never balanced with realistic feedback.

•             Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood.

•             Overindulgence and overvaluation by parents, other family members, or peers.

•             Being praised for perceived exceptional looks or abilities by adults.

•             Severe emotional abuse in childhood.

•             Unpredictable or unreliable caregiving from parents.

•             Learning manipulative behaviors from parents or peers.

•             Valued by parents as a means to regulate their own self-esteem.

Cultural elements are believed to influence the prevalence of NPD as well since NPD traits are more common in modern societies than in traditional ones.

Pathophysiology

There is little research into the neurological underpinnings of narcissistic personality disorder. However, recent research has identified a structural abnormality in the brains of those with narcissistic personality disorder, specifically noting less volume of gray matter in the left anterior insula. Another study has associated the condition with reduced gray matter in the prefrontal cortex.

The brain regions identified in the above studies are associated with empathy, compassion, emotional regulation, and cognitive functioning. These findings suggest that narcissistic personality disorder is related to a compromised capacity for emotional empathy and emotional regulation.

Diagnosis

DSM-5

The formulation of narcissistic personality disorder in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) was criticized for failing to describe the range and complexity of the disorder. Critics said it focuses overly on "the narcissistic individual's external, symptomatic, or social interpersonal patterns—at the expense of ... internal complexity and individual suffering", which they argued reduced its clinical utility.

The Personality and Personality Disorders Work Group originally proposed the elimination of NPD as a distinct disorder in DSM-5 as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains. Some clinicians objected to this, characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice. The general move towards a dimensional (personality trait-based) view of Personality Disorders has been maintained despite the reintroduction of NPD.

ICD-10

The World Health Organization's (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) lists narcissistic personality disorder under other specific personality disorders. It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Subtypes

While the DSM-5 regards narcissistic personality disorder as a homogeneous syndrome, there is evidence for variations in its expression. In a 2015 paper, two major presentations of narcissism are typically suggested, an "overt" or "grandiose" subtype, characterized by grandiosity, arrogance, and boldness, and a "covert" or "vulnerable" subtype characterized by defensiveness and hypersensitivity. Those with "narcissistic grandiosity" express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism." Psychiatrist Glen Gabbard described the subtype, which he referred to as the "oblivious" subtype as being grandiose, arrogant, and thick-skinned. The subtype of "narcissistic vulnerability" entails (on a conscious level) "helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behavior as being socially avoidant in situations where their self-presentation is not possible so they withdraw, or the approval they need/expect is not being met." Gabbard described this subtype, which he referred to as the "hypervigilant" subtype as being easily hurt, oversensitive, and ashamed. In addition, a "high-functioning" presentation, where there is less impairment in the areas of life where those with a more severe expression of the disorder typically have difficulties in, is suggested.

Theodore Millon suggested five subtypes of narcissism. However, there are few pure variants of any subtype, and the subtypes are not recognized in the DSM or ICD.

Unprincipled narcissist including antisocial features. Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive.

Amorous narcissist including histrionic features. Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulge hedonistic desires; bewitch and inveigles others; pathological lying and swindling. Tends to have many affairs, often with exotic partners.

Compensatory narcissists include negative and avoidant features.  Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, and noteworthy; self-worth results from self-enhancement.

Elitist narcissist. A variant of the pure pattern feels privileged and empowered by special childhood status and pseudo-achievements; the entitled façade bears little relation to reality; seeks a favored and good life; is upwardly mobile; and cultivates special status and advantages by association.

Normal narcissist. Absent of the traits of the other four                 Least severe and most interpersonally concerned and empathetic, still entitled and deficient in reciprocity; bold in environments, self-confident, competitive, seeks high targets, feels unique; talent in leadership positions; expecting of recognition from others.

Possible additional categories not cited by the current theory of Millon might include:

Fanatic narcissist including paranoid features. Grandiose delusions are irrational and flimsy; pretentious, expensive supercilious contempt and arrogance toward others; lost pride reestablished with extravagant claims and fantasies. Reclassified under paranoid personality disorder.

Hedonistic narcissist. A mix of Millon's initial four subtypes, Hedonistic and self-deceptive, avoidant of responsibility and blame, shifted onto others; idiosyncratic, often self-biographical, proud of minor quirks and achievements, conflict-averse and sensitive to rejection; procrastinative, self-undoing, avolitive, ruminantly introspective; the most prone to fantastic inner worlds which replace social life

Malignant narcissist.  Including antisocial, sadistic, and paranoid features. Fearless, guiltless, remorseless, calculating, ruthless, inhumane, callous, brutal, rancorous, aggressive, biting, merciless, vicious, cruel, spiteful; hateful and jealous; anticipates betrayal and seeks punishment; desires revenge; has been isolated, and is potentially suicidal or homicidal.

Will Titshaw also suggests three subtypes of narcissistic personality disorder which are not officially recognized in any editions of the DSM or the ICD.

Pure Narcissist.                 Mainly just NPD characteristics.                 Someone who has narcissistic features described in the DSM and ICD and lacks features from other personality disorders.

Attention Narcissist. Including histrionic (HPD) features.                They display the traditional NPD characteristics described in the ICD & DSM along with histrionic features because they think they are superior and therefore should have everyone's attention, and when they do not have everyone's attention they go out of their way to capture the attention of as many people as possible.

Beyond The Rules Narcissist. Including antisocial (ASPD) features. This type of narcissist thinks that because they are so superior to everyone they do not have to follow the rules like most people and therefore show behavior included in the ICD for dissocial personality disorder and behavior, included in the DSM for antisocial personality disorder.

Comorbidity

NPD has a high rate of comorbidity with other mental disorders. Individuals with NPD are prone to bouts of depression, often meeting the criteria for co-occurring depressive disorders. In addition, NPD is associated with bipolar disorder, anorexia, and substance use disorders, especially cocaine. As far as other personality disorders, NPD may be associated with histrionic, borderline, antisocial, and paranoid personality disorders.

Treatment

Narcissistic personality disorder is rarely the primary reason for people seeking mental health treatment. When people with NPD enter treatment, it is typically prompted by life difficulties or to seek relief from another disorder, such as major depressive disorder, substance use disorder, bipolar disorder, or eating disorders, or at the insistence of relatives and friends. This is partly because individuals with NPD generally have poor insight and fail to recognize their perception and behavior as inappropriate and problematic due to their very positive self-image.

Treatment for NPD is centered around psychotherapy. In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time by outlining clinical strategies for using psychoanalytic psychotherapy with clients with NPD that they claimed were effective in treating the disorder. Contemporary treatment modalities commonly involve transference-focused, metacognitive, and schema-focused therapies. Some improvement might be observed through the treatment of symptoms related to comorbid disorders with psycho-pharmaceuticals, but as of 2016, according to Elsa Ronningstam, a psychologist at Harvard Medical School, "Alliance building and engaging the patient's sense of agency and reflective ability are essential for change in pathological narcissism."

Pattern change strategies performed over a long period are used to increase the ability of those with NPD to become more empathic in everyday relationships. To help modify their sense of entitlement and self-centeredness schema, the strategy is to help them identify how to utilize their unique talents and to help others for reasons other than their own personal gain. This is not so much to change their self-perception of their "entitlement" feeling but more to help them empathize with others. Another type of treatment would be temperament change. Psychoanalytic psychotherapy may be effective in treating NPD, but therapists must recognize the patient's traits and use caution in tearing down narcissistic defenses too quickly. Anger, rage, impulsivity, and impatience can be worked on with skill training. Therapy may not be effective because patients may receive feedback poorly and defensively. Anxiety disorders and somatoform disorders are prevalent, but the most common would be depression.

Group treatment has its benefits, as the effectiveness of receiving peer feedback rather than the clinicians may be more accepted, but group therapy can also contradict itself as the patient may show "demandingness, egocentrism, social isolation and withdrawal, and socially deviant behavior". Researchers originally thought group therapy among patients with NPD would fail because it was believed that group therapy required empathy which NPD patients lack. However, studies show group therapy does hold value for patients with NPD because it lets them explore boundaries, develop trust, increase self-awareness, and accept feedback. Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: "...effective expression, empathy, discussion, and problem-solving/conflict resolution". Marital/relationship therapy is most beneficial when both partners participate.

No medications are indicated for treating NPD, but may be used to treat co-occurring mental conditions or symptoms that may be associated with it such as depression, anxiety, and impulsiveness if present.

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 prevalence of NPD is estimated at 1% in the general population and 2% to 16% in clinical populations. A 2010 systematic review found the prevalence of NPD to be between 0% to 6% in community samples. There is a small gender difference, with men having a slightly higher incidence than women.

According to a 2015 meta-analysis that looked at gender differences in NPD, there has recently been a debate about a perceived increase in the prevalence of NPD among younger generations and among women. However, the authors found that this was not reflected in the data and that the prevalence has remained relatively stable for both genders over the last 30 years (when data on the disorder were first collected).

History

The use of the term "narcissism" to describe excessive vanity and self-centeredness predates by many years the modern medical classification of narcissistic personality disorder. The condition was named after Narcissus, a mythological Greek youth who became infatuated with his own reflection in a lake. He did not realize at first that it was his own reflection, but when he did, he died out of grief for having fallen in love with someone who did not exist outside himself.

The term "narcissistic personality structure" was introduced by Kernberg in 1967 and "narcissistic personality disorder" was first proposed by Heinz Kohut in 1968.

Early Freudianism

Sigmund Freud commented, regarding the adult neurotic's sense of omnipotence, "This belief is a frank acknowledgment of a relic of the old megalomania of infancy". He similarly concluded: "We can detect an element of megalomania in most other forms of paranoic disorder. We are justified in assuming that this megalomania is essentially of an infantile nature and that, as development proceeds, it is sacrificed to social considerations".

Edmund Bergler also considered megalomania to be normal in the child, and for it to be reactivated in later life in gambling. Otto Fenichel states that, for those who react in later life to narcissistic hurt with denial, a similar regression to the megalomania of childhood is taking place.

Object relations

Whereas Freud saw megalomania as an obstacle to psychoanalysis, in the second half of the 20th century, object relations theory, both in the United States and among British Kleinians, set about revaluing megalomania as a defense mechanism that offered potential access for therapy. Such an approach is built on Heinz Kohut's view of narcissistic megalomania as an aspect of normal development, by contrast with Kernberg's consideration of such grandiosity as a pathological development distortion.

Society and culture

In popular culture, narcissistic personality disorder has been called megalomania.

Fiction

An article on the Victorian Web argues that Rosamond Vincy, in George Eliot's Middlemarch (1871–72), is a full-blown narcissist as defined by the DSM.

In the film To Die For, Nicole Kidman's character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted: "[she] was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder".

Other examples in popular fiction include television characters Adam Demamp (portrayed by Adam DeVine in Workaholics) and Dennis Reynolds (portrayed by Glenn Howerton in It's Always Sunny in Philadelphia).

Criticism

A Norwegian study concluded that narcissism should be conceived as personality dimensions pertinent to the whole range of PDs rather than as a distinct diagnostic category. Alarcón and Sarabia, in examining past literature on the disorder, concluded that narcissistic personality disorder "shows nosological inconsistency and that its consideration as a trait domain with needed further research would be strongly beneficial to the field".