Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's feelings. Narcissistic personality disorder is one of the sub-types of the broader category known as personality disorders. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.
Personality disorders are a class of mental disorders characterized
by enduring and inflexible maladaptive patterns of behavior, cognition, and
inner experience, exhibited across many contexts and deviating from those
accepted by any culture. These patterns develop by early adulthood, and are
associated with significant distress or impairment. Criteria for diagnosing
personality disorders are listed in the sixth chapter of the International
Classification of Diseases (ICD) and in the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders (DSM).
There is no standard treatment for NPD. Its high comorbidity
with other mental disorders influences treatment choice and outcomes.
Psychotherapeutic treatments generally fall into two categories:
psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing
support for integration of both in therapy. However, there is an almost
complete lack of studies determining the effectiveness of treatments. One's
subjective experience of the mental disorder, as well as their agreement to and
level of engagement with treatment, is highly dependent on their motivation to
change.
Signs and symptoms
Despite outward signs of grandiosity, many people with NPD
struggle with symptoms of intense shame, worthlessness, low self-compassion,
and self-loathing. Their view of themselves is extremely malleable and
dependent on others' opinions of them. They are also hypersensitive to
criticism and possess an intense need for admiration. People with NPD gain
self-worth and meaning through this admiration. Individuals with NPD are often
motivated to achieve their goals, status, improvement, and perfectionism, and
to ignore relationships or avoid situations due to fears of incompetence,
failure, worthlessness, inferiority, shame, humiliation, and losing control.
People with NPD will try to gain social status and approval
in an attempt to avoid and combat these feelings, often by exaggerating their
skills, accomplishments, and their degree of intimacy with people they consider
high-status. Alongside this, they may have difficulty accepting help, vengeful
fantasies, a sense of entitlement, and they may feign humility. They are more
likely to try forms of plastic surgery due to a desire to gain attention and to
be seen as beautiful. A sense of personal superiority may lead them to
monopolize conversations, look down on others or to become impatient and
disdainful when other persons talk about themselves. Drastic shifts in levels
of self-esteem can result in a significantly decreased ability to regulate
emotions.
Patients with NPD have an impaired ability to recognize
facial expressions or mimic emotions, as well as a lower capacity for emotional
empathy and emotional intelligence. However they do not display a compromised
capacity for cognitive empathy or an impaired theory of mind, which are the
abilities to understand others' feelings and attribute mental states to one or
others respectively. They may also have difficulty relating to others’
experiences and being emotionally vulnerable. People with NPD are less likely
to engage in prosocial behavior. They can still act in selfless ways to improve
others' perceptions of them, advance their social status, or if explicitly told
to. Despite these characteristics, they are more likely to overestimate their
capacity for empathy.
It is common for people with NPD to have difficult
relationships. Narcissists may disrespect others' boundaries or idealize and
devalue them. They commonly keep people emotionally distant, and project, deny,
or split. Narcissists respond with anger and hostility towards rejection, and
can degrade, insult, or blame others who disagree with them.
They generally lack self-awareness, and will have a
difficult time understanding their own traits and narcissistic tendencies,
either due to a belief that NPD characteristics do not apply to them, or due to
a refusal to accept or endorse negative characteristics in an attempt to
maintain a positive self-image. Narcissists can have difficulty seeing multiple
perspectives on issues and might engage in black and white thinking. Despite
this, people with NPD will often feel as they are skilled at accurately
assessing others' feelings.
Problematic social
media use
In April 2018, a meta-analysis published in the Journal of
Personality found that the positive correlation between grandiose narcissism
and social networking sites (SNS) usage was replicated across platforms (including
Facebook and Twitter). In July 2018, a meta-analysis published in Psychology of
Popular Media found that grandiose narcissism positively correlated with time
spent on social media, frequency of status updates, number of friends or
followers, and frequency of posting self-portrait digital photographs. In March
2020, the Review of General Psychology published a meta-analysis that found a
small-to-moderate association between SNS use and narcissism. In June 2020,
Addictive Behaviors published a systematic review finding a consistent,
positive, and significant correlation between grandiose narcissism and problematic
social media use.
Diagnosis
The DSM-5 indicates that: "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." Given the high-function sociability associated with
narcissism, some people with NPD might not view such a diagnosis as a functional
impairment to their lives. Although overconfidence tends to make people with
NPD very ambitious, such a mindset does not necessarily lead to professional
high achievement and success, because they refuse to take risks, in order to
avoid failure or the appearance of failure. Moreover, the psychological
inability to tolerate disagreement, contradiction, and criticism, makes it
difficult for persons with NPD to work cooperatively or to maintain long-term
relationships.
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) describes NPD as possessing at least five of the
following nine criteria:
A grandiose sense of
self-importance (exaggerates achievements and talents, expects to be recognized
as superior without commensurate achievements)
Preoccupation with
fantasies of unlimited success, power, brilliance, beauty, or ideal love
Believing that they
are "special" and unique and can only be understood by, or should
associate with, other special or high-status people (or institutions)
Requiring excessive
admiration
A sense of entitlement
(unreasonable expectations of especially favorable treatment or automatic
compliance with their expectations)
Being interpersonally
exploitative (taking advantage of others to achieve their own ends)
Lacking empathy
(unwilling to recognize or identify with the feelings and needs of others)
Often being envious of
others or believing that others are envious of them
Showing arrogant,
haughty behaviors or attitudes
Within the DSM-5, NPD is a cluster B personality disorder.
Individuals with cluster B personality disorders often appear dramatic,
emotional, or erratic. Narcissistic personality disorder is a mental disorder
characterized by a life-long pattern of exaggerated feelings of
self-importance, an excessive craving for admiration, and a diminished ability
to empathize with others' feelings.
A diagnosis of NPD, like other personality disorders, is
made by a qualified healthcare professional in a clinical interview. In the
narcissistic personality disorder, there is a fragile sense of self that
becomes a view of oneself as exceptional.
Narcissistic personality disorder usually develops either in
youth or in early adulthood. True symptoms of NPD are pervasive, are apparent
in varied social situations, and are rigidly consistent over time. Severe
symptoms of NPD can significantly impair the person's mental capabilities to
develop meaningful human relationships, such as friendship, kinship, and
marriage. Generally, the symptoms of NPD also impair the person's psychological
abilities to function socially, either at work or at school, or within
important societal settings. The DSM-5 indicates that, in order to qualify as
symptomatic of NPD, the person's manifested personality traits must substantially
differ from social norms.
ICD-11 and ICD-10
In the International Statistical Classification of Diseases
and Related Health Problems, 11th Edition ICD-11 of the World Health
Organization (WHO), all personality disorders are diagnosed under a single
title called "personality disorder".
The criteria for diagnosis are mainly concerned with assessing dysfunction,
distress and maladaptive behavior. Once a diagnosis has been made, the
clinician then can draw upon five trait domains to describe the particular
causes of dysfunction, as these have major implications for potential treatments.
NPD, as it currently conceptualized, would correspond more or less entirely to
the ICD-11 trait of Dissociality, which includes self-centeredness
(grandiosity, attention-seeking, entitlement and egocentricity) and lack of
empathy (callousness, ruthlessness, manipulativeness, interpersonal exploitativeness,
and hostility).
In the previous edition, the ICD-10, narcissistic
personality disorder (NPD) is listed under the category of "other specific personality disorders", meaning the
ICD-10 required that cases otherwise described as NPD in the DSM-5 would only
need to meet a general set of diagnostic criteria.
Differential
diagnosis
The occurrence of narcissistic personality disorder presents
a high rate of comorbidity with other mental disorders. People with a fragile
variant of NPD (see Subtypes) are prone to bouts of psychological depression,
often to the degree that meets the clinical criteria for a co-occurring
depressive disorder. NPD is associated with the occurrence of bipolar disorder
and substance use disorders, especially cocaine use disorder. NPD may also be
comorbid or differentiated with the occurrence of other mental disorders,
including histrionic personality disorder, borderline personality disorder,
antisocial personality disorder, or paranoid personality disorder. NPD should
also be differentiated from mania and hypomania as these cases can also present
with grandiosity, but present with different levels of functional impairment.
It is common for children and adolescents to display personality traits that
resemble NPD, but such occurrences are usually transient, and register below
the clinical criteria for a formal diagnosis of NPD.
Subtypes
Although the DSM-5 diagnostic criteria for NPD have been
viewed as homogeneous, there are a variety of subtypes used for classification
of NPD. There is poor consensus on how many subtypes exist, but there is broad
acceptance that there are at least two: grandiose or overt narcissism, and
vulnerable or covert narcissism. However, none of the subtypes of NPD are
recognized in the DSM-5 or in the ICD-11.
Empirically verified
subtypes
Some research has indicated the existence of three subtypes
of NPD, which can be distinguished by symptom criteria, comorbidity and other
clinical criteria. These are as follows:
Grandiose/Overt: the group exhibits grandiosity,
entitlement, interpersonal exploitativeness and manipulation, pursuit of power
and control, lack of empathy and remorse, and marked irritability and
hostility. This group was noted for high levels of comorbid antisocial and
paranoid personality disorders, substance abuse, externalizing, unemployment
and greater likelihood of violence. Of note, Russ et al. observed that this
group "do not appear to suffer from
underlying feelings of inadequacy or to be prone to negative affect states
other than anger", an observation corroborated by recent research
which found this variant to show strong inverse associations with depressive,
anxious-avoidant, and dependant/victimized features.
Vulnerable/Covert: this variant is defined by
feelings of shame, envy, resentment, and inferiority (which is occasionally "masked" by arrogance),
entitlement, a belief that one is misunderstood or unappreciated, and excessive
reactivity to slights or criticism. This variant is associated with elevated
levels of neuroticism, psychological distress, depression, and anxiety. In
fact, recent research suggests that vulnerable narcissism is mostly the product
of dysfunctional levels of neuroticism. Vulnerable narcissism is sometimes
comorbid with diagnoses of avoidant, borderline and dependent personality
disorders.
High-functioning/Exhibitionistic: A third subtype for
classifying people with NPD, initially theorized by psychiatrist Glen Gabbard,
is termed high functioning or exhibitionistic. This variant has been described
as "high functioning narcissists
[who] were grandiose, competitive, attention-seeking, and sexually provocative;
they tended to show adaptive functioning and utilize their narcissistic traits
to succeed.” This group has been found to have relatively few psychological
issues and high rates of obsessive-compulsive personality disorder, with
excessive perfectionism posited as a potential cause for their impairment.
Others
Oblivious/Hypervigilant: Glen Gabbard described two
subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and
vulnerable subtypes. The first was the "oblivious"
subtype of narcissist, equivalent to the grandiose subtype. This group was
described as being grandiose, arrogant and thick-skinned, while also exhibiting
personality traits of helplessness and emotional emptiness, low self-esteem and
shame. These were observed in people with NPD to be expressed as socially
avoidant behavior in situations where self-presentation is difficult or
impossible, leading to withdrawal from situations where social approval is not
given.
The second subtype Gabbard described was termed "hypervigilant", equivalent to
the vulnerable subtype. People with this subtype of NPD were described as
having easily hurt feelings, an oversensitive temperament, and persistent
feelings of shame.
Communal narcissism: A fourth type is the communal
narcissist. Communal narcissism is a form of narcissism that occurs in group settings.
It is characterized by an inflated sense of importance and a need for
admiration from others. In relation to the grandiose narcissist, a communal
narcissist is arrogant and self-motivating, and shares the sense of entitlement
and grandiosity. However, the communal narcissist seeks power and admiration in
the communal realm. They see themselves as altruistic, saintly, caring,
helpful, and warm. Individuals who display communal narcissism often seek out
positions of power and influence within their groups.
Millon's subtypes
In the study Disorders of Personality: DSM-IV-TM and Beyond
(1996), Theodore Millon suggested five subtypes of NPD, although they did not
identify specific treatments per subtype.
Unprincipled Narcissist: Deficient conscience; unscrupulous, amoral, disloyal, fraudulent,
deceptive, arrogant, exploitive; a con artist and charlatan; dominating,
contemptuous, vindictive.
Amorous narcissist: Sexually seductive, enticing,
beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulges
hedonistic desires; bewitches and inveigles others; pathological lying and
swindling. Tends to have many affairs, often with exotic partners.
Compensatory narcissist: 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,
noteworthy; self-worth results from self-enhancement.
Elitist narcissist: Feels privileged and empowered by
virtue of special childhood status and pseudo-achievements; entitled façade
bears little relation to reality; seeks favored and good life; is upwardly
mobile; cultivates special status and advantages by association.
Normal narcissist: 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 recognition
from others.
Masterson's subtypes
(exhibitionist and closet)
In 1993, James F. Masterson proposed two subtypes for
pathological narcissism, exhibitionist and closet. Both fail to adequately
develop an age- and phase- appropriate self because of defects in the quality
of psychological nurturing provided, usually by the mother. A person with
exhibitionist narcissism is similar to NPD described in the DSM-IV and differs from
closet narcissism in several ways. A person with closet narcissism is more
likely to be described as having a deflated, inadequate self-perception and
greater awareness of emptiness within. A person with exhibitionist narcissism
would be described as having an inflated, grandiose self-perception with little
or no conscious awareness of feelings of emptiness. Such a person would assume
that their condition was normal and that others were just like them. A person
with closet narcissism is described to seek constant approval from others and
appears similar to those with borderline personality disorder in the need to
please others. A person with exhibitionist narcissism seeks perfect admiration
all the time from others.
Malignant narcissism
Malignant narcissism, a term first coined in Erich Fromm's
1964 book The Heart of Man: Its Genius for Good and Evil, is a syndrome
consisting of a combination of NPD, antisocial personality disorder, and
paranoid traits. A person with malignant narcissism was described as deriving
higher levels of psychological gratification from accomplishments over time,
suspected to worsen the disorder. Because a person with malignant narcissism
becomes more involved in psychological gratification, it was suspected to be a
risk factor for developing antisocial, paranoid, and schizoid personality
disorders. The term malignant is added to the term narcissist to indicate that
individuals with this disorder have a severe form of narcissistic disorder that
is characterized also by features of paranoia, psychopathy (anti-social behaviors),
aggression, and sadism.
Historical
demarcation of grandiose and vulnerable types
Over the years, many clinicians and theorists have described
two variants of NPD akin to the grandiose and vulnerable expressions of trait
narcissism. Some examples include:
Kohut & Wolf (1978): Mirror-hungry Ideal-hungry
Broucek (1982) Egotistical:
Dissociative
Rosenfeld (1987): Thick-skinned Thin-skinned
Gabbard (1989, 1998, 2009): Oblivious, Hypervigilant
Gersten (1991): Overly grandiose, overly vulnerable
Wink (1992): Willful, Hypersensitive
Masterson (1993): Exhibitionist Closet
Fiscalini (1993): Special child, Shamed child
Cooper and Maxwell (1995): Empowered, Disempowered
Assessment and
screening
Narcissistic
Personality Inventory
Risk factors for NPD and grandiose/overt and
vulnerable/covert subtypes are measured using the narcissistic personality
inventory, an assessment tool originally developed in 1979, which has undergone
multiple iterations with new versions in 1984, 2006 and 2014. It captures
principally grandiose narcissism, but also seems to capture elements of
vulnerability. A popular three-factor model has it that grandiose narcissism is
assessed via the Leadership/Authority and Grandiose/Exhibitionism facets, while
a combination of grandiose and vulnerable traits are indexed by the Entitlement/Exploitativeness
facet.
Pathological
Narcissism Inventory
The Pathological Narcissism Inventory (PNI) was designed to
measure fluctuations in grandiose and vulnerable narcissistic states, similar
to what is ostensibly observed by some clinicians (though empirical
demonstration of this phenomenon is lacking). While having both "grandiosity" and
vulnerability scales, empirically both seem to primarily capture vulnerable
narcissism.
The PNI scales show significant associations with
parasuicidal behavior, suicide attempts, homicidal ideation, and several
aspects of psychotherapy utilization.
No comments:
Post a Comment