Narcissistic personality disorder
Narcissistic personality disorder (NPD) is a personality disorder characterized by a long-term pattern of abnormal behavior that includes exaggerated feelings of self-importance, an excessive need for admiration, and a lack of empathy towards other people. People with NPD usually spend much time thinking about achieving power and success, or on their appearance. They often take advantage of the people around them. Such narcissitic behavior typically begins by early adulthood, and occurs across a broad range of situations.
|Narcissistic personality disorder|
|Narcissus by Caravaggio, gazing at his own reflection|
|Specialty||Psychiatry, clinical psychology|
|Symptoms||Exaggerated feelings of self-importance, excessive need for admiration, lack of understanding of others' feelings|
|Usual onset||Early adulthood|
|Differential diagnosis||Bipolar disorder, substance abuse, depressive disorders, anxiety disorders|
The causes of narcissistic personality disorder are unknown. The condition of NPD is included in the cluster B personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). A diagnosis of NPD is made by a healthcare professional interviewing the person in question. The condition of NPD should be differentiated from mania and substance use disorder.
Treatments for narcissistic personality disorder have not been well studied. Therapy is difficult, because people with narcissistic personality disorder usually do not consider themselves to have a mental health problem. About one percent of people are believed to be affected with NPD at some point in their lives. It occurs more often in men than in women, and affects young people more often than older people. The narcissistic personality was first described in 1925, by the psychoanalyst Robert Waelder (1900–1967), and the term NPD came into use in 1968.
- 1 Signs and symptoms
- 2 Causes
- 3 Pathophysiology
- 4 Diagnosis
- 5 Treatment
- 6 Prognosis
- 7 Epidemiology
- 8 History
- 9 Society and culture
- 10 Criticism
- 11 See also
- 12 References
- 13 Further reading
- 14 External links
Signs and symptomsEdit
People with narcissistic personality disorder (NPD) are characterized by the personality traits of persistent grandiosity, an excessive need for admiration, and a personal disdain and lack of empathy for other people. As such, the person with NPD usually displays arrogance and a distorted sense of personal superiority, and seeks to establish abusive power and control over others. Self-confidence (a strong sense of self) is a personality trait different from the traits of narcissistic personality disorder; thus, people with NPD typically value themselves over others, to the extent of openly disregarding the wishes and feelings of anyone else, and expect to be treated as superior, regardless of their actual status or achievements. Socially, the person with narcissistic personality disorder usually exhibits a fragile ego (self-concept), intolerance of criticism, and a tendency to belittle other people, in order to validate his or her own superiority.
The DSM-5 indicates that persons with NPD usually display some or all of the following symptoms, typically without possessing the commensurate personal qualities or accomplishments for which they demand respect and status:
- Grandiosity with expectations of superior treatment from other people
- Constantly demeaning, bullying and belittling others
- Exploiting others to achieve personal gain
- Lack of empathy for the impact they have on others, feelings, wishes, and needs of other people
- Fixation on fantasies of power, success, intelligence, attractiveness, etc.
- Self-perception of being unique, superior, and associated with high-status people and institutions
- Need for continual admiration from others
- Sense of entitlement to special treatment and to obedience from others
- Intense envy of others, and the belief that others are equally envious of them
Narcissistic personality disorder usually develops either in adolescence or in early adulthood; and 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. True symptoms of NPD are pervasive, 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 as a social animal, either at work, or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptoms of NPD, the person's manifested personality traits must substantially differ from the cultural norms of society.
People with NPD exaggerate their skills and accomplishments, and their degree of intimacy with people they consider high-status. Such a sense of personal superiority may cause them to monopolize conversations, or to become impatient and disdainful when other persons talk about themselves. When wounded in the ego, by a real or a perceived criticism, the narcissist's displays of anger can be disproportionate to the nature of the criticism suffered; but typically, the actions and responses of the NPD person are deliberate and calculated. Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.
To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed control freak who passes blame and is intolerant of contradictory views and opinions; is apathetic towards the emotional and psychological needs of other people; and is indifferent to the negative effects of his or her behaviors, whilst insisting that people see him or her as an ideal person. To protect their fragile self-concept, narcissists use psycho-social strategies, such as the tendency to devalue and derogate and to insult and blame other people, usually with anger and hostility towards people's responses to the narcissist's anti-social conduct. Because their fragile egos are hypersensitive to perceived criticism or defeat, people with NPD are prone to feelings of shame, humiliation, and worthlessness over minor incidents of daily life and imagined, personal slights, and usually mask such feelings from people, either by way of feigned humility, or by socially isolating themselves, or by responding with outbursts of rage and defiance, or by seeking revenge. The merging of the inflated self-concept and the actual self is evident in the grandiosity component of narcissistic personality disorder; also inherent to that psychological process are the defense mechanisms of idealization and devaluation and of denial.
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 cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder." Given the high-function sociability associated with narcissism, some people may not view NPD as an 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. Such persons with NPD might be unwilling to compete or might refuse to take risks, in order to avoid failure or the appearance of failure. Moreover, their psychological inability to tolerate disagreement, contradiction, and criticism, and their lack of empathy towards other people, make it difficult for persons with NPD to work cooperatively or to maintain long-term, professional relationships with superiors and colleagues.
The causes of narcissistic personality disorder are unknown. Experts tend to apply a biopsychosocial model of causation, whereby NPD, a pathological amplification of the traits of the narcissistic personality, occurs consequent to a combination of environmental and social, genetic and neurobiological factors.
Narcissistic personality disorder is an inheritable psychological condition; research evidence indicates that a person is more likely to develop NPD if said personality disorder occurs in the medical history of his or her family. The results reported in A Twin Study of Personality Disorders (2000) indicate that the rate of occurrence of personality disorders in twins determined that there is a moderate-to-high likelihood of the heritability of NPD; and the research of The Genetic Epidemiology of Personality Disorders (2010) indicates that specific genes and genetic interactions (epistasis) contribute to the formation of NPD, and to the development of a narcissistic personality, yet how genetics influence the developmental and the physiologic processes underlying NPD remains undetermined.
Environmental and social factors also exert significant influence upon the onset of NPD in a person. In some people, pathological narcissism may develop from an impaired emotional attachment to the primary caregivers, usually the parents. That lack of psychological and emotional attachment to a parental figure can result in the child's perception of himself or herself as unimportant and unconnected to other people, usually family, community, and society. Typically, the child comes to believe that he or she has a personality defect that makes him or her an unvalued and unwanted person; in that vein, either overindulgent and permissive parenting or insensitive and over-controlling parenting are contributing factors towards the development of NPD in a child.
In "Narcissistic Personality Disorder" (2006), Leonard Groopman and Arnold Cooper indicate that research has identified the following factors as possibly promoting the development of NPD:
- An oversensitive temperament (personality trait) at birth.
- Excessive admiration that is never balanced with realistic criticism of the child.
- Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood.
- Overindulgence and overvaluation by the parents, by other family, and by peers.
- Being praised by adults for perceived exceptional physical appearance or abilities.
- Severe emotional abuse in childhood.
- Unpredictable or unreliable care-giving by the parents.
- Learning the behaviors of psychological manipulation from parents or peers.
Moreover, the research reported in "Modernity and Narcissistic Personality Disorders" (2014) indicates that cultural elements also influence the prevalence of NPD, because narcissistic personality traits more commonly occur in modern societies than in traditional societies.
Studies of the occurrence of narcissistic personality disorder (NPD), such as Gray Matter Abnormalities in Patients with Narcissistic Personality Disorder (2013) and Narcissists' Lack of Empathy Tied to Less Gray Matter (2016) identified structural abnormalities in the brains of people afflicted with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex. The results of the study Brain Structure in Narcissistic Personality Disorder: A VBM and DTI Pilot Study (2015) associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex. The regions of the brain identified and studied — the insular cortex and the prefrontal cortex — are associated with the human emotions of empathy and compassion, and with the mental functions of cognition and emotional regulation. The neurologic findings of the studies indicate that narcissistic personality disorder is related to a compromised (damaged) capacity for emotional empathy and emotional regulation.
The American Psychiatric Association's formulation and description of narcissistic personality disorder, published in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), was criticised for failing to describe the range and complexity of the personality disorder that is NPD. That the APA's definition focuses excessively upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns — at the expense of . . . internal complexity and individual suffering", which, the critics argued, reduced the clinical utility of the DSM definition.
As part of the revision of the diagnostic criteria for personality disorders, the work group for Personality and Personality Disorders proposed the elimination of NPD as a distinct personality-disorder entry in the DSM-5, thus replacing a categorical approach to NPD with a dimensional approach, based upon the severity of the dysfunctional personality-trait domains. Some clinicians objected to that revision, by characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", and thus of limited usefulness in clinical practice. The APA's general move towards a dimensional view (based upon personality traits) of Personality Disorders has been maintained, despite the reintroduction of NPD.
The International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), of the World Health Organization (WHO), lists narcissistic personality disorder (NPD) under the category of "Other specific personality disorders". The ICD-10 requires that any personality-disorder diagnosis also meet and satisfy the General diagnostic criteria 2 used for determining that a person has a diagnosable personality disorder.
Subtypes of NPDEdit
Although the DSM-5 regards narcissistic personality disorder as a homogeneous syndrome, there is evidence of overt and covert subtypes in the expression of NPD. The study Narcissistic Personality Disorder: Diagnostic and Clinical Challenges (2015) indicates the existence of two subtypes of narcissism: (i) Grandiose narcissism, characterized by the personality traits of grandiosity, arrogance, and boldness; and (ii) Vulnerable narcissism, characterized by the personality traits of defensiveness and hypersensitivity. The research indicates that people with grandiose narcissism express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."
In the study Initial Construction and Validation of the Pathological Narcissism Inventory (2009), the psychiatrist Glen Gabbard described the "oblivious" subtype of narcissist as being a grandiose, arrogant, and thick-skinned person; and described the "narcissistic vulnerability" of the subtype who consciously exhibits the personality traits of helplessness and emotional emptiness, and of low self-esteem and shame, which usually are expressed as socially avoidant behavior in situations where the narcissist's self-presentation is impossible; therefore, he or she withdraws from situations wherein the needed or expected social approval is not given. Gabbard also described the "hypervigilant" subtype of narcissist whose feelings are easily hurt, is oversensitive, and ashamed; and described the "high-functioning" subtype of narcissist as a person less functionally impaired in the areas of life where narcissists with a severe expression of NPD usually have difficulties in functioning as a normally-socialized person.
In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of narcissist; however, there are few, pure subtypes of narcissist. Morever, Millon's five subtypes of narcissist are not recognized in either the Diagnostic and Statistical Manual of Mental Disorders or in the International Statistical Classification of Diseases and Related Health Problems.
|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; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling. Tends to have many affairs, often with exotic partners.|
|Compensatory narcissist||Including negativistic 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, noteworthy; self-worth results from self-enhancement.|
|Elitist narcissist||Variant of pure pattern||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||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||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 suggested 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 in the 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 due to the fact that they think they are superior and therefore they 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.|
NPD has a high rate of comorbidity with other mental disorders. Individuals with NPD are prone to bouts of depression, often meeting 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.
Narcissistic personality disorder is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they usually are prompted by difficulties in their lives, or are seeking relief from some other disorder of their mental health, such as a major depressive disorder, a substance use disorder (drug addiction), a bipolar disorder (manic depression), or an eating disorder (anorexia nervosa, rumination disorder, bulimia nervosa). The reason for such an indirect path to psychotherapeutic treatment is partly because narcissists generally possess poor insight, and are unaware that their actions produced their mentally unhealthy circumstance, and so fail to recognize that their perceptions and behaviors are socially inappropriate and problematic, because of their very positive self-image (inflated self-concept).
The treatments for narcissistic personality disorder are based upon psychotherapy. In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time with clinical strategies for using psychoanalytic psychotherapy with NPD clients, which, they claimed, were effective in treating that personality disorder. Contemporary psychotherapy treatments include transference-focused therapy; metacognitive therapy; and schema therapy to treat the client's particular subtype of NPD. Moreover, mental health improvements of NPD are possible through the psychopharmaceutical treatment of the symptoms of the comorbid disorders, but, despite such drug therapy, the psychologist Elsa Ronningstam said that "alliance-building and engaging the patient's sense of agency and reflective ability are essential for [achieving] change in pathological narcissism." Psychiatric medications usually are not indicated for the treatment of NPD, but can be used to treat co-occurring symptoms associated with mental conditions, such as psychological depression, anxiety, and impulsiveness, when present in the NPD client. In the field of relationship counseling mental health therapy is most beneficial when both partners participate in the treatments.
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.
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 in 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).
The historical use of the term narcissism, to describe a person's excessive vanity and self-centeredness, predates the modern medical classification of NPD (narcissistic personality disorder) as indicated in the International Statistical Classification of Diseases and Related Health Problems and in the defined in the Diagnostic and Statistical Manual of Mental Disorders. The mental condition of narcissism is named after the Greek, mythological character Narcissus, a beautiful boy, born of a nymph, who became infatuated with his own reflection in a pool of water. At first, Narcissus did not understand that the image he saw in the pool of water was a reflection of himself; when he did understand that fact, he pined for the unattainable image and died of grief, for having fallen in love with someone who did not exist outside of himself.
Further conceptual developments and refinements of the mental condition of Narcissim produced the term narcissistic personality structure, which was introduced by Otto Friedmann Kernberg, in 1967; and the term narcissistic personality disorder, which was proposed by Heinz Kohut, in 1968.
In the case histories of patients, regarding the adult neurotic's sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy." Likewise, he concluded that: "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."
In The Psychology of Gambling (1974), Edmund Bergler also considered megalomania to be a normal occurrence in the child, which condition was reactivated in later, adult life in the vice of gambling. In The Psychoanalytic Theory of Neurosis (1947), Otto Fenichel said that for people who, in their later lives, respond with denial to their own narcissistic rage and narcissistic injury, usually undergo a similar regression to the megalomania of childhood.
In the second half of the 20th century, in contrast to Freud's perspective that megalomania is an obstacle to psychoanalysis, in the U.S. and in Britain, Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defence mechanism, a circumstance that offered the psychotherapist access to the patient for treatment. Such a Kleinian therapeutic approach built upon Heinz Kohut's view of narcissistic megalomania as an aspect of normal mental development, by contrast with Otto Kernberg's consideration of such grandiosity as a pathological distortion of normal psychologic development.
Society and cultureEdit
In the article The Narcissism of Rosamond Vincy (2016), G. Peter Winnington said that in the novel Middlemarch: A Study of Provincial Life (1872–72), by George Eliot, the character Rosamond Vincy is a full-blown narcissist, as defined in the DSM.
In the film To Die For (1995), the character Suzanne Stone (Nicole Kidman) wants to appear on television at all costs, even if satisfying that desire involves murdering her husband. A psychiatric assessment of the character noted that she "was seen as a prototypical narcissistic person, by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder . . . had [Suzanne Stone] 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).
The Norwegian study, Validity Aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Narcissistic Personality Disorder Construct (2011) concluded that narcissism should be conceived as personality dimensions pertinent to the entire range of personality disorders, rather than as a distinct diagnostic category. In the study Debates on the Narcissism Conundrum: Trait, Domain, Dimension, Type, or Disorder? (2012) examining the past literature about NPD, the researchers Renato Alarcón and Silvana Sarabia concluded that narcissistic personality disorder "shows nosological inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field."
- Authoritarian personality
- Brian Blackwell (case study)
- Echo chamber (media)
- Narcissistic abuse
- Narcissistic leadership
- Narcissistic parent
- Narcissistic Personality Inventory
- Narcissistic rage and narcissistic injury
- Narcissistic supply
- Narcissistic withdrawal
- Superiority complex
- True self and false self
- Workplace bullying
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