Narcissistic personality disorder

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ICD9 = | ICDO = | OMIM = | DiseasesDB = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshName = | MeshNumber = | Narcissistic personality disorder (NPD), is defined as a mental illness primarily characterized by extreme focus on oneself, and is a maladaptive, rigid, and persistent condition that may cause significant distress and functional impairment. The term was first used by Heinz Kohut in 1968 in his article “The Psychoanalytic Treatment of Narcissistic Personality Disorders — Outline of a Systematic Approach” Kohut, Heinz, The Search for the Self, Vol. 1, Chapter 34, 1978. and is a form of pathological narcissism acknowledged in the Diagnostic and Statistical Manual of Mental Disorders in 1980, in the edition known as DSM-III. It is classed within the cluster B group of personality disorders in DSM IV-TR along with Borderline- , Histrionic- and Antisocial personality disorders. Most people fulfilling criteria for one personality disorder fulfill those for one or more others.


DSM-IV divides personality disorders into three clusters based on symptom similaritiesDSM IV-TR, Diagnostic criteria for 301.81 Narcissistic Personality Disorder:
  • Cluster A (paranoid, schizoid, schizotypal): odd or eccentric disorders
  • Cluster B (antisocial, borderline, histrionic, narcissistic): dramatic, emotional or erratic disorders
  • Cluster C (avoidant, dependent, obsessive-compulsive): anxious or fearful disorders
  • 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". It relegates it to the category known as "Other specific personality disorders", which also includes the eccentric, "haltlose", immature, passive-aggressive, and psychoneurotic personality disorders.

    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
  • Epidemiology

    Narcissistic Personality Disorder (NPD) is isolating, disenfranchising, painful, and formidable for those diagnosed with it and often those who are in a relationship with them. Distinctions need to be made among those who have NPD because not each and every person with NPD is the same. Even with similar core issues, the way in which one's individual narcissism manifests itself in his or her relationships varies. Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations. 50 to 75% of those with this diagnosis are men.


    The etiology of this disorder is unknown, but, according to Groopman and Cooper, factors identified by researchers as possibly contributing to this disorder include:
  • 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''
  • Diagnostic criteria

    At least five of the following are necessary for a diagnosis (as with many DSM diagnoses, they must form a pervasive pattern; for example, a person who shows these criteria only in one or two relationships or situations would not properly be diagnosed with NPD): #has a grandiose sense of self-importance
      #is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love #believes that he or she is "special" and unique and can only be understood by other special people #requires excessive admiration #strong sense of entitlement #takes advantage of others to achieve his or her own ends #lacks empathy #is often envious or believes others are envious of him or her #arrogant behavior
    ::(see also full list in DSM-IV-TR, p. 717)

    Prevalence, age, and gender features

    According to DSM IV, the prevalence of NPD is less than one percent of the general population, though it manifests itself in 2-16 percent of psychiatric outpatients. Studies have not conclusively demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to NPDAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 660. However, evidence for heritability greater than that of other personality disorders has been reportedLivesley, 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..Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood they may intensify to the point where NPD is diagnosed. It has been suggested that NPD may be exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes.

    Clinical experience

    Pathological narcissism occurs in a spectrum of severity . 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 Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 19-20. 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.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 Johnson, Stephen M PhD (1987). Humanizing the i rock Narcissistic Style. New York: Norton, page 39.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 Rappoport, Alan, Ph. D. Co-Narcissism: How We Adapt to Narcissistic Parents. The Therapist, in press. (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.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 criticism, real or imagined American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 659. 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 Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 22. 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 . 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"Lowen, Alexander, M.D. (1997) Narcissism: Denial of the True Self Touchstone (New York), ISBN 0-7432-5543-7James F. 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 childs 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." ''Masterson, J, M.D. The Hollow Self

    Narcissistic personality disorder and shame

    It has been suggested that Narcissistic personality disorder may be related to defenses against shame. Wurmser L, Shame, the veiled companion of narcissism, in The Many Faces of Shame, edited by Nathanson DL. New York, Guilford, 1987, pp 64–92Gabbard suggested NPD could be broken down into two subtypesGabbard GO, subtypes of narcissistic personality disorder. Bull Menninger Clin 1989; 53:527–532. 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 Schemas. Young, Klosko, Weishaar: Schema Therapy - A Practitioner's Guide, 2003, Page 375. 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 and prognosis

    Though there is controversy in the profession, most psychiatrists and psychologists regard NPD as a relatively stable condition when experienced as a primary disorder Rappoport, Alan, Ph. D. Co-Narcissism: How We Adapt to Narcissistic Parents. The Therapist, in press. James F. Masterson's [ A Therapist's Guide to the Personality Disorders: The Masterson Approach] outlines a prominent approach to healing NPD, while 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. Young, Klosko, Weishaar: Schema Therapy - A Practitioner's Guide, 2003, chapter 10, Pages 373-424It is unusual for people to seek therapy for NPD. Subconscious fears of exposure or inadequacy are often met with defensive disdain of therapeutic processes Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, page 23, Kohut, Heinz, (1971). The Analysis of the Self. Pharmacotherapy is rarely used, though there is one unofficially documented observation of therapeutic response with the atypical anti-depressant bupropion (Wellbutrin). [] 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.

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