Narcissistic personality disorder
Narcissistic personality disorder (NPD) is defined by the Fourth Edition Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, a handbook that mental health professionals use to diagnose mental disorders) as one of ten personality disorders. As a group, these disorders are described by DSM-IV-TRas "enduring pattern[s] of inner experience and behavior" that are sufficiently rigid and deep-seated to bring a person into repeated conflicts with his or her social and occupational environment. DSM-IV-TRspecifies that these dysfunctional patterns must be regarded as nonconforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance.
To meet the diagnosisof a personality disorder, the patient's problematic behaviors must appear in two or more of the following areas:
- perception and interpretation of the self and other people
- intensity and duration of feelings and their appropriateness to situations
- relationships with others
- ability to control impulses
It is important to note that all the personality disorders are considered to have their onset in late adolescence or early adulthood. Doctors rarely give a diagnosis of personality disorder to children on the grounds that children's personalities are still in process of formation and may change considerably by the time they are in their late teens.
NPD is defined more specifically as a pattern of grandiosity (exaggerated claims to talents, importance, or specialness) in the patient's private fantasies or outward behavior; a need for constant admiration from others; and a lack of empathy for others. The term narcissisticis derived from an ancient Greek legend, the story of Echo and Narcissus. According to the legend, Echo was a woodland nymph who fell in love with Narcissus, who was an uncommonly handsome but also uncommonly vain young man. He contemptuously rejected her expressions of love. She pined away and died. The god Apollo was angered by Narcissus' pride and self-satisfaction, and condemned him to die without ever knowing human love. One day, Narcissus was feeling thirsty, saw a pool of clear water nearby, and knelt beside it in order to dip his hands in the water and drink. He saw his face reflected on the surface of the water and fell in love with the reflection. Unable to win a response from the image in the water, Narcissus eventually died beside the pool.
Havelock Ellis, a British psychologist, first used the story of Echo and Narcissus in 1898 as a capsule summary of pathological self-absorption. The words narcissistand narcissistichave been part of the vocabulary of psychology and psychiatry ever since. They have, however, been the subjects of several controversies. In order to understand NPD, the reader may find it helpful to have an outline of the different theories about narcissism in human beings, its relation to other psychiatric disorders, and its connections to the wider culture. NPD is unique among the DSM-IV-TRpersonality disorders in that it has been made into a symbol of the problems and discontents of contemporary Western culture as a whole.
A good place to begin a discussion of the different theories about narcissism is with the observation that NPD exists as a diagnostic category only in DSM-IV-TR, which is an American diagnostic manual. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10, the European equivalent of DSM) lists only eight personality disorders. What DSM-IV-TRdefines as narcissistic personality disorder, ICD-10lumps together with "eccentric, impulsive-type, immature, passive-aggressive, and psychoneurotic personality disorders."
DSM-IV-TRspecifies nine diagnostic criteria for NPD. For the clinician to make the diagnosis, an individual must fit five or more of the following descriptions:
- He or she has a grandiose sense of self-importance (exaggerates accomplishments and demands to be considered superior without real evidence of achievement).
- He or she lives in a dream world of exceptional success, power, beauty, genius, or "perfect" love.
- He or she thinks of him- or herself as "special" or privileged, and that he or she can only be understood by other special or high-status people.
- He or she demands excessive amounts of praise or admiration from others.
- He or she feels entitled to automatic deference, compliance, or favorable treatment from others.
- He or she is exploitative towards others and takes advantage of them.
- He or she lacks empathy and does not recognize or identify with others' feelings.
- He or she is frequently envious of others or thinks that they are envious of him or her.
- He or she "has an attitude" or frequently acts in haughty or arrogant ways.
In addition to these criteria, DSM-IV-TRgroups NPD together with three other personality disorders in its so-called Cluster B. These four disorders are grouped together on the basis of symptom similarities, insofar as patients with these disorders appear to others as overly emotional, unstable, or self-dramatizing. The other three disorders in Cluster B are antisocial, borderline, and histrionic personality disorders.
The DSM-IV-TRclustering system does not mean that all patients can be fitted neatly into one of the three clusters. It is possible for patients to have symptoms of more than one personality disorder or to have symptoms from different clusters. In addition, patients diagnosed with any personality disorder may also meet the criteria for mood, substance abuse, or other disorders.
Subtypes of NPD
AGE GROUP SUBTYPES.Ever since the 1950s, when psychiatrists began to notice an increase in the number of their patients that had narcissistic disorders, they have made attempts to define these disorders more precisely. NPD was introduced as a new diagnostic category in DSM-III, which was published in 1980. Prior to DSM-III, narcissism was a recognized phenomenon but not an official diagnosis. At that time, NPD was considered virtually untreatable because people who suffer from it rarely enter or remain in treatment; typically, they regard themselves as superior to their therapist, and they see their problems as caused by other people's "stupidity" or "lack of appreciation." More recently, however, some psychiatrists have proposed dividing narcissistic patients into two subcategories based roughly on age: those who suffer from the stable form of NPD described by DSM-IVTR, and younger adults whose narcissism is often corrected by life experiences.
This age group distinction represents an ongoing controversy about the nature of NPD-whether it is fundamentally a character disorder, or whether it is a matter of learned behavior that can be unlearned. Therapists who incline toward the first viewpoint are usually pessimistic about the results of treatment for patients with NPD.
PERSONALITY SUBTYPES.Other psychiatrists have noted that patients who meet the DSM-IV-TRcriteria for NPD reflect different clusters of traits within the DSM-IV-TRlist. One expert in the field of NPD has suggested the following subcategories of narcissistic personalities:
- Craving narcissists. These are people who feel emotionally needy and undernourished, and may well appear clingy or demanding to those around them.
- Paranoid narcissists. This type of narcissist feels intense contempt for him- or herself, but projects it outward onto others. Paranoid narcissists frequently drive other people away from them by hypercritical and jealous comments and behaviors.
- Manipulative narcissists. These people enjoy "putting something over" on others, obtaining their feelings of superiority by lying to and manipulating them.
- Phallic narcissists. Almost all narcissists in this subgroup are male. They tend to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies, clothes, and overall "manliness."
Causes and symptoms
At present there are two major theories about the origin and nature of NPD. One theory regards NPD as a form of arrested psychological development while the other regards it as a young child's defense against psychological pain. The two perspectives have been identified with two major figures in psychoanalytic thought, Heinz Kohut and Otto Kernberg respectively.
Both theories about NPD go back to Sigmund Freud's pioneering work On Narcissism,published in1914. In this essay, Freud introduced a distinction which has been retained by almost all later writers-namely, the distinction between primary and secondary narcissism. Freud thought that all human infants pass through a phase of primary narcissism, in which they assume they are the center of their universe. This phase ends when the baby is forced by the realities of life to recognize that it does not control its parents (or other caregivers) but is in fact entirely dependent on them. In normal circumstances, the baby gives up its fantasy of being all-powerful and becomes emotionally attached to its parents rather than itself. What Freud defined as secondary narcissism is a pathological condition in which the infant does not invest its emotions in its parents but rather redirects them back to itself. He thought that secondary narcissism developed in what he termed the pre-Oedipal phase of childhood; that is, before the age of three. From a Freudian perspective, then, narcissistic disorders originate in very early childhood development, and this early origin is thought to explain why they are so difficult to treat in later life.
CAUSES IN THE FAMILY OF ORIGIN.Kohut and Kernberg agree with Freud in tracing the roots of NPD to disturbances in the patient's family of origin-specifically, to problems in the parent-child relationship before the child turned three. Where they disagree is in their accounts of the nature of these problems. According to Kohut, the child grows out of primary narcissism through opportunities to be mirrored by (i.e., gain approval from) his or her parents and to idealize them, acquiring a more realistic sense of self and a set of personal ideals and values through these two processes. On the other hand, if the parents fail to provide appropriate opportunities for idealization and mirroring, the child remains "stuck" at a developmental stage in which his or her sense of self remains grandiose and unrealistic while at the same time he or she remains dependent on approval from others for self-esteem.
In contrast, Kernberg views NPD as rooted in the child's defense against a cold and unempathetic parent, usually the mother. Emotionally hungry and angry at the depriving parents, the child withdraws into a part of the self that the parents value, whether looks, intellectual ability, or some other skill or talent. This part of the self becomes hyperinflated and grandiose. Any perceived weaknesses are "split off" into a hidden part of the self. Splitting gives rise to a lifelong tendency to swing between extremes of grandiosity and feelings of emptiness and worthlessness.
In both accounts, the child emerges into adult life with a history of unsatisfactory relationships with others. The adult narcissist possesses a grandiose view of the self but has a conflict-ridden psychological dependence on others. At present, however, psychiatrists do not agree in their description of the central defect in NPD; some think that the problem is primarily emotional while others regard it as the result of distorted cognition, or knowing. Some maintain that the person with NPD has an "empty" or hungry sense of self while others argue that the narcissist has a "disorganized" self. Still others regard the core problem as the narcissist's inability to test reality and construct an accurate view of him- or herself.
MACROSOCIAL CAUSES.One dimension of NPD that must be taken into account is its social and historical context. Psychiatrists became interested in narcissism shortly after World War II (1939-45), when the older practitioners in the field noticed that their patient population had changed. Instead of seeing patients who suffered from obsessions and compulsions related to a harsh and punishing superego (the part of the psyche that internalizes the standards and moral demands of one's parents and culture), the psychiatrists were treating more patients with character disorders related to a weak sense of self. Instead of having a judgmental and overactive conscience, these patients had a weak or nonexistent code of morals. They were very different from the patients that Freud had treated, described, and analyzed. The younger generation of psychiatrists then began to interpret their patients' character disorders in terms of narcissism.
In the 1960s historians and social critics drew the attention of the general public to narcissism as a metaphorical description of Western culture in general. These writers saw several parallels between trends in the larger society and the personality traits of people diagnosed with narcissistic disorders. In short, they argued that the advanced industrial societies of Europe and the United States were contributing to the development of narcissistic disorders in individuals in a number of respects. Some of the trends they noted include the following:
- The mass media's preoccupation with "lifestyles of the rich and famous" rather than with ordinary or average people.
- Social approval of open displays of money, status, or accomplishments ("if you've got it, flaunt it") rather than modesty and self-restraint.
- Preference for a leadership style that emphasizes the leader's outward appearance and personality rather than his or her inner beliefs and values.
- The growth of large corporations and government bureaucracies that favor a managerial style based on "impression management" rather than objective measurements of performance.
- Social trends that encourage parents to be self-centered and to resent their children's legitimate needs.
- The weakening of churches, synagogues, and other religious or social institutions that traditionally helped children to see themselves as members of a community rather than as isolated individuals.
Although discussion continues about the location and forms of narcissism in the larger society, no one now denies that personality disorders both reflect and influence the culture in which they arise. Family therapists are now reporting on the treatment of families in which the children are replicating the narcissistic disorders of their parents.
Most observers regard grandiosity as the most important single trait of a narcissistic personality. It is important to note that grandiosity implies more than boasting or prideful display as such-it signifies self-aggrandizement that is not borne out by reality. For example, a person who claims that he or she was the most valuable player on a college athletic team may be telling the truth about their undergraduate sports record. Their claim may be bad manners but is not grandiosity. On the other hand, someone who makes the same claim but had an undistinguished record or never even made the team is being grandiose. Grandiosity in NPD is related to some of the diagnostic criteria listed by DSM-IV-TR, such as demanding special favors from others or choosing friends and associates on the basis of prestige and high status rather than personal qualities. In addition, grandiosity complicates diagnostic assessment of narcissists because it frequently leads to lying and misrepresentation of one's past history and present accomplishments.
Other symptoms of NPD include:
- a history of intense but short-term relationships with others; inability to make or sustain genuinely intimate relationships
- a tendency to be attracted to leadership or high-profile positions or occupations
- a pattern of alternating between unrealistic idealization of others and equally unrealistic devaluation of them
- a need to be the center of attention or admiration in a working group or social situation
- hypersensitivity to criticism, however mild, or rejection from others
- an unstable view of the self that fluctuates between extremes of self-praise and self-contempt
- preoccupation with outward appearance, "image," or public opinion rather than inner reality
- painful emotions based on shame (dislike of who one is) rather than guilt (regret for what one has done)
People diagnosed with NPD represent a range of levels of functioning. Otto Kernberg has described three levels of narcissistic impairment. At the top are those who are talented or gifted enough to attract all the admiration and attention that they want; these people may never enter therapy because they don't feel the need. On the second level are those who function satisfactorily in their jobs but seek professional help because they cannot form healthy relationships or because they feel generally bored and aimless. Narcissists on the lowest level have frequently been diagnosed with another mental disorder and/or have gotten into trouble with the law. They often have severe difficulties with anxiety and with controlling their impulses.
DSM-IV-TRstates that 2% to 16% of the clinical population and slightly less than 1% of the general population of the United States suffers from NPD. Between 50% and 75% of those diagnosed with NPD are males. Little is known about the prevalence of NPD across racial and ethnic groups.
The high preponderance of male patients in studies of narcissism has prompted researchers to explore the effects of gender roles on this particular personality disorder. Some have speculated that the gender imbalance in NPD results from society's disapproval of self-centered and exploitative behavior in women, who are typically socialized to nurture, please, and generally focus their attention on others. Others have remarked that the imbalance is more apparent than real, and that it reflects a basically sexist definition of narcissism. These researchers suggest that definitions of the disorder should be rewritten in future editions of DSMto account for ways in which narcissistic personality traits manifest differently in men and in women.
Professional and leadership positions
One important aspect of NPD that should be noted is that it does not prevent people from occupying, as well as aspiring to, positions of power, wealth, and prestige. Many people with NPD, as Kernberg's classification makes clear, are sufficiently talented to secure the credentials of success. In addition, narcissists' preoccupation with a well-packaged exterior means that they often develop an attractive and persuasive social manner. Many high-functioning narcissists are well liked by casual acquaintances and business associates who never get close enough to notice the emptiness or anger underneath the polished surface.
Unfortunately, narcissists in positions of high visibility or power-particularly in the so-called helping professions (medicine, education, and the ministry)-often do great harm to others. In recent years a number of books and articles have been published within the religious, medical, and business communities regarding the problems caused by professionals with NPD. One psychiatristnoted in a lecture on substance abuse among physicians that NPD is one of the three most common psychiatric diagnoses among physicians in court-mandated substance abuse programs. A psychologist who serves as a consultant in the evaluation of seminary students and ordained clergy has remarked that the proportion of narcissists in the clergy has risen dramatically since the 1960s. Researchers in the field of business organization and management styles have compiled data on the human and economic costs of executives with undiagnosed NPD.
The diagnosis of NPD is complicated by a number of factors.
Complications of diagnosis
NPD is difficult to diagnose for several reasons. First, some people with NPD function sufficiently well that they do not come to the attention of therapists. Second, narcissists are prone to lie about themselves; thus it may take a long time for a therapist to notice discrepancies between a patient's version of his or her life and information gained from others or from public records. Third, many traits and behaviors associated with NPD may be attributed to other mental disorders. Low functioning narcissists are often diagnosed as having borderline personality disorder(BPD), particularly if they are female; if they are male, they may be diagnosed as having antisocial personality disorder(ASPD). If the person with NPD has a substance abuse disorder, some of their narcissistic behaviors may be written off to the mood-altering substance. More recently, some psychiatrists have pointed to a tendency to confuse narcissistic behaviors in people with NPD who have had a traumatic experience with full-blown post-traumatic stress disorder(PTSD). Given the lack of clarity in the differential diagnosis of NPD, some therapists are calling for a fundamental revision of DSM-IV-TRdefinitions of the personality disorders.
An additional complication is posed by economic considerations. The coming of managed carehas meant that third-party payers (insurance companies) prefer short-term psychotherapythat concentrates on a patient's acute problems rather than on underlying chronic issues. Since narcissists are reluctant to trust others or form genuine interpersonal bonds, there is a strong possibility that many therapists do not recognize NPD in patients that they are treating for only a few weeks or months.
Diagnosis of NPD is usually made on the basis of several sources of information: the patient's history and self-description, information from family members and others, and the results of diagnostic questionnaires. One questionnaire that is often used in the process of differential diagnosis is the Structured Clinical Interview for DSM-III-RDisorders, known as the SCID-II.
The most common diagnostic instrument used for narcissistic NPD is the Narcissistic Personality Inventory (NPI). First published by Robert R. Raskin and Calvin S. Hall in 1979, the NPI consists of 223 items consisting of paired statements, one reflecting narcissistic traits and the other nonnarcissistic. Subjects are required to choose one of the two items. The NPI is widely used in research as well as diagnostic assessment.
Treatments for NPD include a variety of pharmacologic, individual, and group approaches; none, however, have been shown to be particularly effective as of 2002.
As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms. There are anecdotal reports in the medical literature that the selective serotonin reuptake inhibitors, or SSRIs, which are frequently prescribed for depression, reinforce narcissistic grandiosity and lack of empathy with others.
Several different approaches to individual therapy have been tried with NPD patients, ranging from classical psychoanalysisand Adlerian therapy to rationalemotive approaches and Gestalt therapy. The consensus that has emerged is that therapists should set modest goals for treatment with NPD patients. Most of them cannot form a sufficiently deep bond with a therapist to allow healing of early-childhood injuries. In addition, the tendency of these patients to criticize and devalue their therapists (as well as other authority figures) makes it difficult for therapists to work with them.
An additional factor that complicates psychotherapy with NPD patients is the lack of agreement among psychiatrists about the causes and course of the disorder. One researcher has commented that much more research is necessary to validate DSM-IV-TR's description of NPD before outcome studies can be done comparing different techniques of treatment.
Low-functioning patients with NPD may require inpatient treatment, particularly those with severe self-harming behaviors or lack of impulse control. Hospital treatment, however, appears to be most helpful when it is focused on the immediate crisis and its symptoms rather than the patient's underlying long-term difficulties.
The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older within a youth-oriented culture and lose their looks and overall vitality. The retirement years are especially painful for patients with NPD because they must yield their positions in the working world to the next generation. In addition, they do not have the network of intimate family ties and friendships that sustain most older people.
The best hope for prevention of NPD lies with parents and other caregivers who are close to children during the early preschool years. Parents must be able to demonstrate empathy in their interactions with the child and with each other. They must also be able to show that they love their children for who they are, not for their appearance or their achievements. And they must focus their parenting efforts on meeting the child's changing needs as he or she matures, rather than demanding that the child meet their needs for status, comfort, or convenience.
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Rebecca J. Frey, Ph.D.