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Narcissistic Pesonality Disorder
http://emedicine.medscape.com/article/1519417-overview
Background
Narcissistic personality disorder, as described in the case study below, is one
of 10 clinically recognized personality disorders listed in the Diagnostic and
Statistical Manual of Mental Disorders,Fourth Edition-Text Revision (DSM-IV-
TR). It is one of 4 Cluster B personality disorders, which are those marked by an
intense degree of drama and emotionality. Historically, there has been much debate
surrounding the exact definition of the disorder and competing theories exist
regarding its etiology and optimal treatment.
A relatively new diagnostic entity, narcissistic personality disorder was only
formally recognized as a unique personality disorder in 1980 in the DSM-III.
However, the term narcissism traces its roots back to 1898 when the British
psychologist Havelock Ellis first used the term to describe a pathological form of
self-love or autoeroticism.[1] More than a decade later, Otto Rank published the first
psychoanalytic paper on narcissism and Sigmund Freud later explored the concept
in his 1914 work, On Narcissism.[2] A host of psychologists and psychiatrists since
have made important contributions to our theoretical and clinical understanding of
the disorder.
As defined in the 2000 edition of the DSM-IV-TR, narcissistic personality
disorder is a pervasive pattern of grandiosity (in fantasy or behavior), a constant
need for admiration, and a lack of empathy, beginning by early adulthood and
present in a variety of contexts, as indicated by at least 5 of the following criteria:[3]
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1. A grandiose sense of self-importance (eg, the individual exaggerates
achievements and talents and expects to be recognized as superior without
commensurate achievements)
2. A preoccupation with fantasies of unlimited success, power, brilliance,
beauty, or ideal love
3. A belief that he or she is special and unique and can only be understood by,
or should associate with, other special or high-status people (or institutions).
4. A need for excessive admiration
5. A sense of entitlement (ie, unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations)
6. Interpersonally exploitative (ie, takes advantage of others to achieve his or
her own ends)
7. A lack of empathy (is unwilling to recognize or identify with the feelings
and needs of others)
8. Envy of others or a belief that others are envious of him or her
9. A demonstration of arrogant and haughty behaviors or attitudes
Case study
Mr. L is a 26-year-old third-year medical student who has been suffering
from depression and anxiety for several years and is currently engaged in
psychotherapy. Mr. L is an overachiever who has always excelled academically—
he was at the top of his class at Princeton, received a Rhodes scholarship to study
at Oxford, and was granted admission to many of the nation's best medical schools.
In addition to his academic accomplishments, Mr. L prides himself on his physical
appearance and considers himself to be much better looking than his medical
school peers.
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During his first therapy session with the psychiatrist, Mr. L brings in a copy
of his curriculum vitae as well as copies of his medical school essays and insists
that the psychiatrist read these before beginning the session. He states with a small
chuckle, "I'm different than most of your clients." In addition, Mr. L asks the
psychiatrist, "Exactly how long have you been doing this? You look really young,
like you could be my age. I took quite a few advanced courses in psychology at
Princeton. Where did you go to medical school again?"
During subsequent sessions, Mr. L talks at length about his disdain for his
medical school professors, classmates, and the medical school curriculum in
general. He feels that many of his professors are “not that bright” and that their
understanding of fundamental medical concepts is cursory at best. He recounts an
episode during one of his internal medicine rotations when the attending professor
was asked a question by a junior resident but could not provide an adequate
answer. Mr. L knew the answer and stated it without hesitation, declaring to the
psychiatrist, "It was clear to everyone on rounds that I knew more than both the
attending and the resident, I can't believe those a**holes didn't give me Honors on
that rotation. They were just jealous that a medical student knew more than them."
Socially, Mr. L has very few close friends and believes that this is because
he doesn't meet people who are up to his high intellectual and physical standards.
He has 1 or 2 medical school peers who he studies with on a sporadic basis, but
beyond this, his interactions with classmates are superficial and devoid of any real
friendship. When asked if he has ever gotten into any conflicts with his peers, Mr.
L recounts a recent episode when he took the only copy of a valuable study guide
out of the school library so that he could read it at home at his leisure. When one of
his fellow classmates found out and demanded that Mr. L return the book to the
library, Mr. L scoffed and refused, stating, "I can't believe Tom had the guts to ask
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me to return the book. It's not like it would have done him any good anyway; he's
only going into Psychiatry, I'm the one going into Surgery."
Pathophysiology
The exact mechanism of the development of narcissistic personality disorder
is unknown. Biological, psychological, social, and environmental factors all likely
play a role, but further research is necessary to confirm this supposition. Several
psychodynamic theories point to an unhealthy early parent-child relationship as
salient in the development of the disorder.
Epidemiology Frequency
United States
According to current research, narcissistic personality disorder is present in
0.5% of the general United States population[4] and in 2-16% of those who seek
help from a mental health professional. It is found in 6% of the forensic
population[5, 9] , 20% of the military population (the actual disorder as well as
narcissistic traits)[6, 7, 9] , and in 17% of first-year medical students.[8, 9]
International
Narcissistic personality disorder is not recognized as a separate diagnostic
entity outside of the United States. The International Statistical Classification of
Diseases and Related Health Problems, Tenth Revision (ICD-10) lists only 8
personality disorders (as opposed to the 10 found in the DSM-IV-TR). What the
DSM-IV-TR defines specifically as narcissistic personality disorder falls under the
ICD-10 heading of "Other Specific Personality Disorders" or "eccentric,
5
impulsive-type, immature, passive-aggressive, and psychoneurotic personality
disorders."[10]
Mortality/Morbidity
Patients diagnosed with narcissistic personality disorder are more likely to have
comorbid Axis I diagnoses, such as major depressive disorder, bipolar disorder,
substance-related disorders (specifically related to cocaine and alcohol), anxiety
disorders, and anorexia nervosa.[11, 12]
Race
Narcissistic personality disorder has not been shown to have any racial or
ethnic predilection.
Sex
Narcissistic personality disorder is more commonly found in males than in
females. Of those diagnosed with the disorder, approximately 75% are male.
Age
Narcissistic personality disorder manifests by young adulthood (early to mid
20s) and may worsen in middle or old age due to the onset of physical infirmities
or a decline in physical attractiveness. (In addition to feeling intellectually and
socially superior to others, people who are narcissistic are often quite vain
regarding their physical appearance). Narcissistic traits can be exhibited by typical
adolescents who are unlikely to go on to develop narcissistic personality disorder.
6
History
Patients with narcissistic personality disorder often present to the healthcare
professional after hitting "rock bottom" in their careers or personal lives, or at the
strong urging of a family member who insists that they get professional help for
their behavior. Because the nature of the disorder involves a haughty disregard for
others and an insistence on one's own innate superiority, narcissistic patients are
unlikely to recognize their need for treatment and even less likely to voluntarily
seek help. For this reason, patients with this diagnosis alone (ie, no concomitant
Axis I diagnoses) comprise a very small percentage of the total patient population
seen by mental health professionals.
To be diagnosed with narcissistic personality disorder, a patient must
demonstrate a consistent and long-standing pattern of maladaptive behavior
starting in adolescence or early adulthood that exemplifies 5 or more of the
following criteria:[3]
1. A sense of grandiosity and self-importance that is not necessarily
commensurate with the person's actual achievements or standing.
2. Unrealistic and dearly-held fantasies of extreme success, power, beauty, or
romantic love. For example, such a person may choose to remain single
rather than date those they deem beneath him or her.
3. An overweening sense of superiority and a constant desire to associate only
with the best of everything (eg, best health club, best doctor, best
institutions) as a way to enhance one's own self-esteem. For example, an
aging business executive who insists on only dating young supermodels or a
wealthy socialite who insists on befriending only other high-status society
matrons.
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4. A desire to always be the center of attention and to be widely admired for his
or her achievements. This desire largely stems from low self-esteem.
5. A sense of entitlement and an expectation that others will readily cater to his
or her needs.
6. Interpersonally exploitative to the extent that others merely serve to further
his or her own wishes and desires. The patient with narcissistic personality
disorder is solely concerned with his or her own advancement in life and will
manipulate, exploit, or sabotage others to achieve his or her end goal.
7. A lack of empathy and sensitivity to the feelings and experiences of others.
People with narcissistic personality disorder often talk at length about
themselves with little interest in the experiences of others.
8. A feeling of deep-seated envy towards those he or she perceives to be better
situated than themselves. Also present is an egotistical belief that others are
envious of him or her.
9. A self-centered and conceited air, as well as a haughty disdain for others.
While many people display some degree of the above-mentioned criteria, it is
only when the symptoms are pervasive, debilitating, and socially and personally
destructive, that narcissistic personality disorder is diagnosed.
Patients with narcissistic personality disorder are also acutely sensitive to
rejection or criticism and may avoid people or situations where there is the
possibility of feeling "less than." When criticized, they may become furious and
lash out or withdraw into a shell of sullen hate. At the core, both of these reactions
are thought to be due to intrinsically low self-esteem or a feeling of inferiority.[3]
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Physical
Narcisistic personality disorder is not associated with any defining physical
characteristics.[13]
Mental Status Examination may reveal depressed mood due to dysthymia or
major depressive disorder, both of which may be related to the paradoxically low
self-esteem often present in patients with narcissistic personality disorder.
Conversely, patients in the throes of narcissistic grandiosity may display signs of
hypomania or mania.[3]
The following is a sample Mental Status Examination for Mr. L, the patient who
was described in the case study at the beginning of this article.
General appearance and behavior - Well-groomed, well-dressed male in no
acute distress
Attitude - Resistant and haughty
Psychomotor activity - Normal, no agitation or retardation
Eye contact - Intense
Affect - Restricted
Mood - Angry
Speech - Normal rate and tone, high volume; no pressured speech
Thought process - No evidence of thought blocking, flight of ideas, loose
associations, or ideas of reference; some tangentiality present
Thought content - Denies suicidal ideation and homicidal ideation; denies
audiovisual hallucinations; no paranoid delusions elicited or endorsed
Orientation - Oriented to person, place, and time
Attention and concentration - Good
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Insight - Poor
Judgment - Limited
Narcissistic personality disorder is also associated with the abuse of substances,
particularly cocaine and alcohol; thus, the physical consequences of such abuse
may be apparent on examination.
Causes
The cause of narcissistic personality disorder is unknown. Currently, genetic
links to the disorder have not been determined, but future research into the
biological basis of personality disorders may yield more information on the origins
of narcissistic personality disorder.
From a psychoanalytic standpoint, the 2 main schools of thought regarding
the origins of the disorder are the Object Relations model described by Otto
Kernberg and the Self-Psychology model developed by Heinz Kohut. Both models
posit that an inadequate relationship between parent and child lays the groundwork
for the eventual development of narcissistic personality disorder.
According to Otto Kernberg, narcissistic personality disorder is the result of
a young child having an unempathetic and distant mother who is hypercritical and
devaluing of her child. As a defense against this perceived lack of love and to
guard against emotional pain, the child creates an internalized grandiose self.
Kernberg believed that this grandiose self was a combination of 3 elements: (1) the
child’s own positive traits, (2) a fantastical, larger-than-life version of
himself/herself, and (3) an idealized version of a nurturing mother. In keeping with
the Object Relations model, on which Kernberg based much of his theory, the child
eventually splits-off the unloveable and needy image of him or herself and
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relegates it to the unconscious, where it later forms the basis for the fragile self-
esteem and sense of inferiority present in narcissistic personality disorder.[2]
By contrast, Heinz Kohut felt that narcissistic personality disorder was the
result of a developmental arrest in normal psychological growth. According to
Kohut, narcissism is a natural feature of the young child, who is bound to think of
himself or herself as the center of his or her universe. Through the twin processes
of mirroring (whereby the parent provides appropriate praise) and idealization
(where the child effectively internalizes positive parental images), the normal child
without narcissism is able to temper his or her former conception of his or herself
as the center of the universe. However, if the parents do not effectively mirror the
child or do not provide a basis for the child to idealize them, the child will be stuck
with a grandiose, wholly unrealistic sense of self. Kohut believed it was this
developmental arrest that eventually lead to the development of narcissistic
personality disorder.
Differentials
Antisocial Personality Disorder
Histrionic Personality Disorder
Hypomania
Major Depressive Disorder
Mania
Obsessive-Compulsive Disorder
Paranoid Personality Disorder
Personality Change Due to a General Medical Condition
Personality Disorder: Borderline
Schizotypal Personality Disorder
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Substance-Related Disorders
Laboratory Studies
No specific laboratory studies are used to diagnose narcissistic personality
disorder. Nevertheless, due to the high incidence of substance abuse in patients
with the disorder, it is wise to obtain a toxicology screen to rule out drugs and
alcohol as possible causes of narcissistic character pathology.
Other Tests
The diagnosis of narcissistic personality disorder is often made after
obtaining a history of narcissistic symptoms from pertinent sources (including the
patient, the patient's family/friends, and the clinician's own observations of the
patient). However, more specific personality tests can also be used to aid in the
diagnosis. The usefulness and reliability of these tests is a matter of debate, but
they can be helpful in elucidating character pathology outside of the strict confines
of the DSM-IV-TR criteria.
These personality tests either take the form of self-report questionnaires
given directly to the patient or semi-structured interviews conducted by the
clinician. Several such tests include the Personality Diagnostic Questionnaire–4
(PDQ-4), the Millon Clinical Multiaxial Inventory III (MCMI-III), the Structured
Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), the
International Personality Disorder Examination (IPDE), and the Structured
Interview for the DSM-IV Personality Disorders (SIDP-IV). Each test uses a series
of questions to determine the presence or absence of character pathology and may
be a useful aid to the clinician trying to formally diagnose narcissistic personality
disorder in a patient.[17]
12
Medical Care
The mainstay of treatment for narcissistic personality disorder is individual
psychotherapy, specifically psychoanalytic psychotherapy. Other therapeutic
modalities used to treat the disorder include group, family, and couples therapy, as
well as cognitive-behavioral therapy and short-term objective focused
psychotherapy.[18] Psychotropic medications are not specifically used to treat
narcissistic personality disorder but are often used to treat concomitant anxiety,
depression, impulsivity, or other mood disturbances.
While individual psychoanalytic psychotherapy is the method of choice for
the treatment of narcissistic personality disorder, there has been much debate as to
what exactly constitutes optimal treatment. The 2 main schools of thought in this
regard are Otto Kernberg's object-relations based approach and Heinz Kohut's self-
psychological approach, both of which provide us with different and seemingly
contradictory ways of approaching the narcissistic patient.[18]
According to Kernberg's object-relations based approach, the job of the
therapist is to actively interpret the patient's narcissistic defenses while at the same
time illuminating the patient's negative transferences. Kernberg believed the end
goal of therapy was to eradicate or diminish the patient's pathological grandiose
self by direct confrontation.[18]
By contrast, Kohut advocated a more empathic approach, with the therapist
actually encouraging the patient's grandiosity and promoting the development of
idealization in the transference. Kohut's end goal was to bolster the patient's
inherently deficient self-structure.[18]
13
While no definitive studies support one therapeutic stance over another,
most clinicians today have come to embrace a style that fuses elements of both
Kernberg's and Kohut's viewpoints. A flexible and moderate approach that
combines an empathic understanding of the patient's need for narcissistic defenses
and a thorough exploration of those defenses is preferred. The therapist should
recognize the self-preserving role narcissism plays in the patient's daily life and
should use caution in tearing down narcissistic defenses too quickly. At the same
time, the therapist will strive to help the patient gain a realistic understanding of his
or her own behavioral deficiencies.[18]
In addition to individual psychoanalytic psychotherapy, other treatment
modalities for narcissistic personality disorder include group therapy and
cognitive-behavioral therapy. Group therapy was initially thought to be unsuitable
for the patient with narcissism because clinicians assumed that these patients
would be unable to handle the requisite give and take inherent in the group process.
This was a reasonable assumption given that group processes usually require
empathy, patience, and the ability to relate and connect to others (traits that are
deficient in those with narcissism). However, studies[19] have suggested that long-
term group therapy has therapeutic value for the patient with narcissism by
providing the patient with a safe haven in which to explore boundaries, receive and
accept feedback, develop trust, and increase self-awareness.[20]
Cognitive behavioral therapy has also been shown to have the potential to
benefit the narcissistic patient.[21] A specific form of cognitive behavioral therapy,
called schema-focused therapy, centers around repairing narcissistic schemas and
the defective moods and coping styles associated with them.[22] This very active and
work-intensive form of treatment encourages patients to confront narcissistic
cognitive distortions, such as black and white thinking and perfectionism, and has
14
been shown to have promising results for the treatment of narcissistic personality
disorder.[18]
Medication Summary
No psychiatric medications are tailored specifically toward the treatment of
narcissistic personality disorder. Nevertheless, patients with narcissistic personality
disorder often benefit from the use of psychiatric medications to help alleviate
certain symptoms associated with the disorder, such as depression, anxiety,
transient psychosis, mood lability, and poor impulse control. In addition, many
patients with narcissistic personality disorder have concomitant Axis I diagnoses
for which they are taking regular psychiatric medication. The following is an
abbreviated list of sample medications from the 3 major psychiatric drug classes
(antidepressants, antipsychotics, and mood stabilizers) that can be used to treat
certain symptoms associated with narcissistic personality disorder.
Antidepressant, Serotonin Reuptake Inhibitor
Class Summary
SSRIs such as citalopram may be used to treat depressive symptoms in adult
patients with narcissistic personality disorder. Determining whether the patient
with narcissistic personality disorder has a formal Axis I diagnosis of major
depression or depressive symptoms related to narcissistic pathology is important as
this will influence the length and course of treatment.
15
Citalopram (Celexa)
Enhances serotonin activity due to selective reuptake inhibition at the
neuronal membrane. No head-to-head comparisons of SSRIs exist, although, based
on metabolism and adverse effects, citalopram is considered the SSRI of choice for
patients with head injury.
SSRIs are the antidepressants of choice due to minimal anticholinergic
effects. All are equally efficacious. The choice depends on adverse effects and
drug interactions.
Antipsychotic Agent
Class Summary
Atypical antipsychotic agents such as risperidone may be used in adult
patients with narcissistic personality disorder to treat transient psychosis, mood
lability, and poor impulse control.
Risperidone (Risperdal, Risperdal Consta IM Injection, Risperdal M-Tab)
Binds to dopamine D2 receptor with a 20-times lower affinity than for the 5-
HT2 receptor. Improves negative symptoms of psychoses and reduces incidence of
extrapyramidal adverse effects.
Response to antipsychotics is less dramatic than in true psychotic Axis I
disorders, but symptoms such as anxiety, hostility, and sensitivity to rejection may
be reduced. Antipsychotics are typically used for a short time while the symptoms
are active.
16
Anticonvulsant
Class Summary
Mood stabilizers such as lamotrigine may be used in adult patients with
narcissistic personality disorder to help with affect regulation and impulse control.
Lamotrigine (Lamictal)
Anticonvulsant that appears to be effective in the treatment of the depressed
phase in bipolar disorders.
Note: Some literature indicates use of medications like Valproic acid or Lithium as
mood stabilizers.
Further Inpatient Care
Patients with narcissistic personality disorder are usually treated on a long-
term outpatient basis. However, inpatient hospitalization is warranted if the patient
acutely decompensates or becomes a danger to themselves or others. Shorter
hospital stays are usually best for patients with narcissistic personality disorder
since prolonged time in the hospital will do little to change the underlying severity
of the illness. Hospitalization should only be used as a temporizing measure to
stabilize environmental stressors and/or adjust medication dosages.[13]
Further Outpatient Care
Long-term, consistent outpatient care is the method of choice in the
treatment of narcissistic personality disorder and usually involves a combination of
psychotherapy and medication management.
17
Inpatient & Outpatient Medications
See Medication section.
Deterrence/Prevention
See Pathophysiology and Causes sections.
Complications
Patients with Cluster B personality disorders (including narcissistic,
borderline, antisocial, and histrionic personality disorders) are at a significantly
increased risk for suicide. In the case of the patient with narcissistic personality
disorder, sudden life stressors such as job loss or unexpected financial misfortune
can lead to "surprise” or "shame" suicides.[23]
Patients with narcissistic personality disorder are also at increased risk for
substance abuse, specifically the abuse of cocaine and alcohol.
Prognosis
As with all personality disorders, the natural history of narcissistic
personality disorder is unfavorable and the condition is typically life long.
However, many patients can and do show improvement with appropriate treatment.
Recent research also suggests that corrective life events, such as new
achievements, stable relationships, and manageable disappointments, can lead to
considerable improvement in the level of pathological narcissism over time.[24]
18
Patient Education
Educating patients with narcissistic personality disorder about the signs and
symptoms of the disorder and explaining to them in a supportive way that their
behavior is a result of many different factors is important. During this
psychoeducational phase of treatment, presenting the patient with reading material
is helpful so that he or she may become aware of how the diagnosis specifically
applies to them.[18]
The Narcissistic Family: Diagnosis and Treatment by Stephanie Donaldson-
Pressman and Robert M. Pressman, 1997, Jossey-Bass. The Wizard of Oz and
Other Narcissists: Coping with the One-Way Relationship in Work, Love, and
Family by Eleanor Payson, 2002, Julian Day Publications. Trapped in the
Mirror by Elan Golomb, 1995, Perennial Currents.
Contributor Information and Disclosures
Author
Sheenie Ambardar, MD Physician, Kaiser Permanente Southern California
Sheenie Ambardar, MD is a member of the following medical societies: American
Psychiatric Association Disclosure: Nothing to disclose.
Coauthor(s)
Spencer Eth, MD Voluntary Professor of Psychiatry, University of Miami,
Leonard M Miller School of Medicine; Director of Outpatient Mental Health
Programs, Miami VA Healthcare System.
Spencer Eth, MD is a member of the following medical societies: American
Academy of Child and Adolescent Psychiatry, American Orthopsychiatric
Association, American Psychiatric Association, and Phi Beta Kappa
19
Disclosure: Nothing to disclose.
Specialty Editor Board
Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist,
Department of Psychiatry, Spartanburg Regional Medical Center .
Mohammed A Memon, MD is a member of the following medical societies:
American Association for Geriatric Psychiatry, American Medical Association,
and American Psychiatric Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of
Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug
Reference
Disclosure: Medscape Salary Employment
Harold H Harsch, MD Program Director of Geropsychiatry, Department of
Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and
Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American
Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer
Grant/research funds Speaking and teaching; Northstar None None; Novartis
Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion
20
Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline
Grant/research funds research; Merck Honoraria Speaking and teaching
Chief Editor
David Bienenfeld, MD Professor of Psychiatry, Vice-Chair and Director of
Residency Training, Department of Psychiatry, Wright State University, Boonshoft
School of Medicine .
David Bienenfeld, MD is a member of the following medical societies: American
Medical Association, American Psychiatric Association, and Association for
Academic Psychiatry.
Disclosure: Nothing to disclose.
Acknowledgments
Dr. Ambardar would like to thank Dr. Donald C. Fidler, Farnsworth Endowed
Chair of Psychiatric Education at West Virginia University, for generously
granting permission to use his video clip in the multimedia section of this article.
21
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