Narcissistic Personality Disorder

NARCISSISTIC PERSONALITY DISORDER

Clinical Picture

Narcissistic personality disorder is characterized by a per-vasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. It occurs in 1% to 2% of the general population and in 2% to 16% of the clinical population. Fifty percent to 75% of people with this diag-nosis are men. Narcissistic traits are common in adoles-cence and do not necessarily indicate that a personality disorder will develop in adulthood. Individual psychother-apy is the most effective treatment, and hospitalization is rare unless comorbid conditions exist for which the client requires inpatient treatment (APA, 2000).

Clients may display an arrogant or haughty attitude. They lack the ability to recognize or to empathize with the feelings of others. They may express envy and begrudge others any recognition or material success because they believe it rightfully should be theirs. Clients tend to disparage, belittle, or discount the feelings of oth-ers. They may express their grandiosity overtly, or they quietly may expect to be recognized for their perceived greatness. They often are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. These fantasies reinforce their sense of superiority. Clients may ruminate about long-overdue admiration and privilege and compare themselves favorably with famous or privileged people.

Thought processing is intact, but insight is limited or poor. Clients believe themselves to be superior and special and are unlikely to consider that their behavior has any relation to their problems: they view their problems as the fault of others.

Underlying self-esteem is almost always fragile and vulnerable. These clients are hypersensitive to criticism and need constant attention and admiration. They often display a sense of entitlement (unrealistic expectation of special treatment or automatic compliance with wishes). They may believe that only special or privileged people can appreciate their unique qualities or are worthy of their friendship. They expect special treatment from others and often are puzzled or even angry when they do not receive it. They often form and exploit relationships to elevate their own status. Clients assume total concern from others about their welfare. They discuss their own concerns in lengthy detail with no regard for the needs and feelings of others and often become impatient or contemptuous of those who discuss their own needs and concerns.

At work, these clients may experience some success because they are ambitious and confident. Difficulties are common, however, because they have trouble working with others (whom they consider to be inferior) and have limited ability to accept criticism or feedback. They also are likely to believe they are underpaid and underappreci-ated or should have a higher position of authority even though they are not qualified.

Nursing Interventions

Clients with narcissistic personality disorder can present one of the greatest challenges to the nurse. The nurse must use self-awareness skills to avoid the anger and frustration that these clients’ behavior and attitude can engender. Cli-ents may be rude and arrogant, unwilling to wait, and harsh and critical of the nurse. The nurse must not inter-nalize such criticism or take it personally. The goal is to gain cooperation of these clients with other treatment as indicated. The nurse teaches about comorbid medical or psychiatric conditions, medication regimen, and any needed self-care skills in a matter-of-fact manner. He or she sets limits on rude or verbally abusive behavior and explains his or her expectations of the client.