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Chapter: Essentials of Psychiatry: Personality Disorders

Narcissistic Personality Disorder

Narcissistic PD (NPD) is a pervasive pattern of grandiosity, need for admiration and lack of empathy .

Narcissistic Personality Disorder




Narcissistic PD (NPD) is a pervasive pattern of grandiosity, need for admiration and lack of empathy (American Psychiatric Asso-ciation, 2000). Persons with NPD can be very vulnerable to threats to their self-esteem. They may react defensively with rage, disdain, or indifference but are in fact struggling with feelings of shock, humiliation and shame. NPD is indicated by the presence of five or more of the nine diagnostic criteria presented in the DSM-IV-TR Criteria for NPD.


Etiology and Pathology


There are no data on the heritability of the narcissistic PD, although there are data on the heritability of arrogance, modesty and conceit. The etiological theories have been primarily socio-logical, psychodynamic and interpersonal. For example, it has been suggested that current Western society has become overly self-centered with the decreasing importance of familial bonds, traditional social, religious and political values or ideals, and ris-ing materialism .


Narcissism may also develop through unempathic, neglect-ful and/or devaluing parental figures (Kernberg, 1991). The child may develop the belief that a sense of worth, value, or meaning is contingent upon accomplishment or achievement. Kohut (1977) has suggested that the parents failed adequately to mirror an infant’s natural need for idealization. Benjamin (1993) and Millon and colleagues (1996) suggest that narcissistic persons received excessive idealization by parental figures, which they incorpo-rated into their self-image. The irrationality of this idealization, or its being coupled with inconsistent indications of an actual disinterest and devaluation, may contribute to the eventual dif-ficulties and conflicts surrounding self-image.


Conflicts and deficits with respect to self-esteem have been shown empirically to be central to the pathology of NPD. Narcissistic persons must continually seek and obtain signs and symbols of recognition to compensate for feelings of inadequacy


They are not persons who feel valued for their own sake. Value is contingent upon a success, accomplishment, or status. Their feel-ings of insecurity may be masked by a disdainful indifference to-wards rebuke and by overt expressions of arrogance, conceit and even grandiosity. However, the psychopathology is still evident in such cases by the excessive reliance and importance that is continually placed upon status and recognition. Some narcissistic persons may in fact envy those who are truly indifferent to suc-cess and who can enjoy a modest, simple and unassuming life.


Assessment and Differential Diagnosis


All of the semi-structured interviews and self-report inventories described earlier include scales for the assessment of NPD. There is also a semi-structured interview devoted to the assessment of nar-cissism (Diagnostic Interview for Narcissism [DIN]; Gunderson et al., 1990), the research with which was highly influential in the development of the DSM-IV-TR diagnostic criteria. There are also a number of self-report inventories devoted to the assessment of narcissistic personality traits, including the Narcissistic Person-ality Inventory (NPI) that has been used in a number of informa-tive personality and social–psychological studies of narcissism(Rhodewalt and Morf, 1995). The DIN and NPI have the useful feature of subscales for the assessment of various components of narcissism (e.g., NPI scales for superiority, vanity, leadership, au-thority, entitlement, exploitativeness and exhibitionism).


Individuals with narcissistic PD may often appear rela-tively high functioning. Exaggerated self-confidence may in fact contribute to success in a variety of professions and narcissistic traits will at times be seen in highly successful persons. A diag-nosis of NPD requires the additional presence of interpersonal exploitation, lack of empathy, a sense of entitlement, and other symptoms beyond simply arrogance and grandiosity.


Both narcissistic and antisocial persons may exploit, de-ceive and manipulate others for personal gain, and both may demonstrate a lack of empathy or remorse. As indicated above, many of the traits of narcissism, such as arrogance and glib charm, are seen in psychopathic persons. Prototypic cases can be distinguished, as the motivation for the narcissistic person will be for recognition, status and other signs of success, whereas the prototypic antisocial person would be motivated more for mate-rial gain or for the subjugation of others. Antisocial persons will also display an impulsivity, recklessness and lax irresponsibility that may not be seen in narcissistic persons.


Epidemiology and Comorbidity


Approximately 18% of males and 6% of females may be charac-terized as being excessively immodest (i.e., arrogant or conceited; Costa and McCrae 1992) but only a small percent of these persons would be diagnosed with NPD. In fact, the median prevalence rate obtained across 10 community data collections was zero. The absence of any cases within community studies, however, may reflect inadequacies within the diagnostic criteria or limitations of semi-structured interview assessments of narcissism. NPD is observed within clinical settings (approximately 2 to 20% of pa-tients) although it is also among the least frequently diagnosed personality disorders (American Psychiatric Association, 2000 ). Persons with NPD are considered to be prone to mood disorders, as well as anorexia and substance-related disorders, especially cocaine. Persons with NPD are likely to have comorbid antisocial (psychopathic), histrionic, paranoid and borderline personality traits.




Little is known about the premorbid behavior pattern of NPD, other than through retrospective reports of persons diagnosed when adults. As adolescents, persons with NPD are likely to be self-centered, assertive, gregarious, dominant and perhaps ar-rogant. They may have achieved well in school or within some other activity. As adults, many persons with NPD will have ex-perienced high levels of achievement. However, their relation-ships with colleagues, peers and staff will eventually become strained as their exploitative use of others and self-centered egotism become evident. Success may also be impaired by their difficulty in acknowledging or resolving criticism, deficits and setbacks. Interpersonal and sexual relationships are usually easy for them to develop but difficult to sustain due to their low empathy, self-centeredness and need for admiration. Persons who are deferential and obsequious, or who share a mutual need for status and recognition, may help sustain a relationship. As parents, persons with NPD may attempt to live through their children, valuing them as long as they are a source of pride. Their personal sense of adjustment may be fine for as long as they continue to experience or anticipate success. Some may not recognize the maladaptivity of their narcissism until middle-age, when the emphasis given to achievement and status may begin to wane.




Persons with narcissistic personality traits seek treatment for feelings of depression, substance-related disorders and occupa-tional or relational problems that are secondary to their narcis-sism. Their self-centeredness and lack of empathy are particu-larly problematic within marital, occupational and other social relationships, and they usually lack an appreciation of the con-tribution of their conflicts regarding self-esteem, status and rec-ognition. It is difficult for them even to admit that they have a psychological problem or that they need help, as this admission is itself an injury to their self-esteem. In addition, one of the charac-teristics of NPD is the belief that they can only be understood by persons of a comparably high social status or recognition. They may be unable to accept advice or insight from persons they consider less intelligent, talented, or insightful than themselves, which may eventually effectively eliminate most other persons.


When they are involved in treatment, persons with NPD will often require some indication that their therapist is among the best or at least worth their time. They are prone to idealizing their therapists (to affirm that he or she is indeed of sufficient status or quality) or to devalue them (to affirm that they are of greater intelligence, capacity, or quality than their therapist, to reject the insights that they have failed to identify, and to indicate that they warrant or deserve an even better therapist). How best to respond is often unclear. It may at times be preferable simply to accept the praise or criticism, particularly when exploration will likely be unsuccessful, whereas at other times it is preferable to confront and discuss the motivation for the devaluation (or the idealization).


Psychodynamic approaches to the treatment of NPD vary in the extent to which emphasis is given to an interpretation of underlying anger and bitterness, or to the provision of empa-thy and a reflection (or mirroring) of a positive regard and self-esteem (Cooper and Ronningstam, 1992; Kernberg, 1991; Kohut, 1977; Gabbard, 2000). It does appear to be important to identify the current extent and historical source of the conflicts and sensi-tivities regarding self-esteem. Active confrontation may at times be useful, particularly when the therapeutic alliance is strong, but at other times the vulnerability of the patient may require a more unconditional support. Cognitive–behavior approaches to NPD emphasize increasing awareness of the impact of narcis-sistic behaviors and statements on interpersonal relationships. The idealization and devaluation can be responsive to role play-ing and rational introspection, an intellectual approach that may itself be valued by some persons with NPD. However, therapists must be careful not to become embroiled within intellectual con-flicts (or competitions). This approach may not work well with the narcissistic person who is motivated to defeat or humiliate the therapist.


Group therapy can be useful for increasing awareness of the grandiosity, lack of empathy and devaluation of others. How-ever, these traits not only interfere with the narcissistic person’s ability to sustain membership within groups (and within individ-ual therapy), they may also become quite harmful and destructive to the rapport of the entire group. There is no accepted pharma-cologic approach to the treatment of narcissism.


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