It’s all about me: Narcissistic Personality Disorder

Diagnostic criterion of personality disorders

Narcissism is wrought with colorful details of over compensation for an underdeveloped sense of self. The Narcissistic Personality suffers with Personality Disordered Character traits, as described in “Portrait of a Drama Queen: Histrionic Personality Disorder, whereby personality disorder is defined as, “a pervasive pattern of maladaptive “behavior, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual’s culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.(APA, 2013). Personality disorders begin in childhood or adolescence although they are not usually diagnosable until adulthood. Like many illnesses, the severity of Personality Disorders is variable, often depends upon the disorder itself, and the degree of functional impairment may be capricious.” (

Personality disorders are coded on Axis II unlike mood, anxiety, or psychotic disorders, which are coded on Axis I in the mutiaxial system for diagnostic assessment.

Narcissistic Personality Disorder criterion

Those with Narcissistic Personality disorder (NPD) have a grandiose sense of self-importance, whereby he will exaggerates his achievements and talents, expecting to be recognized as superior without commensurate achievements; he is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love; he or she believes 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.

He or she also requires excessive admiration, and has a sense of entitlement, where he or she has unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. He is interpersonally exploitative, and takes advantage of others to achieve his or her own ends. He lacks empathy, and is unwilling to recognize or identify with the feelings and needs of others.

Most importantly, he or she is envious of others or believes that others are envious of him or her and shows arrogant, haughty behaviors or attitudes.

Narcissistic Personality Disorder is diagnosed if the individual shows a pervasive pattern of grandiosity in fantasy or behavior, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the above criterion. (American Psychiatric Association, 2013).

The DSM V classifies NPD along with the other cluster B personality disorders listed as the erratic-dramatic, the others being Antisocial, Histrionic, and Borderline Personality Disorders. Cluster B Personality Disorders are categorized as dramatic types, unlike Cluster A (odd), and Cluster C (anxious) types.

Etiologies and development of NPD

Freud originally believed that fear was a primary motivator for the personality pathology in NPD, to include over-exaggerated fear of rejection, falling short of ideals, loss of perfection, fear of humiliation, isolation, loss of admiration and important objects as in attachment people in one’s life, subconscious wishes, a fear of dependency, wish for retaliation, a fear of one’s destruction or possibly illness, and fear of death.  It is not that we all don’t have such fears and anxieties; in patients with NPD these fears and unconscious concerns are magnified and augmented to traumatic levels.

Childhood developmental and parental factors have been implicated in the development of NPD to include oversensitive temperament in the child, excessive attention and admiration by parents and lack of realistic feedback by the parents during development, unreliable or inconsistent parenting or care giving, or even emotional abuse during childhood. There is evidence that there is a sense of inadequacy and shame underlying the narcissist subconsciously driving the behaviors.

In Kohut’s model, by describing the quest for a narcissistic individual to fulfill unmet self-object needs, he describes a certain aspect of narcissism inherent in all of us and describes the self as the center of the psychological universe, where we spend our lives trying to build and maintain our self-esteem through the use of self-objects. However, in contrast to other theorists, he does not believe this type of narcissism to be pathologic. Kohut argues that pathologic narcissism “occurs only with early self-object failures, where narcissists are also are fearful of encountering, and repeating, earlier past failures, therefore, they may present with an attitude of superiority, reflecting anxiety they feel over encountering further self object failures. This may manifest in relationships as the disappointment in the longed-for childhood gratification and their missing self-object needs.” (Jamie McLean, MD)

Studies have confirmed a range of characteristics that can occur in those with NPD, including individuals with “insecure, shy, and hypersensitive traits, internal emotional distress, interpersonal vulnerability, fear, emotional pain, anxiety, a sense of inadequacy, along with prominent internalized narcissistic features and functioning.” (Ronningstam E) This could explain some of the newer research that seems to confirm the relevance and accuracy of earlier theories, as studies suggest that those with a strong degree of narcissism may appear to be good leaders early on in their careers but soon fall out of favor.   (H. Steven Moffic, MD, 2015).

Genetics and epidemiology of NPD

Heritability estimates for borderline, histrionic, and narcissistic PD are high, including up to 69%, 63%, and 77% respectively, based upon results from twin studies and clinical sampling. The same researchers subsequently conducted a population based twin study where heritability was estimated to be 24% for narcissistic PD, where no shared environmental influences or sex effects were found. (Jamie McLean, MD)

In clinical samples, between 50% and 75% are male and usually 25% are female. It is difficult to ascertain precisely what percentage of the general population suffers with the disorder or these traits, as patients with NPD rarely present for treatment for the disorder itself, and it is usually an incidental finding. However, in one review, it was cited that it is estimated that the disorder or narcissistic traits, are present in a large number of patients presenting to a psychiatrist’s office with complaints of depression or other mood symptoms and that approximately 18 percent of males and six percent of females have narcissistic traits. (Jamie McLean, MD)

NPD has been historically difficult to study, is one of the least diagnosed of the personality disorders, however a recent large epidemiologic survey on the subject revealed a lifetime prevalence of 6.2% with rates in men of 7.7%, and 4.8% for women, and there is comorbidity with substance use, mood, anxiety, and other personality disorders. In this study, association were found with bipolar I disorder, PTSD, schizotypal and borderline PDs, specific phobia, generalized anxiety disorder, and bipolar II disorder among women; and alcohol abuse, alcohol dependence, drug dependence, and histrionic and obsessive-compulsive PDs among men. However, dysthymia was significantly and negatively associated with NPD. (Frederick S. Stinson, Ph.D, et al)

Treatment of NPD and discussion

Although therapy is the mainstay of treatment, there are other considerations when treating the patient with NPD. The vast majority of patients with NPD present not for narcissism itself, but for mood, anxiety, or perfectionist symptoms and which must be addressed prior to treating the narcissism and then, only if the patient is functionally impaired, and is amenable to treatment for his or her personality disorder.

Narcissistic Personality Disordered patents may benefit from Kohut’s self-psychology model, which focuses on their limited empathy, or self object relations, among other issues.  (Baker HSBaker MN.)  Dialectical, CBT, and group therapies are currently being studied for use in NPD.

Brief hospitalization may be required in cases where decompensation occurs where judgment is impaired, where there is chaotic acting out behaviors, or where there is impaired reality testing.

Some narcissists do reasonably well provided they do not suffer with underlying pathology such as mood, substance use disorders, and anxiety symptoms; others do not fare as well, and like most with Axis II pathology, depression or other illnesses only serves to exacerbate their preexisting characterologic disorder.  There are cases where narcissistic PD are able to form attachments and have satisfying relationships; although relationship difficulties are one of the hallmarks of the disorder, and likely due to impaired empathy.

Couple’s counseling, to include treatment compliance and success rate is currently being researched.


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