Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is 1 of the 10 clinically recognized personality disorders listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition, Text Revision (DSM-5-TR). It belongs to the subset of 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 NPD, and competing theories exist regarding its etiology and optimal treatment.

Diagnostic criteria (DSM-5-TR)

In DSM-5-TR, NPD is defined as comprising 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 the presence of at least 5 of the following 9 criteria: ^[1]

• A grandiose sense of self-importance (eg, the individual exaggerates achievements and talents and expects to be recognized as superior without commensurate achievements)

• A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

• 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

• A need for excessive admiration

• A sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)

• Interpersonally exploitive behavior (ie, the individual takes advantage of others to achieve his or her own ends)

• A lack of empathy (unwillingness to recognize or identify with the feelings and needs of others)

• Envy of others or a belief that others are envious of him or her

• A demonstration of arrogant and haughty behaviors or attitudes

These official diagnostic criteria are unchanged from the previous DSM edition. 

The exact mechanism by which narcissistic personality disorder (NPD) develops is unknown. Biologic, psychological, social, and environmental factors all probably 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. To date, no genetic links to the disorder have been determined, but future research into the biologic basis of personality disorders may yield more information on the origins of NPD.

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 NPD.

According to Kernberg, NPD is the result of a young child having an unempathetic and distant mother who is hypercritical and devaluing of her child. ^[3] 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 the following 3 elements:

• The child’s own positive traits

• A fantastical, larger-than-life version of himself or herself

• 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 unlovable and needy image of himself or herself and relegates it to the unconscious, where it later forms the basis for the fragile self-esteem and sense of inferiority present in NPD. ^[3]

By contrast, Heinz Kohut felt that NPD was the result of a developmental arrest in normal psychological growth. ^[3] He maintained that narcissism is a natural feature of the young child, who is bound to think of himself or herself as the center of the universe.

According to Kohut, through the twin processes of mirroring (whereby the parent provides appropriate praise) and idealization (whereby the child effectively internalizes positive parental images), a child without narcissism can temper his or her former sense of being the center of the universe. However, if the parents do not offer effective mirroring or do not provide a basis for idealization, the child will be stuck with his or her initial grandiose, wholly unrealistic sense of self, and this developmental arrest will eventually lead to NPD. ^[3]

United States statistics

It is estimated that narcissistic personality disorder (NPD) 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. NPD is found in 6% of the forensic population, ^{[5, 6]} in 20% of the military population (the actual disorder as well as narcissistic traits), ^{[7, 8, 6]} and in 17% of first-year medical students. ^{[9, 6]}

International statistics

Outside the United States, NPD is not recognized as a separate diagnostic entity. 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 DSM-5). What DSM-5 defines specifically as NPD falls under the ICD-10 heading of “Other Specific Personality Disorders” or “eccentric, impulsive-type, immature, passive-aggressive, and psychoneurotic personality disorders.” ^[10]

Age-, sex-, and race-related demographics

NPD manifests by young adulthood (early to middle 20s) and may worsen in middle or old age as a consequence of the onset of physical infirmities or declining 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 NPD.

NPD is more commonly found in males than in females; of those diagnosed with the disorder, approximately 75% are male. No racial or ethnic predilection has been identified.

The natural history of narcissistic personality disorder (NPD), like those of all personality disorders, is unfavorable, and the condition is typically lifelong. However, many patients can and do show improvement with appropriate treatment. 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 pathologic narcissism over time. ^[11]

Patients diagnosed with NPD 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. ^{[12, 13]}

It is important to educate patients with narcissistic personality disorder (NPD) about the signs and symptoms of the disorder and explain to them in a supportive way that their behavior is a result of many different factors. During this psychoeducational phase of treatment, it is helpful to present patients with relevant reading material so that they may become aware of how the diagnosis specifically applies to them. ^[14]

There are a myriad of Web sites for patients seeking lay information about NPD, of which the following are representative examples:

• MayoClinic.com, Narcissistic Personality Disorder

• MedlinePlus, Narcissistic personality disorder

• WebMD.com, Mental Health: Narcissistic Personality Disorder

In addition, the following resources are available to patients who may have questions about NPD:

• National Alliance for the Mentally Ill (NAMI) (800-950-NAMI[6264])

• Mental Health America (800-969-6642)

Family education is also important, in that relatives and loved ones of people with NPD are often profoundly affected by the illness as well. The following books may be helpful for those who may be in close contact with people who have NPD:

• The Narcissistic Family: Diagnosis and Treatment - Stephanie Donaldson-Pressman and Robert M Pressman, Jossey-Bass, 1997

• The Wizard of Oz and Other Narcissists: Coping with the One-Way Relationship in Work, Love, and Family - Eleanor Payson, Julian Day Publications, 2002

• Trapped in the Mirror - Elan Golomb, Perennial Currents, 1995