Narcissistic Personality Disorder Clinical Presentation

  • Author: Sheenie Ambardar, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: May 09, 2016
 

History

Patients with narcissistic personality disorder (NPD) 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 NPD, by its nature, 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 seek help of their own accord. For this reason, patients with a diagnosis of NPD alone (ie, with no concomitant axis I diagnoses) make up a very small percentage of the total patient population seen by mental health professionals.

To be diagnosed with NPD, 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 9 criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).[1] (See Overview.) Although many people display these criteria to some degree, NPD is diagnosed only when the symptoms are pervasive, debilitating, and socially and personally destructive.

Patients with NPD 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, such patients may become furious and lash out or withdraw into a shell of sullen hate. At their core, both of these reactions are thought to be due to intrinsically low self-esteem or a feeling of inferiority.[1]

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Physical Examination

NPD is not associated with any specific defining physical characteristics.[15] However, physical consequences of the abuse of substances (particularly cocaine and alcohol), with which NPD is often associated, may also be apparent on examination.

Mental status examination (MSE) 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 NPD. Conversely, patients in the throes of narcissistic grandiosity may display signs of hypomania or mania.[1]

The following is a sample MSE for a patient with NPD:

  • 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
  • Insight - Poor
  • Judgment - Limited

The video below includes an actor’s portrayal of an individual with NPD.

This is an actor portrayal of a patient with narcissistic personality disorder. This video clip was provided courtesy of Donald C. Fidler, MD, FRCP-I.
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Complications

In general, patients with cluster B personality disorders (including narcissistic, borderline, antisocial, and histrionic personality disorders) are at substantially greater risk for suicide. In patients with NPD in particular, sudden life stressors (eg, job loss or unexpected financial misfortune) can lead to “surprise” or “shame” suicides.[16] Patients with NPD are also at increased risk for substance abuse—specifically, abuse of cocaine and alcohol.

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Contributor Information and Disclosures
Author

Sheenie Ambardar, MD Adult Psychiatrist, Private Practice

Sheenie Ambardar, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

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

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.

References
  1. American Psychiatric Association. Personality disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013.

  2. American Psychiatric Association. Alternative DSM-5 model for personality disorders. Fifth Edition. Washington, DC: American Psychiatric Publishing, Inc; 2013. 761-81.

  3. Akhtar S, Thomson JA Jr. Overview: narcissistic personality disorder. Am J Psychiatry. 1982 Jan. 139(1):12-20. [Medline].

  4. Torgersen, S. Epidemiology. Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing; 2005. 129-141.

  5. de Ruiter C, Greeven PG. Personality disorders in a Dutch forensic psychiatric sample: convergence of interview and self-report measures. J Pers Disord. 2000 Summer. 14(2):162-70. [Medline].

  6. Ronningstam E. Narcissistic Personality Disorder: Facing DSM-V. Psychiatric Annals. 2009 Mar. 39:111-121.

  7. Crosby RM, Hall MJ. Psychiatric evaluation of self-referred and non-self-referred active duty military members. Mil Med. 1992 May. 157(5):224-9. [Medline].

  8. Bourgeois JA, Hall MJ, Crosby RM, Drexler KG. An examination of narcissistic personality traits as seen in a military population. Mil Med. 1993 Mar. 158(3):170-4. [Medline].

  9. Maffei C, Fossati A, Lingiardi V, Madeddu F, Borellini C, Petrachi M. Personality maladjustment, defenses and psychopathological symptoms in non-clinical subjects. J Pers Disord. 1995 Apr. 9:330-345.

  10. Rebecca J. Frey, Ph.D. Narcissistic Personality Disorder. Encyclopedia of Mental Disorders. Available at http://www.minddisorders.com/Kau-Nu/Narcissistic-personality-disorder.html. Accessed: September 8, 2008.

  11. Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry. 1995 Feb. 152(2):253-7. [Medline].

  12. Waller G, Sines J, Meyer C, et al. Narcissism and narcissistic defences in the eating disorders. Int J Eat Disord. 2007 Mar. 40(2):143-8. [Medline].

  13. Ronningstam E. Pathological narcissism and narcissistic personality disorder in Axis I disorders. Harv Rev Psychiatry. 1996 Mar-Apr. 3(6):326-40. [Medline].

  14. Ronningstam EF, Maltsberger JT. Part X: Personality Disorders. Gabbard GO. Gabbard's Treatments of Psychiatric Disorders. Fourth Edition. Washington DC: American Psychiatric Publishing; 2007. Chapter 52: Narcissistic Personality Disorder, pages 791-804.

  15. David Bienenfeld, MD. Personality Disorders. Medscape Reference. Available at http://emedicine.medscape.com/article/294307-overview. Accessed: July 1, 2008.

  16. Simon RI. Outpatients. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington DC: American Psychiatric Publishing; 2004. 89-90.

  17. Holdwick DJ Jr, Hilsenroth MJ, Castlebury FD, et al. Identifying the unique and common characteristics among the DSM-IV antisocial, borderline, and narcissistic personality disorders. Compr Psychiatry. 1998 Sep-Oct. 39(5):277-86. [Medline].

  18. Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Personal Disord. 2001 Apr. 15(2):103-9. [Medline].

  19. Stormberg D, Ronningstam E, Gunderson J, et al. Brief communication: pathological narcissism in bipolar disorder patients. J Personal Disord. 1998. 12(2):179-85. [Medline].

  20. Clarkin JF, Howieson DB, McClough J. The Role of Psychiatric Measures in Assessment and Treatment. Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing Textbook of Psychiatry. 5th Edition. Arlington, VA: American Psychiatric Publishing; 2008. Chapter 3.

  21. Roth BE. Narcissistic patients in group therapy: containing affects in the early group. Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998. 221-238.

  22. Alonso A. The shattered mirror: treatment of a group of narcissistic patients. Group. 1992 Dec. 16:210-219.

  23. Young J, Flanagan C. Schema-focused therapy for narcissistic patients. Ronningstam E. Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Washington DC: American Psychiatric Press; 1998. 239-268.

  24. Young J, Klosko JS, Weishaar ME. Schema Therapy. A Practitioner's Guide. New York: Guilford; 2003.

  25. Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry. 2003 Jun. 48(5):301-10. [Medline].

  26. Links PS, Kolla N. Assessing and Managing Suicide Risk. Oldham JM, Skodol AE, Bender DS. The American Psychiatric Publishing Textbook Of Personality Disorders. Washington DC: American Psychiatric Publishing; 2005. 459.

 
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This is an actor portrayal of a patient with narcissistic personality disorder. This video clip was provided courtesy of Donald C. Fidler, MD, FRCP-I.
 
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