Narcissistic Personality Disorder

Updated: Mar 23, 2017
  • Author: Sheenie Ambardar, MD; Chief Editor: David Bienenfeld, MD  more...
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Overview

Practice Essentials

Narcissistic personality disorder (NPD) is a cluster B personality disorder defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy.

Signs and symptoms

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), [1] 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:

  • A grandiose sense of self-importance
  • 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
  • Interpersonally exploitive behavior
  • A lack of empathy
  • Envy of others or a belief that others are envious of him or her
  • A demonstration of arrogant and haughty behaviors or attitudes

In a proposed alternative model cited in DSM-5, NPD is characterized by moderate or greater impairment in personality functioning, manifested by characteristic difficulties in 2 or more of the following 4 areas [2] :

  • Identity
  • Self-direction
  • Empathy
  • Intimacy

In addition, NPD is characterized by the presence of both grandiosity and attention seeking.

NPD is not associated with any specific defining physical characteristics; however, physical consequences of substance abuse, with which NPD is often associated, may also be apparent on examination. Mental status examination may reveal depressed mood. Patients in the throes of narcissistic grandiosity may display signs of hypomania or mania.

See Presentation for more detail.

Diagnosis

NPD must be distinguished from the other 3 cluster B personality disorders, which are as follows:

  • Antisocial personality disorder (ASPD)
  • Borderline personality disorder (BPD)
  • Histrionic personality disorder (HPD)

Patients with NPD may also meet criteria for separate axis I diagnoses. Alternatively, patients with only NPD may at times have symptoms that mimic those of axis I disorders.

No specific laboratory studies are employed to diagnose NPD; however, it is wise to obtain a toxicology screen to rule out drugs and alcohol as possible causes of the pathology.

Although there is some debate regarding their usefulness and reliability, personality tests such as the following may be administered to help elucidate character pathology and facilitate the diagnosis of NPD:

  • Personality Diagnostic Questionnaire–4 (PDQ-4)
  • Millon Clinical Multiaxial Inventory III (MCMI-III)
  • International Personality Disorder Examination (IPDE)

See Workup for more detail.

Management

Long-term, consistent outpatient care is the treatment approach of choice, usually involving a combination of psychotherapy and medication management.

Options for psychotherapy include the following:

  • Individual psychotherapy (specifically, psychoanalytic psychotherapy) - Mainstay of treatment; schools of thought include Kernberg’s object-relations approach and Kohut’s self-psychology approach, as well as various combinations of the 2 approaches
  • Group therapy
  • Family therapy
  • Couples therapy
  • Cognitive-behavioral therapy (CBT; in particular, schema-focused therapy)
  • Short-term objective-focused psychotherapy

If the patient acutely decompensates or becomes a danger to self or others, inpatient treatment (for as short a period as possible) is warranted

No psychiatric medications are tailored specifically toward the treatment of NPD. Nevertheless, patients with this disorder often benefit from the use of psychiatric medications to help alleviate certain symptoms associated with the disorder or to manage concomitant axis I diagnoses. Agents that may be indicated include the following:

  • Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class (eg, citalopram)
  • Antipsychotics (eg, risperidone)
  • Mood stabilizers (eg, lamotrigine)

See Treatment and Medication for more detail.

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Background

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 (DSM-5). 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)

In DSM-5, 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. It should be noted, however, that there is currently a general inclination away from a strict criterion-based approach to diagnosis and toward a more “dimensional” model, as outlined in section III of DSM-5 (“Emerging Measures and Models”). In the subsection of section III entitled “Alternative DSM-5 Model for Personality Disorders,” NPD is newly characterized on the basis of (1) impairment in personality functioning and (2) pathologic personality traits. [2]

Specifically, in this proposed new model, NPD is characterized by moderate or greater impairment in personality functioning, manifested by characteristic difficulties in 2 or more of the following 4 areas [2] :

  • Identity - Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirroring fluctuations in self-esteem
  • Self-direction - Goal setting based on gaining approval from others; personal standards that are either unreasonably high (in order to see oneself as exceptional) or too low (from a sense of entitlement); frequent unawareness of one’s own motivations
  • Empathy - Impaired ability to recognize or identify with the feelings and needs of others; excessive attunement to reactions of others, but only if these are perceived as relevant to the self; over- or underestimation of one’s own effect on others
  • Intimacy - Relationships that are largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain

In addition, NPD is characterized by the presence of both of the following pathologic personality traits [2] :

  • Grandiosity (an aspect of antagonism) - Feelings of entitlement, either overt or covert; self-centeredness; firm attachment to the belief that one is better than others; condescension toward others
  • Attention seeking (an aspect of antagonism) - Excessive attempts to attract and be the focus of the attention of others; admiration seeking
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Pathophysiology and Etiology

The exact mechanism by which 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]

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Epidemiology

United States statistics

It is estimated that 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.

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Prognosis

The natural history of 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]

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Patient Education

It is important to educate patients with 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:

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

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:

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