Diagnostic Considerations
Narcissistic personality disorder (NPD) is 1 of the 4 cluster B personality disorders, which also include antisocial personality disorder (ASPD), borderline personality disorder (BPD), and histrionic personality disorder (HPD). Whereas NPD is a distinct entity, it shares many similarities with the other cluster B disorders, which can be concomitantly diagnosed if the appropriate diagnostic criteria are met. It is therefore important to be aware of the salient differences among the cluster B personality disorders. [1]
Borderline personality disorder
BPD and NPD are both characterized by a constant need for attention, as well as affective instability and unpredictable behavior. However, the patient with NPD has a much greater sense of grandiosity than the patient with BPD and requires attention that is specifically of the admiring kind. The patient with BPD also demonstrates more self-destructive behaviors (eg, cutting and self-mutilation) and has a much less stable sense of self than the patient with NPD does. [17]
Antisocial personality disorder
ASPD and NPD are both characterized by a disregard for the needs and feelings of others and a disturbing lack of empathy. However, ASPD is characterized by repeated transgressions with the law, physical aggressiveness, and a history of conduct disorder in childhood, which generally are not seen in NPD. Patients with narcissism are also more grandiose and arrogant than patients who are antisocial. [18]
Histrionic personality disorder
HPD and NPD are both marked by attention-seeking behavior; however, people with narcissism specifically require attention that is adulatory. In addition, patients with HPD are comparatively more needy and emotionally demonstrative than patients with NPD, who are usually cold and impersonal.
Axis I disorders
Patients with NPD may also meet criteria for separate axis I diagnoses (eg, major depressive disorder, bipolar disorder, or a substance-related disorder). Alternatively, patients with only NPD may at times have symptoms that mimic those of axis I disorders, such as grandiosity that is mistaken for the mania or hypomania of bipolar disorder. [19]
It is therefore important to ascertain the exact nature and duration of the symptoms, keeping in mind that personality disorders are associated with long-standing, chronic patterns of behavior rather than isolated episodes of transient pathology.
Differential Diagnoses
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Borderline Personality Disorder
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Major Depressive Disorder
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Obsessive-Compulsive Disorder
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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.
