Diagnosing narcissistic personality disorder

Narcissistic Personality Disorder - StatPearls

Continuing Education Activity

Narcissistic personality disorder (NPD) is a complex personality disorder often detected with other affective and personality disorders. This activity outlines the evaluation of narcissistic personality disorder and discusses a multi-modal approach to treatment. This article also outlines complications related to personality disorder and discusses interprofessional approaches to the same.

Objectives:

Identify the etiology of narcissistic personality disorder.
Summarize the evaluation of narcissistic personality disorder.
Review management options available for narcissistic personality disorder.
Describe the complications of narcissistic personality disorder, including comorbid diagnosis and relation to suicidal behavior.

Access free multiple choice questions on this topic.

Introduction

Narcissistic personality disorder (NPD) is a pattern of grandiosity, need for admiration, and lack of empathy per the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). The disorder is classified in the dimensional model of "Personality Disorders."NPD is highly comorbid with other disorders in mental health. Persons with NPD can often present with impairment in maintaining work and relationships.[1] NPD is highly prevalent in society; however, there has been limited research on the same. Given the limited research on the same and differences in the diagnosis of the disease, it was initially going to be discontinued from the DSM.NPD is under the umbrella of Cluster B personality disorders, which include antisocial personality disorder, histrionic personality disorder, and borderline personality disorder. Cluster B typically presents with overtly emotional and unpredictable behavior.[2]

NPD has been associated with the concept of " development." "Development" has been central to studies that have been done to understand the psychopathology and etiology of NPD. Experts such as Otto Kernberg and Eve Caligor have introduced more standardized evaluation tools to understand the disorder. Due to NPD comorbidity with other mental disorders and its elevated medical, social, and psychiatric complications, and a gap of knowledge about the disorder, understanding NPD is warranted. This paper aims to cover the gap and incite more research on NPD.

Etiology

The etiology of narcissistic personality disorder is multifaceted. Some studies have suggested a genetic predisposition toward the disorder.[3] Traits such as aggression, reduced tolerance to distress, and dysfunctional affect regulation is prominent in persons with NPD.[4] Developmental experiences, negative in nature, being rejected as a child, and a fragile ego during early childhood may have contributed to the occurrence of NPD in adulthood.[5][6] In contrast, excessive praise, including the belief that a child may have extraordinary abilities, may also lead to NPD.

Epidemiology

Given the challenges of diagnosing narcissistic personality disorder, there have been varying reports of prevalence in the United States of America( USA). Prevalence rates from community samples have been from 0.5% to 5% of the US population.[7] However, in clinical settings, NPD appears to be more prevalent. Prevalence rates can be from 1% to 15% of the United States population. NPD may coexist with other mental disorders rendering its diagnosis challenging. Substance use disorders are among the most comorbid conditions.[8] Other personality disorders such as antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and schizotypal personality disorder are also common in people with NPD.[9]

Comorbid antisocial personality disorder is said to have the most negative effect. There is much contention around the diagnosis of NPD. There are two basic subtypes, including grandiose and vulnerable narcissistic personality disorder. The grandiose subtype includes overt grandiosity, presence of aggression, and boldness. The vulnerable subtype presents with hypersensitivity and defensiveness and is often easy to miss. [10] There has been some research on the grandiose subtype, which includes evidence of behavior such as overt aggression, lack of empathy, and exploitation of the other.[11][12] Interviews of 34,653 adults who participated in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions revealed a lifetime prevalence of NPD of 6.2%: 7.7% greater in men and 4.8% in women. A high prevalence of NPD was found among Black men and women and Hispanic women.[1]

Pathophysiology

There has been limited work done on neuroimaging in persons diagnosed with narcissistic personality disorder. A voxel-based morphometry (VBM) study done in Germany with a small sample size showed gray matter abnormalities in the prefrontal and insular regions.[13] Another voxel-based morphometry and diffuse tensor imaging study(DTI) done in Germany showed grey matter abnormalities in the right prefrontal and anterior cingulate cortices. There were abnormalities detected in the white matter of the frontal lobe as well. [14]

History and Physical

Obtaining an accurate history can be somewhat challenging for persons with narcissistic personality disorder, given the variability of the presentation. In the outpatient setting, individuals can be well related and high functioning, while in the inpatient setting, they can be some of the most aggressive and challenging patients. Most of the time, NPD patients come into contact with clinicians during emergencies were more often than not, they are noted to behave aggressively.[15]

The aggression indicates the severity of the personality disorder, i.e., the more aggression detected, the personality disorder is considered more severe. Otto Kernberg cited extensive cases correlating aggression with the severity of personality disorders.[16]

Per the DSM, NPD includes:

A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and with lack of empathy, beginning by early adulthood, as indicated by at least five of the following:

Has a grandiose sense of self-importance (e. g., exaggerates achievements, expects to be recognized as superior without actually completing the achievements)
Is preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.
Believes that they are "special" and can only be understood by or should only associate with other special people (or institutions).
Requires excessive admiration.
Has a sense of entitlement, such as an unreasonable expectation of favorable treatment or compliance with his or her expectations).
Is exploitative and takes advantage of others to achieve their own ends.
Lacks empathy and is unwilling to identify with the needs of others.
Is often envious of others or believes that others are envious of them.
Shows arrogant, haughty behaviors and attitudes

The diagnosis of NPD as other personality disorders requires evaluation of long-term patterns of functioning. One needs to be cautious not to jump to hasty conclusions because NPD can trigger countertransference. A careful evaluation of the different aspects of a person's life and an understanding of the person's childhood development can assist in the evaluation and diagnosis of NPD.

Evaluation

A standard psychiatric interview is often used to make a diagnosis of personality disorders. Otto Kernberg's structured clinical interview, which was created in 1981, has continued to undergo revisions and restructuring as a structured clinical interview for personality disorders. The current version is a semi-structured diagnostic interview with questions focused on personality organization, defenses, object relations, and coping skills. This interview focuses on interpersonal relationships. The current version is copyrighted by the Personality Institute at The Weill Cornell Institute. The interview is based on psychodynamic principles and is expected to be used by persons who had have had previous training in psychoanalytical work. [17]

Other instruments may measure the severity of narcissistic personality disorder, such as the five-factor narcissism inventory that looks at the five aspects of general personality. There are about 148 questions that are asked on the measure.[18] Another measure that may be useful is the Narcissistic Personality Inventory.[19]

The instruments above are mostly used in research settings. In the clinical world, the clinical interview is of most value. An excellent clinical interview focuses on interpersonal relationships as persons with an NPD often present with conflicts with others in inpatient or outpatient settings. In outpatient settings, referrals are often made at the behest of a loved one. In inpatient or emergency room settings, symptoms often come into play when there is interaction with other personnel, especially others in authority. Persons with NPD often describe themselves in relation to others with themes of comparison.[10]

Often a clinician's countertransference may help with forming a diagnosis. Often, persons with NPD create feelings of either feeling flattered or admired, or on the other extreme, having feelings of inadequacy and low self-worth.[20][21] Glen Gabbard is another analyst who has done extensive work in understanding these feelings described as "countertransference" in the therapist. As a clinician, it is always important to pay attention to the feelings evoked by a patient in themselves as this is often diagnostic.

Treatment / Management

No standardized pharmacological or psychological treatment has been established for persons with narcissistic personality disorder.[10] More often than not, NPD is present, along with other mood disorders. Once a diagnosis is established, it is essential to discuss the diagnosis because of several challenges that will mostly be present in the future. It is equally important to treat ongoing symptoms of co-occurring affective disorders.[22]

Kohut and Kernberg have focused on long-term therapy and exploring the relationship between a therapist and patient, which continues to be an established treatment for persons with a narcissistic personality disorder. [23] Psychodynamic psychotherapy focuses on defenses present during therapy sessions.[24] Many therapists have advocated for ongoing therapy for patients with an established diagnosis of NPD. NPD may significantly reduce emergency department visits and lower the incidence of self-harm. Of note, studies are more focused on borderline personality disorder; however, borderline personality disorder's findings may be generalizable to other disorders as well.

Transference-focused therapy is structured twice a week psychoanalytic therapy that focuses on personal expression of emotions toward a therapist. Given that persons with NPD can often be provoked by their perception of being treated by another, their own emotions towards other people are essential.[25]

Schema-focused therapy is relatively new and focuses on alternate forms of cognitive-behavioral therapy, including activating emotional senses.[26]

There are no FDA-approved medications for the treatment of NPD, but many patients may benefit from the treatment of symptoms, including anxiety, depression, mood lability, transient psychosis, and impulse control issues. Antidepressants, including selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, have been used. Risperidone, an antipsychotic, has shown benefit in some patients. Some patients are given mood stabilizers like lamotrigine.

Differential Diagnosis

The differential diagnosis often includes prevailing mood or anxiety disorders. Often persons with grandiose narcissism can present with heightened mood and more energy when excited by a new idea, which may initially point to a hypomanic/manic presentation; however, the personality aspect would be prominent in their interaction with others. On the other extreme, persons with vulnerable narcissism may present with salient features of dysthymia, depression, and anhedonia. However, the grandiosity and need for admiration would be prominent despite the affective symptoms, which would differentiate it from a major depressive disorder.

The closest differentials continue to remain other cluster B personality disorders, including antisocial personality disorder, histrionic personality disorder, and borderline personality disorder. It bears mention that persons with NPD do not show overt signs of impulsivity and self-destructiveness associated with borderline personality disorder. Similarly, apparent emotional responses are associated with histrionic personality disorder. NPD is most similar to antisocial personality disorder with a lack of empathy and superficial charm. However, persons with an antisocial personality disorder would show a lack of morals compared to persons with NPD and have a past diagnosis of conduct disorder.

Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Major depressive disorder
Obsessive-compulsive disorder
Substance-induced mood disorder

Prognosis

The prognosis, as discussed above, depends on the presence of comorbid disorders and the level of functioning of the patient. Aggression is often directly related to the severity of the disease; rather, the more aggressive the patient appears, the more severe is the personality disorders.

Complications

The complications essentially involve the presence of comorbid conditions, including mood and substance use disorders. The presence of other personality disorders is also common. However, narcissistic personality disorder is associated with a higher risk of death by suicide compared to other personality disorders.[27] In contrast, there is mixed evidence of suicide attempts and persons with narcissistic personality disorder since NPD is associated with factors such as “self-love” and “grandiosity” and comparatively less impulsivity.[28] Substance use disorder is also related to NPD, and when there is an association of substance use disorder with NPD, there is significantly more hostility, and aggression is also present. This makes treatment even more challenging than usual. There are several theories related to both biology and trauma regarding the same.[29][30]

Deterrence and Patient Education

As detailed above, it is necessary to discuss the diagnosis with the patient as soon as possible. It is equally important to discuss the process of arriving at this conclusion, including clinical information gathered and observed behaviors. Discussion of other comorbid disorders, including mood and substance use disorders, if present, needs to be addressed. Often family members also require education about personality disorders, their behaviors, and complications.

Pearls and Other Issues

Obtaining a detailed history is vital. A primary psychiatric interview focuses on symptoms; however, longitudinal assessments focusing on interpersonal relations are helpful to point toward a diagnosis of NPD.
Given that there are two subtypes established, it is essential to focus on identifying both grandiose and vulnerable forms, given that the latter is missed in place of other diagnoses.
It is essential to be mindful of other comorbid diagnoses given the high levels of comorbidity with affective and other cluster B personality disorders.
Literature has shown that most persons with narcissistic personality disorder are difficult to engage; hence, being empathetic is necessary when beginning treatment.
Once a diagnosis is established, it is important to share the same with the patient. Lack of sharing may lead to further complications during care.
It is equally important to treat comorbid mood and substance use disorders.
It is crucial for treating clinicians to be aware that there are high rates of drop-outs and increased rates of therapeutic disruption with persons with a narcissistic personality disorder.
It is essential to recognize that most clinicians experience negative countertransference when treating persons with NPD. Clinicians are advised to be aware of the same and process emotions that arise in treatment.

Enhancing Healthcare Team Outcomes

Often collaborative work is required in the medical setting when patients with NPD work with non-mental health professionals such as surgeons, medical nursing, nutritionists, etc. These patients are often described as "difficult and demanding," and importantly, their medical needs remain untreated. Often mental health professionals may be consulted for a mood disorder on the inpatient floor for a patient with underlying NPD and have to liaison with the primary medical team in charge of the patient. Other medical professionals must be educated about personality disorder and their countertransference towards the patient so that it does not impact clinical care. Mental health professionals in the consult-liaison service may provide support and education to the first medical teams as well.

In the outpatient setting, patients are asked to discuss their diagnosis as they feel relevant to their medical providers. A partnership among medical professionals and other ancillaries may ensure optimal care. Pharmacists need to have input into the medication process, ensuring proper dosing and the absence of interactions. Nurses function as the glue that holds the team together and are often the primary point of patient contact. The education of both patients and their providers is also helpful. All these disciplines functioning as an interprofessional team are vital to achieving optimal patient outcomes. [Level 5]

Review Questions

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Comment on this article.

References

1.: Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2008 Jul;69(7):1033-45. [PMC free article: PMC2669224] [PubMed: 18557663]
2.: Dixon-Gordon KL, Whalen DJ, Layden BK, Chapman AL. A Systematic Review of Personality Disorders and Health Outcomes. Can Psychol. 2015 May;56(2):168-190. [PMC free article: PMC4597592] [PubMed: 26456998]
3.: Jang KL, Livesley WJ, Vernon PA, Jackson DN. Heritability of personality disorder traits: a twin study. Acta Psychiatr Scand. 1996 Dec;94(6):438-44. [PubMed: 9020996]
4.: Weinberg E. Mentalization, affect regulation, and development of the self. Panel report. J Am Psychoanal Assoc. 2006 Winter;54(1):251-70. [PubMed: 16602354]
5.: Zvelc G. Object and subject relations in adulthood--towards an integrative model of interpersonal relationships. Psychiatr Danub. 2010 Dec;22(4):498-508. [PubMed: 21169889]
6.: Otway LJ, Vignoles VL. Narcissism and childhood recollections: a quantitative test of psychoanalytic predictions. Pers Soc Psychol Bull. 2006 Jan;32(1):104-16. [PubMed: 16317192]
7.: Ronningstam E. An update on narcissistic personality disorder. Curr Opin Psychiatry. 2013 Jan;26(1):102-6. [PubMed: 23187086]
8.: Ronningstam E. Narcissistic personality disorder: a current review. Curr Psychiatry Rep. 2010 Feb;12(1):68-75. [PubMed: 20425313]
9.: Ronningstam E. Narcissistic personality disorder in DSM-V--in support of retaining a significant diagnosis. J Pers Disord. 2011 Apr;25(2):248-59. [PubMed: 21466253]
10.: Caligor E, Levy KN, Yeomans FE. Narcissistic personality disorder: diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22. [PubMed: 25930131]
11.: Pincus AL, Ansell EB, Pimentel CA, Cain NM, Wright AGC, Levy KN. Initial construction and validation of the Pathological Narcissism Inventory. Psychol Assess. 2009 Sep;21(3):365-379. [PubMed: 19719348]
12.: Dickinson KA, Pincus AL. Interpersonal analysis of grandiose and vulnerable narcissism. J Pers Disord. 2003 Jun;17(3):188-207. [PubMed: 12839099]
13.: Schulze L, Dziobek I, Vater A, Heekeren HR, Bajbouj M, Renneberg B, Heuser I, Roepke S. Gray matter abnormalities in patients with narcissistic personality disorder. J Psychiatr Res. 2013 Oct;47(10):1363-9. [PubMed: 23777939]
14.: Nenadic I, Güllmar D, Dietzek M, Langbein K, Steinke J, Gaser C. Brain structure in narcissistic personality disorder: a VBM and DTI pilot study. Psychiatry Res. 2015 Feb 28;231(2):184-6. [PubMed: 25492857]
15.: Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Pers Disord. 2001 Apr;15(2):103-9. [PubMed: 11345846]
16.: Tuttman S. Otto Kernberg's concepts about narcissism. Am J Psychoanal. 1981 Winter;41(4):307-16. [PubMed: 7345937]
17.: Hörz-Sagstetter S, Caligor E, Preti E, Stern BL, De Panfilis C, Clarkin JF. Clinician-Guided Assessment of Personality Using the Structural Interview and the Structured Interview of Personality Organization (STIPO). J Pers Assess. 2018 Jan-Feb;100(1):30-42. [PubMed: 28388222]
18.: Glover N, Miller JD, Lynam DR, Crego C, Widiger TA. The five-factor narcissism inventory: a five-factor measure of narcissistic personality traits. J Pers Assess. 2012;94(5):500-12. [PubMed: 22475323]
19.: Vater A, Schröder-Abé M, Ritter K, Renneberg B, Schulze L, Bosson JK, Roepke S. The Narcissistic Personality Inventory: a useful tool for assessing pathological narcissism? Evidence from patients with Narcissistic Personality Disorder. J Pers Assess. 2013;95(3):301-8. [PubMed: 23101721]
20.: Betan E, Heim AK, Zittel Conklin C, Westen D. Countertransference phenomena and personality pathology in clinical practice: an empirical investigation. Am J Psychiatry. 2005 May;162(5):890-8. [PubMed: 15863790]
21.: Tanzilli A, Muzi L, Ronningstam E, Lingiardi V. Countertransference when working with narcissistic personality disorder: An empirical investigation. Psychotherapy (Chic). 2017 Jun;54(2):184-194. [PubMed: 28581327]
22.: Ellison WD, Levy KN, Cain NM, Ansell EB, Pincus AL. The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: a naturalistic investigation. J Pers Assess. 2013;95(3):291-300. [PubMed: 23186259]
23.: Kernberg OF. An overview of the treatment of severe narcissistic pathology. Int J Psychoanal. 2014 Oct;95(5):865-88. [PubMed: 24902768]
24.: Gabbard GO. Psychotherapy of personality disorders. J Psychother Pract Res. 2000 Winter;9(1):1-6. [PMC free article: PMC3330582] [PubMed: 10608903]
25.: Kernberg OF, Yeomans FE, Clarkin JF, Levy KN. Transference focused psychotherapy: overview and update. Int J Psychoanal. 2008 Jun;89(3):601-20. [PubMed: 18558958]
26.: Dieckmann E, Behary W. [Schema Therapy: An Approach for Treating Narcissistic Personality Disorder]. Fortschr Neurol Psychiatr. 2015 Aug;83(8):463-77; quiz 478. [PubMed: 26327479]
27.: Giner L, Blasco-Fontecilla H, Mercedes Perez-Rodriguez M, Garcia-Nieto R, Giner J, Guija JA, Rico A, Barrero E, Luna MA, de Leon J, Oquendo MA, Baca-Garcia E. Personality disorders and health problems distinguish suicide attempters from completers in a direct comparison. J Affect Disord. 2013 Nov;151(2):474-483. [PubMed: 23859005]
28.: Bolton JM, Robinson J. Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population. Am J Public Health. 2010 Dec;100(12):2473-80. [PMC free article: PMC2978176] [PubMed: 21068419]
29.: Verheul R. Co-morbidity of personality disorders in individuals with substance use disorders. Eur Psychiatry. 2001 Aug;16(5):274-82. [PubMed: 11514129]
30.: Parmar A, Kaloiya G. Comorbidity of Personality Disorder among Substance Use Disorder Patients: A Narrative Review. Indian J Psychol Med. 2018 Nov-Dec;40(6):517-527. [PMC free article: PMC6241194] [PubMed: 30533947]

Narcissistic Personality Disorder - StatPearls

Continuing Education Activity

Objectives:

Identify the etiology of narcissistic personality disorder.
Summarize the evaluation of narcissistic personality disorder.
Review management options available for narcissistic personality disorder.
Describe the complications of narcissistic personality disorder, including comorbid diagnosis and relation to suicidal behavior.

Access free multiple choice questions on this topic.

Introduction

Narcissistic personality disorder (NPD) is a pattern of grandiosity, need for admiration, and lack of empathy per the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). The disorder is classified in the dimensional model of "Personality Disorders. "NPD is highly comorbid with other disorders in mental health. Persons with NPD can often present with impairment in maintaining work and relationships.[1] NPD is highly prevalent in society; however, there has been limited research on the same. Given the limited research on the same and differences in the diagnosis of the disease, it was initially going to be discontinued from the DSM.NPD is under the umbrella of Cluster B personality disorders, which include antisocial personality disorder, histrionic personality disorder, and borderline personality disorder. Cluster B typically presents with overtly emotional and unpredictable behavior.[2]

Etiology

Epidemiology

Comorbid antisocial personality disorder is said to have the most negative effect. There is much contention around the diagnosis of NPD. There are two basic subtypes, including grandiose and vulnerable narcissistic personality disorder. The grandiose subtype includes overt grandiosity, presence of aggression, and boldness. The vulnerable subtype presents with hypersensitivity and defensiveness and is often easy to miss.[10] There has been some research on the grandiose subtype, which includes evidence of behavior such as overt aggression, lack of empathy, and exploitation of the other. [11][12] Interviews of 34,653 adults who participated in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions revealed a lifetime prevalence of NPD of 6.2%: 7.7% greater in men and 4.8% in women. A high prevalence of NPD was found among Black men and women and Hispanic women.[1]

Pathophysiology

History and Physical

Per the DSM, NPD includes:

A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and with lack of empathy, beginning by early adulthood, as indicated by at least five of the following:

Has a grandiose sense of self-importance (e.g., exaggerates achievements, expects to be recognized as superior without actually completing the achievements)
Is preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.
Believes that they are "special" and can only be understood by or should only associate with other special people (or institutions).
Requires excessive admiration.
Has a sense of entitlement, such as an unreasonable expectation of favorable treatment or compliance with his or her expectations).
Is exploitative and takes advantage of others to achieve their own ends.
Lacks empathy and is unwilling to identify with the needs of others.
Is often envious of others or believes that others are envious of them.
Shows arrogant, haughty behaviors and attitudes

Evaluation

Other instruments may measure the severity of narcissistic personality disorder, such as the five-factor narcissism inventory that looks at the five aspects of general personality. There are about 148 questions that are asked on the measure. [18] Another measure that may be useful is the Narcissistic Personality Inventory.[19]

Treatment / Management

Kohut and Kernberg have focused on long-term therapy and exploring the relationship between a therapist and patient, which continues to be an established treatment for persons with a narcissistic personality disorder.[23] Psychodynamic psychotherapy focuses on defenses present during therapy sessions.[24] Many therapists have advocated for ongoing therapy for patients with an established diagnosis of NPD. NPD may significantly reduce emergency department visits and lower the incidence of self-harm. Of note, studies are more focused on borderline personality disorder; however, borderline personality disorder's findings may be generalizable to other disorders as well.

Schema-focused therapy is relatively new and focuses on alternate forms of cognitive-behavioral therapy, including activating emotional senses.[26]

Differential Diagnosis

Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Major depressive disorder
Obsessive-compulsive disorder
Substance-induced mood disorder

Prognosis

Complications

Deterrence and Patient Education

Pearls and Other Issues

Obtaining a detailed history is vital. A primary psychiatric interview focuses on symptoms; however, longitudinal assessments focusing on interpersonal relations are helpful to point toward a diagnosis of NPD.
Given that there are two subtypes established, it is essential to focus on identifying both grandiose and vulnerable forms, given that the latter is missed in place of other diagnoses.
It is essential to be mindful of other comorbid diagnoses given the high levels of comorbidity with affective and other cluster B personality disorders.
Literature has shown that most persons with narcissistic personality disorder are difficult to engage; hence, being empathetic is necessary when beginning treatment.
Once a diagnosis is established, it is important to share the same with the patient. Lack of sharing may lead to further complications during care.
It is equally important to treat comorbid mood and substance use disorders.
It is crucial for treating clinicians to be aware that there are high rates of drop-outs and increased rates of therapeutic disruption with persons with a narcissistic personality disorder.
It is essential to recognize that most clinicians experience negative countertransference when treating persons with NPD. Clinicians are advised to be aware of the same and process emotions that arise in treatment.

Enhancing Healthcare Team Outcomes

Review Questions

Access free multiple choice questions on this topic.
Comment on this article.

References

1.: Stinson FS, Dawson DA, Goldstein RB, Chou SP, Huang B, Smith SM, Ruan WJ, Pulay AJ, Saha TD, Pickering RP, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2008 Jul;69(7):1033-45. [PMC free article: PMC2669224] [PubMed: 18557663]
2.: Dixon-Gordon KL, Whalen DJ, Layden BK, Chapman AL. A Systematic Review of Personality Disorders and Health Outcomes. Can Psychol. 2015 May;56(2):168-190. [PMC free article: PMC4597592] [PubMed: 26456998]
3.: Jang KL, Livesley WJ, Vernon PA, Jackson DN. Heritability of personality disorder traits: a twin study. Acta Psychiatr Scand. 1996 Dec;94(6):438-44. [PubMed: 9020996]
4.: Weinberg E. Mentalization, affect regulation, and development of the self. Panel report. J Am Psychoanal Assoc. 2006 Winter;54(1):251-70. [PubMed: 16602354]
5.: Zvelc G. Object and subject relations in adulthood--towards an integrative model of interpersonal relationships. Psychiatr Danub. 2010 Dec;22(4):498-508. [PubMed: 21169889]
6.: Otway LJ, Vignoles VL. Narcissism and childhood recollections: a quantitative test of psychoanalytic predictions. Pers Soc Psychol Bull. 2006 Jan;32(1):104-16. [PubMed: 16317192]
7.: Ronningstam E. An update on narcissistic personality disorder. Curr Opin Psychiatry. 2013 Jan;26(1):102-6. [PubMed: 23187086]
8.: Ronningstam E. Narcissistic personality disorder: a current review. Curr Psychiatry Rep. 2010 Feb;12(1):68-75. [PubMed: 20425313]
9.: Ronningstam E. Narcissistic personality disorder in DSM-V--in support of retaining a significant diagnosis. J Pers Disord. 2011 Apr;25(2):248-59. [PubMed: 21466253]
10.: Caligor E, Levy KN, Yeomans FE. Narcissistic personality disorder: diagnostic and clinical challenges. Am J Psychiatry. 2015 May;172(5):415-22. [PubMed: 25930131]
11.: Pincus AL, Ansell EB, Pimentel CA, Cain NM, Wright AGC, Levy KN. Initial construction and validation of the Pathological Narcissism Inventory. Psychol Assess. 2009 Sep;21(3):365-379. [PubMed: 19719348]
12.: Dickinson KA, Pincus AL. Interpersonal analysis of grandiose and vulnerable narcissism. J Pers Disord. 2003 Jun;17(3):188-207. [PubMed: 12839099]
13.: Schulze L, Dziobek I, Vater A, Heekeren HR, Bajbouj M, Renneberg B, Heuser I, Roepke S. Gray matter abnormalities in patients with narcissistic personality disorder. J Psychiatr Res. 2013 Oct;47(10):1363-9. [PubMed: 23777939]
14.: Nenadic I, Güllmar D, Dietzek M, Langbein K, Steinke J, Gaser C. Brain structure in narcissistic personality disorder: a VBM and DTI pilot study. Psychiatry Res. 2015 Feb 28;231(2):184-6. [PubMed: 25492857]
15.: Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Pers Disord. 2001 Apr;15(2):103-9. [PubMed: 11345846]
16.: Tuttman S. Otto Kernberg's concepts about narcissism. Am J Psychoanal. 1981 Winter;41(4):307-16. [PubMed: 7345937]
17.: Hörz-Sagstetter S, Caligor E, Preti E, Stern BL, De Panfilis C, Clarkin JF. Clinician-Guided Assessment of Personality Using the Structural Interview and the Structured Interview of Personality Organization (STIPO). J Pers Assess. 2018 Jan-Feb;100(1):30-42. [PubMed: 28388222]
18.: Glover N, Miller JD, Lynam DR, Crego C, Widiger TA. The five-factor narcissism inventory: a five-factor measure of narcissistic personality traits. J Pers Assess. 2012;94(5):500-12. [PubMed: 22475323]
19.: Vater A, Schröder-Abé M, Ritter K, Renneberg B, Schulze L, Bosson JK, Roepke S. The Narcissistic Personality Inventory: a useful tool for assessing pathological narcissism? Evidence from patients with Narcissistic Personality Disorder. J Pers Assess. 2013;95(3):301-8. [PubMed: 23101721]
20.: Betan E, Heim AK, Zittel Conklin C, Westen D. Countertransference phenomena and personality pathology in clinical practice: an empirical investigation. Am J Psychiatry. 2005 May;162(5):890-8. [PubMed: 15863790]
21.: Tanzilli A, Muzi L, Ronningstam E, Lingiardi V. Countertransference when working with narcissistic personality disorder: An empirical investigation. Psychotherapy (Chic). 2017 Jun;54(2):184-194. [PubMed: 28581327]
22.: Ellison WD, Levy KN, Cain NM, Ansell EB, Pincus AL. The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: a naturalistic investigation. J Pers Assess. 2013;95(3):291-300. [PubMed: 23186259]
23.: Kernberg OF. An overview of the treatment of severe narcissistic pathology. Int J Psychoanal. 2014 Oct;95(5):865-88. [PubMed: 24902768]
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How to recognize a person with narcissism

July 19 Likbez Health

Psychotherapy may be required even for those who associate with a narcissist.

You can listen to the article. If it's more convenient for you, turn on the podcast.

Narcissists are traditionally called narcissists, fixated on their own person. However, not every narcissist suffers from narcissism.

Narcissistic personality disorder has very specific symptoms. nine0003

How to recognize a person with narcissistic personality disorder

Every psychotherapist's reference book, the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), lists nine signs of a true narcissist. At the same time, it is enough to make a diagnosis if a person meets only five of them.

1. Maintains relationships with “special” people

The narcissist always has authoritative, influential acquaintances from circles that are difficult for “mere mortals” to access: businessmen from the top hundred of the Forbes list, brilliant artists, owners of various rarities, close friends and lovers of world famous stars. Well, at least the narcissist himself likes to talk about such connections. nine0003

A person with a narcissistic disorder uses the status of acquaintances as a way to increase self-esteem and authority in the eyes of others.

By the way, this is one of the reasons why daffodils seem so attractive, why it is easy to fall in love with them and difficult to leave them. When a person is “with such connections!”, “so sophisticated!” suddenly draws attention to you, it tickles pride very much. It’s as if you are on the same social level with the narcissist’s great acquaintances and begin to feel “special” too. And this is a kind of psychological drug, which is hard to give up. nine0003

2. Often talks about his own victories and achievements

Whether it's a controversial moment at work, a conflict in a store or public transport, a random traffic light race - the narcissist emerges victorious from any situation. In fact, that's what he tells the people around him.

It is important for Narcissus to demonstrate that he is the best and smartest of all. This helps him feel more confident.

Jacqueline Krol

Psychotherapist, for Healthline online edition

It is typical that stories about victories always proceed in the form of monologues. Narcissists need admiring listeners. As soon as one of them begins to pull the blanket over himself and talk about his own achievements, the person with narcissism gets bored and turns off the conversation. nine0003

3. Needs compliments and can't stand criticism

From the outside, the narcissist seems to be an extremely confident person. But, as experts suggest, most people with narcissistic personality disorder have serious problems with self-esteem.

That is why they expect constant compliments from others. If admiration is not enough, or worse, the narcissist is criticized, they react very emotionally. Can theatrically exclaim: "I'm not appreciated here!" Often reproaches relatives and colleagues for inattention and callousness. Because of the slightest remark, he may cry or run away, slamming the door and shouting something insulting in the end. nine0003

Then, perhaps, he will return to still get recognition from you. For this, the narcissist manipulates guilt: it is not he who is emotionally unrestrained, but you meanly offended him, underestimated and provoked him.

4. Seems to be a dreamer and idealist

Narcissus seems ideal to himself and therefore counts on a special, impeccable life. And if something does not work out, the responsibility for it shifts to the people around.

If there are difficulties in love or family relationships, the partner is to blame: he didn't look the right way, did the wrong thing, didn't appreciate it. “All women are bitches, and I am looking for that one, my soul mate who will understand me” is the demonstrative position of the classic narcissist. nine0003

Narcissistic personality disorder is more common in men. At risk are young (under 45) unmarried people.

If it doesn't work out with a career and money, the society is to blame, of course. More precisely, his successful representatives, who (from the point of view of a narcissist) probably achieved their position with the help of influential relatives, through bed, by deceit. Narcissists often oppose themselves to society, emphasizing their status as an unrecognized genius and a lone wolf, disappointed in an imperfect world. nine0003

5. Feels worthy of special treatment

This means that the narcissist demands more rights for himself than for others. He will not stand in line - he will find a way to get into the right office or to the counter first, even if it turns into a scandal. He expects priority service at the restaurant. Or he sincerely counts on an “understanding” attitude from his superiors, even if he is late for the fifth time in a week or misses a deadline.

He "needs" to sit at the window, open (or close) the window or do his hobby - instead of washing the dishes, cleaning or going shopping. nine0003

The interests of a person with narcissistic personality disorder always come first. People around are encouraged to come to terms with it.

6. Often arrogant, shows disrespect for those who are lower in status

One of the characteristics of the classic narcissist is a sense of superiority over others. This is clearly shown in situations where a person suffering from narcissism is faced with the service industry. He can be rude to waiters, wardrobe workers, consultants, petty clerks. Subordinates or those who are younger also suffer from his arrogance. nine0003

If the narcissist is reproached for this, he will explain his behavior with shortcomings in the work of the "lower class" and say that he simply demands a little respect for himself.

7. Exploits others

For a narcissist, being served is in the order of things, and he is not interested in what forces and at the expense of what this is achieved. For example, in family relationships, he will expect dinner, cleanliness and excellent physical shape from his partner - simply because he “should” (even if he has two jobs, a child and an objective lack of time for sports). nine0003

If the partner tries to rebel, discounting, gaslighting and other abuse techniques will be used.

8. Openly manipulates people

Pressing on pity, hitting on feelings of guilt and conscience, twisting the facts and blaming others for what they did not do - this is not a complete list of what the narcissist does to achieve his goals.

It cannot be said that he manipulates consciously. It’s just that this is how his psyche works on justifying himself and blaming others. nine0003

9. Not able to empathize

Lack of empathy (sympathy for the experiences and problems of others) is one of the most characteristic signs of a narcissist.

A person with narcissistic personality disorder is completely self-centered. To delve into other people's problems, to provide support for him is simply boring.

This is one of the reasons why narcissists almost never have long-term relationships, either friendships or romantic relationships.

What to do if a person is a narcissist

Narcissism is one of the least understood personality disorders. It is extremely difficult to treat, as narcissists usually do not believe that they have mental health problems. On the contrary: they are sure that others have problems, which means that they should be treated.

In addition, narcissism is often accompanied by other types of mental disorders - manic-depressive psychosis (bipolar disorder), depression, anxiety and dissocial (sociopathic) disorders. So therapy, even if the narcissist agrees to it, runs the risk of being long and complicated. nine0003

What should you do if you encounter a narcissist? The least energy-consuming, but also the least humane way is to run away from him.

If you have the opportunity not to take on the solution of other people's psychological problems, it makes sense not to do this.

However, this is not always the case. After all, a colleague, a valuable business partner, a close relative, or even a loved one can be a narcissist. Refusal to communicate will be tantamount to a complete severing of these important ties. nine0003

In this case, the only thing left is to persuade the narcissist to see a psychotherapist. The doctor will get to know the patient better and, depending on his condition, will select the most effective type of psychotherapy. Sometimes, in addition to it, medication may be needed - antidepressants and antipsychotics.

Psychotherapy will also be useful for you if you are forced to contact a narcissist every day. Communication with a person who suffers from narcissistic personality disorder has a destructive effect on people close to him: it undermines self-esteem, makes you doubt yourself, and can provoke the development of an anxiety disorder or depression. nine0003

Narcissism - what it is, signs and causes of narcissistic personality disorder

About who people with narcissism are, where it comes from and whether it is always necessary to break off relationships with narcissists, says a clinical psychologist and co-founder of the YouTalk online psychological assistance service Anna Krymskaya

Surely among your acquaintances there is someone about whom you thought “yes, he is a typical narcissist”. Most likely, the description of this person will look like this: self-confident, ambitious, somewhat selfish. Possibly manipulative.

Finished reading here

The term "narcissism" sounds everywhere: in psychological blogs, films, "Tiktok". There are articles and studies about him. But often in them this phenomenon is simplified and stigmatized. Who are narcissists, should they be avoided, and when can one speak of a narcissistic disorder? nine0003

What is narcissism

Narcissism in psychology is an exaggerated opinion about one's contribution to society or a group, otherwise known as excessive narcissism or even egocentrism. This is not a monolithic concept, but a whole spectrum. To some extent, its features are present in many of us, this is normal and even useful in some ways. For example, people with a narcissistic temperament are often ambitious, take care of themselves and achieve great success in their careers.

Depending on how pronounced narcissistic tendencies are and whether they interfere with life, the spectrum of narcissism can be divided into four parts:

individual features
character
accentuation
personality disorder.

Character and accentuation are options for a healthy manifestation of narcissism, and a personality disorder is already a psychiatric diagnosis.

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The extreme degree of the norm is the narcissistic accentuation of the personality. This means that the narcissistic qualities of character are so pronounced that in some cases they begin to interfere with a person's life. They can affect his relationships with others or the professional sphere. However, their influence is not so serious as to diagnose a personality disorder. For example, they can lead to conflicts with superiors or prevent a person from sincerely opening up to another, removing the mask of ideality. nine0003

What qualities are considered narcissistic

Based on the Narcissistic Personality Inventory, one of the most popular tools for identifying non-clinical cases of narcissism, the following qualities can be considered narcissistic:

Demonstration. It is expressed in the idea of one's own unusualness, uniqueness, physical attractiveness and ability to influence others
Authority. Confidence in possessing leadership qualities, the ability to influence others, power over people, the ability to succeed. nine0116
Chosenness. The feeling of one's own peculiarity, the expectation of an exceptionally good attitude, respect, recognition of one's merits, submission to one's requirements and desires.
Vanity. The desire to look good in the eyes of others, the need to confirm one's superiority, the desire to hear flattery from other people.

Self-sufficiency. Confidence in one's independence from people in achieving results, competence, responsibility for making decisions, confidence in the correctness of one's actions, the ability to live in accordance with one's desires, the ability to become a great person. nine0116
Excellence. Conviction in the extraordinary and uniqueness of one's personality, the presence of special achievements and talents, the deserving of appropriate recognition from others.
Operation. Confidence in one's ability to use other people, the ease of manipulating others to achieve one's own goals, the ability to understand others well, influence their behavior, and convince of something.

Along with these traits, there are often such characteristics as increased sensitivity to shame, perfectionism, a feeling of inner emptiness and loneliness. nine0003

People with a narcissistic psychotype are demonized, attributing to them aggressiveness, lack of empathy, a tendency to violence

The traits listed above are manifestations of narcissism as a personality trait, that is, a norm. To be diagnosed with Narcissistic Personality Disorder, according to the American DSM-5 classification of diseases, in early adulthood, a person must exhibit five or more of the following characteristics of narcissism: nine0116

Preoccupation with fantasies of unlimited achievement, influence, power, intelligence, beauty, or ideal love.

Belief in one's specialness and uniqueness, accompanied by the need to communicate only with people of the highest level.

The need for unconditional admiration.

Feeling the right to a reward.

Exploitation of others to achieve one's own goals.

Lack of empathy.

Envy of others and belief that others envy them. nine0116

Arrogance and arrogance.

In Russia, however, since January 2022 it has become impossible to get a diagnosis of Narcissistic Personality Disorder, because our doctors do not follow the DSM-5, but the International Classification of Diseases from the World Health Organization. In the latest edition, the division into individual personality disorders was removed: now they look at whether a person has general signs of a personality disorder, the degree of their severity and specific manifestations. This will make the approach more comprehensive and personalized. nine0003

Is it worth it to label a person "narcissus"

There are two sides to the use of such labels. They can be a guide, explain individual patterns in their own and others' behavior, feelings and thinking; can help you get the big picture. But they can also become a stigmatizing stigma, if you do not pay attention to the individual characteristics of a person. Unfortunately, in modern culture, this often happens and any people with a narcissistic psychotype are demonized, attributing to them aggressiveness, lack of empathy, a tendency to violence, and offering to avoid any contact with them. But this will not be true for every person with narcissistic traits. Because of such generalizations, even the expression "narcissist" itself has acquired a negative connotation, and its use is considered not entirely ethical. nine0003

In addition, in psychology there are many different classifications of narcissism that better convey the shades of this phenomenon than one term.

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What types of narcissism are distinguished by psychologists

Most often they talk about two types:

Grandiose. Such a person wants to be the best. Faster, higher, stronger than all. Career, appearance, relationships - everything should be perfect. This characteristic fits well with the modern philosophy of success and achievement, so often this type achieves a lot in life. Grandiose narcissists can embellish reality to fit their ideal image if reality falls short. The self-esteem of such people is unstable: from the outside it may seem high or even inflated, but inside they often feel empty and dissatisfied. nine0003

Vulnerable. He is also hidden or thin-skinned. Clinical psychologist Paul Wink in his work "The Two Faces of Narcissism" described the mental portrait of representatives of this type as prone to introversion, submission, anxiety, vulnerability and always being on the defensive. However, like the grandiose type, they are vain, interested in others, impulsive, and often take risks.

While grandiose narcissists tend to exalt themselves in the eyes of others, vulnerable narcissists may appear to hate themselves. In fact, this is the same idealization, but turned inside out. While grandiose narcissists tend to see themselves as the best, covert narcissists tend to see themselves as the worst, stupidest, most miserable. Keyword: most. nine0003

From the grandiose pole, a person with narcissism can fall into the other extreme: feel like a partner unworthy of love in principle

Some researchers believe that these types are not mutually exclusive, but can change depending on the circumstances of a person's life. For example, there was a successful period at work: a person exceeded KPI and received praise from his superiors. At this point, he will be inclined to idealize himself, to feel his own exclusivity and superiority, life will seem beautiful. A week later, the partner shares that some aspect of the relationship does not suit him. From the grandiose pole, a person with narcissism can fall into the other extreme: to feel like a disgusting partner, unworthy of love in principle. And at the same time devalue all previous achievements. In this state, a person may impulsively propose a breakup or show aggression, trying to avoid corrosive shame. nine0003

And if the narcissistic disorder is accompanied by features of sociopathy (indifference, aggressiveness, disregard for social norms), one can speak of perverse narcissism. It is this type that is prone to emotional violence and even crime due to a lack of empathy. Perverted narcissists are people who prove their worth and value through the humiliation of others. It is extremely difficult for them to build a healthy relationship, as they are not able to empathize, lie, manipulate and overly control their partner. This type rarely turns to a psychotherapist, and it is difficult for him to stay in therapy. nine0003

Narcissism in men and women

Scientists at the Buffalo Institute reviewed studies of narcissistic personality disorder published over the past 30 years and found that it is more common in men and manifests itself somewhat differently than in women.

First, men are more likely to exploit others and feel entitled to enjoy privileges. Secondly, they show more desire for power and leadership. But in the manifestations of vanity and egocentrism, there was no particular difference. Scientists suggest that such results may be the result of a certain gender socialization - that is, the attitudes broadcast by society about what men and women can and cannot be. nine0003

Because women are often criticized for being aggressive and authoritarian, they can suppress these narcissistic traits while men do not have to. But the authors note that this topic requires further study

Causes of narcissism

There are different concepts as to why people develop narcissism. The conducted studies have not proved an unambiguous connection with genetics, so the sociocultural concept remains the main one. nine0003

Representatives of psychoanalysis have paid particular attention to the nature of narcissism. For example, Sigmund Freud and Heinz Kohut were of the opinion that at a certain stage in the development of a child, the emergence of narcissism is a natural and healthy phenomenon - this is called primary narcissism. In infancy, the child has no other needs than his own, and he does not have to make any effort to satisfy them. In fact, he is the center of his own universe. This is a normal developmental stage that everyone goes through. nine0003

However, certain circumstances can lead to secondary narcissism - that is, its unhealthy form. Such a circumstance could be a lack of parental love and acceptance. Moreover, the child did not necessarily encounter excessive severity, cruelty or indifference. It is quite possible that his parents, on the contrary, praised him for any reason and did not forbid anything. Child idealization and permissiveness can also be perceived as dislike and cause secondary narcissism, according to Karen Horney. When only the positive side is seen in a child, ignoring the existence of negative traits, he feels unseen. As if they love not him, but some other person, an image. In both cases, the defensive reaction is the creation of an imaginary ideal "I", designed to deserve the love and attention of others. nine0003

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Psychoanalyst Andre Green considers another reason in his article "Dead Mother". He talks about a situation in which the mother was physically alive, but was emotionally unavailable and absent due to depression. For this reason, the child did not receive love, care, support in the proper amount. The researcher believed that the mother's depression becomes a trauma for the child, since the baby, up to a certain age, sees in himself the cause of everything that happens around him and, among other things, blames himself for his mother's condition. nine0003

Lack of communication and warmth leads to the fact that the child tries to "bring the mother back to life", changing behavior, attracting attention. Failures give rise to tremendous anxiety and a feeling of a bottomless hole inside. Over time, the baby begins to feel the emptiness, which he will later try to fill: with achievements, attention, other people. In this case, those around him can become his narcissistic extension - like an extension of his personality, an attribute to maintain status and high self-esteem. Other consequences are the replacement of emotions with reasoning, a tendency to depression, aggressiveness, the inability to let someone in, to accept and experience love, to build warm trusting relationships. nine0003

Narcissistic trauma

Trauma associated with the narcissistic part of the personality can occur not only in childhood. According to Freud, a narcissistic injury is a situation in which the narcissist feels that his hidden true self has been discovered. Its imperfection is revealed. For example, if he faced failure or his authority was called into question. Narcissistic trauma can lead to depression or what is known as narcissistic rage, an attempt to regain control and avenge the pain. nine0003

Treatment of narcissism

Both narcissistic personality disorder and narcissism in the broad sense of the word are generally amenable to psychotherapy. It's not exactly a "treatment" in the medical sense of the word. Rather, the process of knowing, accepting and adapting to the characteristics of one's personality.

For therapy to be effective, the person must be interested in it. In many cases, the benefits of narcissistic character traits and the difficulty in recognizing one's own imperfection lead to the fact that a person is not too willing to change something in his life and turn to a psychotherapist. And in a situation where we are talking simply about character traits that do not interfere with the person himself and do not harm others, the therapy of narcissism is, in principle, not needed. nine0003

If you feel bad in a relationship, then whether the person is a narcissist or not, it makes sense to think about parting. Working with the deep structures of personality requires a lot of effort and time. But at the same time, the very arrival of psychotherapy already has a positive effect. The therapeutic relationship is built on trust, acceptance, and recognition of the person in all of his manifestations, and this is exactly the kind of experience that people with narcissistic disorder or pronounced narcissism practically do not have. nine0003
Together with the client, the therapist looks for points of support and support. The psychologist is able to endure regular cycles of idealization and devaluation, which allows the relationship to last. Teaches the client to see himself, not to fall into one of the poles of adoration and hatred, to endure his fears, doubts, vulnerability, envy and a constant sense of shame. See the value of other people in isolation from himself and, if necessary, control his aggression.

Having received the experience of warm acceptance of different aspects of his personality in therapy, a person with narcissism learns to apply this experience in everyday life, to build relationships with the world and himself in a new way. nine0003
How to communicate with a person if you suspect narcissism or NPD

There are two main principles to follow: focus on how you feel in contact with this person and not try to save him. In general, these rules can be applied to any relationship, regardless of the type of person.
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