Narcissistic personality disorder

Narcissistic personality disorder (NPD) is a personality disorder.

The narcissist is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity. Narcissistic personality disorder is closely linked to self-centeredness.

Causes


The cause of this disorder is unknown, according to Groopman and Cooper. However, they list the following factors identified by various researchers as possibilities.


 * An oversensitive temperament at birth is the main symptomatic chronic form
 * Being praised for perceived exceptional looks or talents by adults
 * Excessive admiration that is never balanced with realistic feedback
 * Excessive praise for good behaviors or excessive criticism for poor behaviors in childhood
 * Overindulgence and overvaluation by parents
 * Severe emotional abuse in childhood
 * Unpredictable or unreliable caregiving from parents
 * Valued by parents as a means to regulate their own self-esteem

Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood, they may intensify to the point where NPD is diagnosed. Some psychotherapists believe that the etiology of the disorder is, in Freudian terms, the result of fixation to early childhood development. If a child does not receive sufficient recognition for their talents during about ages 3–7 they will never mature and continue to be in the narcissistic early development stage. It has been suggested that NPD may be exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes as can most personality traits.

A 1994 study by Gabbard and Twemlow reports that histories of incest, especially mother-son incest are associated with NPD in some male patients.

Theories
Pathological narcissism occurs in a spectrum of severity. In its more extreme forms, it is narcissistic personality disorder (NPD). NPD is considered to result from a person's belief that they are flawed in a way that makes them fundamentally unacceptable to others. This belief is held below the person's conscious awareness; such a person would typically deny thinking such a thing, if questioned. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognized their supposedly defective nature, such people make strong attempts to control others’ view of them and behavior towards them.

Pathological narcissism can develop from an impairment in the quality of the person's relationship with their primary caregivers, usually their parents, in that the parents were unable to form a healthy, empathic attachment to them. This results in the child conceiving of themselves as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.

Narcissistic personality disorder is isolating, disenfranchising, painful, and formidable for those living with it and often those who are in a relationship with them. Distinctions need to be made among those who have NPD because not each and every person with NPD is the same. Even with similar core issues, the way in which one's individual narcissism manifests itself in his or her relationships varies.

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others' needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen.

People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight criticism, real or imagined. To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility. In the case of feeling the lack of admiration, adulation, attention and affirmation the person can also manifest wishes to be feared and to be notorious (narcissistic supply).

Though individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements. With narcissistic personality disorder, the person's perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.

The exploitativeness, sense of entitlement, lack of empathy, disregard for others, and constant need for attention inherent in NPD adversely affect interpersonal relationships.

Relationship to shame
It has been suggested that narcissistic personality disorder may be related to defenses against shame.

Glen Gabbard suggested NPD could be broken down into two subtypes. He saw the "oblivious" subtype as being grandiose, arrogant and thick-skinned and the "hypervigilant" subtype as easily hurt, oversensitive and ashamed.

He suggested that the oblivious subtype presents a large, powerful, grandiose self to be admired, envied and appreciated. This self is the antithesis of the weakened and internalized self that hides in a generic state of shame. This is how the internalized self fends off devaluation, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers. This hypervigilant type does not fend off devaluation; he is obsessed with it.

Jeffrey Young, who coined the term "Schema Therapy", a technique originally developed by Aaron T. Beck (1979), also links shame to NPD. He sees the so-called Defectiveness Schema as a core schema of NPD, next to the Emotional Deprivation and Entitlement Schemas. All Schemas may incorporate maladaptive coping styles, for example, the defectiveness schema may include:

Note that an individual with this schema might not employ all three maladaptive coping responses.
 * Surrender: Chooses critical partners and significant others; puts him- or herself down.
 * Avoidance: Avoids sharing "shameful" thoughts and feelings with partners and significant others due to fear of rejection.
 * Overcompensation: Behaves in a critical or superior way toward others; tries to come across as perfect.

Diagnostic criteria (DSM-IV-TR = 301.81)
The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines narcissistic personality disorder (in Axis II Cluster B) as:


 * A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
 * has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
 * is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
 * believes 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)
 * requires excessive admiration
 * has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
 * is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
 * lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
 * is often envious of others or believes others are envious of him or her
 * shows arrogant, haughty behaviors or attitudes

It is also a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Diagnostic criteria (ICD-10)
The World Health Organization's ICD-10 lists narcissistic personality disorder under  Other specific personality disorders.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Millon's subtypes
Theodore Millon identified five subtypes of narcissist:. Any individual narcissist may exhibit none or one of the following:


 * unprincipled narcissist - including antisocial features. A charlatan - is a fraudulent, exploitative, deceptive and unscrupulous individual.


 * amorous narcissist - including histrionic features. The Don Juan or Casanova of our times - is erotic, exhibitionist.


 * compensatory narcissist - including negativistic (passive-aggressive), avoidant features.
 * elitist narcissist - variant of pure pattern.  Corresponds to Wilhelm Reich's "phallic narcissistic" personality type.


 * fanatic type - including paranoid features. A severely narcissistically wounded individual, usually with major paranoid tendencies who holds onto an illusion of omnipotence. These people are fighting the reality of their insignificance and lost value and are trying to re-establish their self-esteem through grandiose fantasies and self-reinforcement. When unable to gain recognition of support from others, they take on the role of a heroic or worshipped person with a grandiose mission.

Differential diagnosis
The following conditions commonly coexist (comorbid) with narcissistic personality disorder:


 * Anorexia nervosa
 * Antisocial personality disorder
 * Borderline personality disorder
 * Dysthymia
 * Histrionic personality disorder


 * Hypomania
 * Major depressive disorder
 * Paranoid personality disorder
 * Substance-related disorders (especially cocaine)

Treatment
Most psychiatrists and psychologists regard NPD as a relatively stable condition when experienced as a primary disorder. Stephen M. Johnson outlines a prominent approach to healing NPD, while discussing a continuum of severity and the kinds of therapy most effective in different cases.

Schema Therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD. It is unusual for people to seek therapy for NPD. Subconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes. Pharmacotherapy is rarely effective.

Epidemiology
Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.

History
The history of narcissism predates the discovery of narcissistic personality disorder. The term "narcissistic personality structure" was introduced by Kernberg in 1967 and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.

Proposed removal from DSM-5
The Personality and Personality Work Group has proposed eliminating NPD as a distinct disorder in DSM-5 as part of a major revamping of the diagnostic criteria for personal disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains, raising objections from some clinicians who characterize the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice.

Cultural depictions
In the film To Die For, Nicole Kidman's character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder."