Basics

Description

• A personality disorder (PD) is best understood as a disorganization of the capacity for affect regulation, mediated by dysfunction in early attachments.
• Narcissism is characterized as a Cluster B PD. It is defined as an enduring pattern of inflexible and maladaptive behaviors/traits that cause either significant impairment in social or occupational functioning or subjective distress. The features of narcissistic personality disorder (NPD) are 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 (see Diagnosis).

Epidemiology

Incidence

• Predominant age: Early adulthood
• Predominant sex: Male > Female (50–75%)

Prevalence

The lifetime prevalence rate is ∼0.5–1% among the general population; however, the estimated prevalence in clinical settings is ∼2–16%.

Etiology

It is postulated that NPD (and all PDs) result from an impairment in the quality of the interpersonal relationship with the primary caregiver. This leads to dysregulation in affect and subsequent inability to achieve homeostasis after a traumatic (or perceived traumatic) event. Through secure attachments, an infant learns how to balance the sympathetic hyperarousal (fight or flight) that occurs in response to a threat with the homeostasis-restoring parasympathetic response. Insecure attachments will leave the infant with an inability to balance the 2 states, causing him to have hyperarousal in response to a threat or the production of an inadequate parasympathetic response. Secure attachments lead to development of the building blocks needed to self-regulate later in life.

Commonly Associated Conditions

• It’s been noted that having a personality disorder during the formative years increases the individual’s risk of developing mood disorders, anxiety, substance abuse, or exhibiting self-harm behaviors in adult life.
• Bipolar disorder
• Depression
• Obsessive-compulsive disorder
• Substance abuse

Diagnosis

History

• Must rule out other general medical conditions or other psychiatric illnesses; it has been suggested that the disorder has 2 subgroups, the better-known grandiose subgroup and the hypervigilant subgroup (1).
• Grandiose subgroup (essential features):
  • Superiority: Grandiose sense of self-importance. These individuals exaggerate achievements and talents to the point of lying; they demand to be recognized as superior without commensurate achievements.
  • Grandiose fantasies and preoccupation with beauty, brilliance, ideal love, power, or unlimited success
  • Uniqueness: Possess the belief of being special and unique, and can only be understood by or can only associate with people of high status
  • Requires excessive admiration
  • Sense of entitlement: Possesses unreasonable expectation of being treated with favor or expecting an automatic compliance with their wishes. They will use others to achieve their goals.
  • Lack of empathy: These individuals are unable or unwilling to identify with or acknowledge the feelings and needs of others.
  • Envy: These individuals believe that others are envious of them or are envious of others.
  • Exhibit arrogant or haughty attitudes/behaviors
  • High achievement: These individuals often have periods of success (e.g., academic, employment, or social), which may only serve to verify their sense of superiority.
  • This grandiose subtype presents the grandiose self to be admired, envied, and appreciated to combat feelings of devaluation and shame felt by the weaker internalized self.
• Hypervigilant subtype (essential features):
  • Easily hurt, overly sensitive, and ashamed
  • This subtype, rather than fighting devaluation and shame, is consumed with it and defends against it by seeing others as their unjust abusers (1,2).

Diagnostic Tests & Interpretation

Patients can be evaluated for NPD using the Diagnostic Interview for Narcissism (3)[A].

Differential Diagnosis

• Other PDs are often confused with NPD due to their common features (4):
  • Histrionic, antisocial, and borderline PDs also possess the indifferent, callous, and often needy characteristics. NPD can be distinguished by the grandiosity characteristic.
  • The relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help to distinguish NPD from borderline PD.
  • Borderline, histrionic, and NPD individuals require attention; however, NPD individuals require that attention to be admiring.
  • Individuals with antisocial and NPD tend to be self-centered, superficial, exploitative, and unempathetic. However, individuals with NPD do not necessarily show characteristics of impulsivity, aggression, and deceit, and usually do not give the same history of conduct disorder or criminal behavior.
  • Individuals with both NPD and obsessive-compulsive PD have a goal of perfectionism and believe that others cannot do things as well. But NPD individuals often believe that they have achieved perfection.
  • NPD individuals may exhibit suspiciousness and social withdrawal similar to schizotypal or paranoid PD; however, when present with NPD, these emotions are usually derived from fears of having their imperfections or flaws revealed.
• Traumatic brain injury
• Central nervous system tumor/infection
• Dementia
• Delirium
• Substance abuse: NPD also must be distinguished from symptoms that may develop in association with chronic substance use (e.g., cocaine-related disorder).

Geriatric Considerations

Exacerbated by aging due to the inability to adapt to the physical, mental, and occupational restrictions age imposes, leading to depression

Treatment

Medication

• Individuals with NPD are vulnerable to severe depression, particularly when their superiority is challenged or with maladaptation to the effects of aging.
• Antidepressant medication may be needed:
  • Selective serotonin reuptake inhibitors (SSRIs) have been used to reduce target symptoms of interpersonal reactivity (5)[B].

Additional Treatment

General Measures

• Individual and group psychotherapy is offered for NPD, with only anecdotal reports of success. Regardless of the modality the goals should be to engage the patient, establish methods of crisis stabilization, and solidify the importance of long-term counselling. The different forms of therapy available are:
  • Psychodynamic therapy, to increase reflective capacity and emotional and interpersonal understanding (6)[A]
  • Cognitive-behavioral therapy, designed to alter dysfunctional core beliefs (6)[A]
  • Dialectical behavioral therapy (6)[A]
  • Therapeutic community, used to effect attitudinal and behavioral change (6)[A]
  • Cognitive-analytic therapy, designed to achieve greater self-understanding (6)[B]
  • Behavioral therapy, designed to improve maladaptive behaviors (6)[C]
• Individuals with NPD usually come for therapy with presenting issues other than the aforementioned diagnostic features—most often for depression and anxiety (7).
• They often see the difficulties that they have with others as external and independent of their behavior. Their depression is often precipitated by situations that challenge the narcissistic grandiosity and reflects the discrepancy between NPD expectations or fantasies and reality.
• Individuals with NPD may have trouble entering treatment because they associate needing help as demeaning and unacceptable.
• If the situation becomes severe enough, however, they will seek treatment in order to reestablish feelings of superiority and achievement.
• Therapy is often complicated by narcissists’ view of themselves. Their past, their current situation, and what they need from treatment all will be distorted by their need for acknowledgment of their superiority. They will resist feedback and may reject treatment if they are not sufficiently affirmed:
  • NPDs chronically devalue those around them and demonstrate little empathy, thereby setting up potential countertransference situations with health care providers.
  • The return to comfort for individuals with NPD may be all they are seeking, and they will leave treatment prematurely.
  • Treatment also can be complicated by concomitant depression.
• Treatment can fail in terms of psychotherapy when consideration of possible substance abuse is ignored.

Issues for Referral

• Refer for individual or group therapy, if the patient is willing.
• May need a psychiatrist for associated severe depression

Ongoing Care

Patient Education

The National Institute of Mental Health (NIMH) at http://www.nimh.nih.gov

Prognosis

The prognosis for an adult suffering from NPD is poor, although the person’s adaptation to situations and relationships can improve with treatment.

Complications

• Family and relationship dysfunction
• Alcohol and other substance abuse. No single pattern of substance use or abuse can be identified for NPD; however, cocaine, as a high-status drug, is particularly attractive to the narcissist.
• Major depressive disorder
• Dysthymia
• Obsessive-compulsive behaviors
• Eating disorders (particularly in young women)

References

1. Gabbard GO. Two subtypes of narcissistic personality disorder. Bull Menninger Clin. 1989;53:527–32.

2. Ronningstam E, Gunderson J. Identifying criteria for narcissistic personality disorder. Am J Psychiatry. 1990;147:918–22.

3. Gunderson JG, Ronningstam E, Bodkin A. The diagnostic interview for narcissistic patients. Arch Gen Psychiatry. 1990;47:676–80.

4. American Psychiatric Association. DSM-IV-TR 2000: Diagnostic & Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Publishing, 2000.

5. Sperry L. Handbook of Diagnosis and Treatment of the DSM-IV Personality Disorders. New York: Brunner/Mazel, 1995.

6. Bateman A, et al. Psychological treatment for personality disorders. Adv Psychiatr Treat. 2004;10:378–88.

7. Beck AT, et al. Cognitive Therapy of Personality Disorders. New York: Guilford, 1990.

Additional Reading

Brunton JN, Lacey JH, Waller G. Narcissism and eating characteristics in young nonclinical women. J Nerv Ment Dis. 2005;193:140–3.

Fonagy P, et al. Morality, disruptive behavior, borderline personality disorder, crime, and their relationship to security of attachment. In: Atkinson L, et al., eds. Attachment and Psychopathology. New York: Guilford, 1997:233–77.

Codes

ICD9

301.81 Narcissistic personality disorder

Snomed

80711002 Narcissistic personality disorder (disorder)

Clinical Pearls

• The relative stability of self-image as well as the lack of self-destructiveness, impulsivity, and abandonment concerns help to distinguish NPD from borderline PD.
• Borderline, histrionic, and NPD patients all require attention; however, NPD individuals require that attention to be admiring.
• Individuals with NPD and obsessive-compulsive PD have a goal of perfectionism and believe that others cannot do things as well, but NPD individuals often believe that they have achieved perfection.
• Individuals with NPD are vulnerable to severe depression, particularly when their superiority is challenged or with maladaptation to the effects of aging. Antidepressant medications such as SSRIs may be useful.