What is Narcissistic Personality Disorder?
Narcissistic personality disorder (NPD) is a mental condition marked by excessive self-importance, a need for admiration, lacking empathy, and an inflated sense of self. People with NPD often appear boastful, arrogant, or even unlikable to others. It’s a long-lasting behavior pattern that persists in various situations, leading to significant problems in social and work settings. NPD can also coexist with other mental illnesses, which could worsen the person’s ability to function independently. Unfortunately, treatment options for NPD are limited and may not always be effective.
The concept of narcissism was first mentioned by Roman poet Ovid in his work Metamorphoses: Book III, based on the character Narcissus who fell in love with his reflection. However, the use of narcissism to describe a psychological state didn’t occur until the late 1800s. The term ‘narcissism’ was first used in psychology by Havelock Ellis in 1898, connecting the story of Narcissus with behaviors in his patients. Following that, Sigmund Freud discussed narcissistic behaviors in his book, while other psychologists contributed to understanding the condition, like Robert Waelder who authored the first report on pathological narcissism.
However, narcissistic personality disorder wasn’t officially recognized in the medical field until 1968, in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II).
In the Diagnostic and Statistical Manual of Mental Disorders, personality disorders are grouped into clusters based on shared characteristics. This includes three clusters:
- Cluster A includes personality disorders with strange or unusual characteristics, like paranoid, schizoid, and schizotypal personality disorders
- Cluster B encompasses personality disorders with dramatic, emotional, or unpredictable behaviors, such as antisocial, borderline, histrionic, and narcissistic personality disorders
- Cluster C consists of personality disorders marked by anxieties and fears, including avoidant, dependent, and obsessive-compulsive personality disorders
Regardless, the validity of this clustering system has limitations and is not always supported by scientific research.
What Causes Narcissistic Personality Disorder?
Research on the causes of Narcissistic Personality Disorder (NPD) is still limited. However, several studies suggest that NPD, along with other similar personality disorders, can be highly inherited. Certain medical conditions that can damage nerve cells, including head injuries, brain disease, tumors, epilepsy, multiple sclerosis, Huntington disease, and AIDS can also be associated with personality disorders or changes.
Psychological factors can influence personality traits and disorders. Narcissistic traits aren’t necessarily unhealthy as they are a normal part of human growth. Narcissism usually begins around age 8, increases during teenage years, and decreases in adulthood. However, individuals who exhibit high levels of narcissism during their early years often remain narcissistic as they grow older.
Psychoanalyst Wilhelm Reich introduced the concept of “character armor”, which refers to defense mechanisms that form with personality types to ease mental conflict from inner urges and personal anxiety. Those with narcissistic tendencies often have fantasy, projection, and splitting mechanisms. Negative experiences in childhood like rejection and fragile egos, can contribute to the development of NPD in adulthood. Conversely, excessive praise in childhood can lead to a lifelong need for constant approval and admiration.
Personality is a complex blend of biological, psychological, societal, and developmental factors, and so each one is unique. Personality describes an individual’s unique behavioral patterns in response to constant changes in internal and external stimuli, also known as temperament. Inherited and innate, temperament is further shaped by life experiences like trauma and socio-economic conditions. Some of the temperament traits include harm avoidance, novelty seeking, reward dependence, and persistence.
Harm avoidance refers to the tendency to avoid actions that might lead to punishment. People with NPD tend to have low harm avoidance, often ignoring the potential consequences of their actions and viewing potential gains as outweighing potential harm. People with NPD also tend to be outgoing with few social inhibitions.
Novelty seeking is the desire to seek out new experiences expected to provide a reward, and people with NPD tend to have moderate to high novelty-seeking behaviors. They tend to be easily irritated, social, and sometimes seek trends or thrills.
Reward dependence is the drive to cater behaviors in response to social reward cues. People with NPD tend to seek social approval, often demanding praise when they achieve tasks or enter into new relationships. They try to socialize, often associating with high-status individuals to get validation.
Persistence is the ability to maintain behaviors despite challenges. People with NPD can be quite persistent with an intense desire for rewards. They tend to continue with certain behaviors, especially when combined with their low harm avoidance. These individuals often strive for high social status and achievements worthy of praise.
Risk Factors and Frequency for Narcissistic Personality Disorder
Diagnosing NPD (Narcissistic Personality Disorder) can be challenging. This is because people with this disorder may not often seek out mental health evaluations. There’s also a lack of high-quality tools to measure the disorder across various populations. In the United States, the estimated amount of people with NPD in the general population varies widely – between 0% and 6.2%.
Data from a large study involving 34,653 adults (known as the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions) shows a lifetime occurrence rate of NPD to be around 6.2%. Broken down by gender, about 7.7% of men and 4.8% of women are likely to have NPD in their lives.
- NPD diagnosis can be hard, as patients may not seek mental health checks frequently.
- We need better measures for NPD that can be applied across different populations.
- In the United States, estimates for NPD vary from 0% to 6.2% of the population.
- Data from a large study shows the lifetime occurrence of NPD to be around 6.2% in general, 7.7% for men, and 4.8% for women.
Signs and Symptoms of Narcissistic Personality Disorder
Narcissistic Personality Disorder (NPD) can vary greatly in how it shows up in different people. People with NPD typically discuss things from a self-centered point of view and may demand special treatment. For instance, in a doctor’s office, they may act friendly towards people they see as important, but be mean to others they see less important. They may brag about their accomplishments or their well-known friends. It can be very hard for them to handle criticism and they may often become angry.
- Self-centered
- Demanding of special treatment
- Friendly towards high-status individuals
- Mean towards less significant people
- Brag about accomplishments or friends
- Difficulty handling criticism
- Generally become enraged when criticized
When looking back at their past relationships, you might find they’ve had strained relationships and have become more isolated as they got older. This might be because it’s tough for others to maintain a friendship with someone with NPD. They may have a history of legal charges due to not following rules, as they may believe rules don’t apply to them. They usually show little empathy when discussing failed relationships. Even though they may deny feeling sad or weak, symptoms of depression might be present because of an ego that is easily bruised and their difficulties in relating to others at work or socially.
When evaluating someone for NPD, a few things are worth noting:
- Appearance: Attention-getting clothing, accessories, hairstyles, or tattoos might suggest NPD.
- Behavior: Look out for uncontrolled behaviors, arrogance, smirking, and scoffing. Their willingness to cooperate may change depending on who they are interacting with.
- Speech: They may talk more, trying to prove themselves or brag, but there’s usually no issue with starting speech, volume, or vocabulary.
- Affect: Their emotions may fluctuate dramatically, especially when they feel challenged. More instability and irritability are common.
- Thought content: It’s essential to check for delusions. Grandiose thinking might be non-delusional or delusional. This doesn’t affect the treatment but can help to understand how severe the NPD is.
- Thought process: People with NPD tend to have one-track minds, centered on their greatness. They are still capable of logical thinking, especially when it serves their purposes.
- Cognition: There’s usually no issue with general cognition and orientation, but these should still be evaluated.
- Insights: People with NPD typically have trouble recognizing their disorder. Acceptance of self-deficit is typically not in line with NPD.
- Judgment: The severity of NPD can impact a person’s judgment. This can often be gauged by delving into a patient’s legal and relationship histories.
- Impulse control: People with NPD typically have poor impulse control, due to a high need for reward and low fear of negative consequences. This can also be assessed by reviewing past legal and relationship histories.
Testing for Narcissistic Personality Disorder
Diagnosing a personality disorder, like Narcissistic Personality Disorder (NPD), isn’t an easy or quick process. It requires monitoring a patient’s behavior over time and across different situations to get a wider view of how they function long-term. It’s important to remember that symptoms of a personality disorder can often be seen during another mental health problem. So, it’s best to make a diagnosis when no other mental health issues are happening at the same time, if possible.
However, some patients could have a personality disorder that worsens another mental health problem. For such cases, the personality disorder diagnosis could be made earlier. Nevertheless, it might take several interactions with a patient to establish a concrete diagnosis of NPD.
It’s common for patients with certain types of personality disorders to transfer their past conflicts onto their doctor. This is called transference. The opposite can also be true, where the doctor starts transferring their unresolved conflicts onto the patient, known as counter-transference. This often happens because patients with personality disorders can sometimes be aggressive or rude.
It’s crucial for doctors to realize when they’re displaying counter-transference to avoid any biases that could affect the patient’s care. A psychological defense mechanism called sublimation can be helpful here. This means transforming unwanted or unhelpful feelings into less harmful or useful ones. If doctors start feeling frustrated with their patients, they can use this feeling as a tool to guide their diagnosis towards a personality disorder, which in turn can help shape the treatment plan.
There are several structured interviews and questionnaires to aid in diagnosing NPD. One of these, called the Kernberg’s structured clinical interview, has been improved many times since its creation in 1981. It now includes questions about personality organization, defenses, coping skills, and interpersonal relationships. Keep in mind, this interview is based on psychodynamic principles and is best used by those with training in psychoanalytic work.
Other tools can help determine how severe a patient’s NPD is. The five-factor narcissism inventory assesses five main personality traits with about 148 questions. The Narcissistic Personality Inventory can be another useful tool. The diagnosis should be based on a variety of sources including personal history, collateral information, mental status examination, and psychometric tools. The patient must also meet the NPD criteria in the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders).
This manual lists several behaviors that are characteristic of NPD, such as a pattern of grandiosity, a need for admiration, and lack of empathy. This usually starts in early adulthood and persists across different contexts. At least five clinical features are needed for a diagnosis, including a grandiose sense of self-importance, preoccupation with success and power, belief of being “special,” craving excessive admiration, a sense of entitlement, using others, lack of empathy, jealous of others, and displaying arrogant behaviors.
Treatment Options for Narcissistic Personality Disorder
People with Narcissistic Personality Disorder (NPD) often don’t recognize their condition because it aligns with their self-perception. They usually seek help at the urging of a close relative or friend, often after their behavior has caused stress to others, not themselves. This is why it’s crucial to assess what treatment goals may be best for each specific case of NPD. Since NPD typically doesn’t improve on its own, treatment usually focuses on reducing conflict with others and improving social functioning.
Medication doesn’t usually help treat NPD unless the person also has a separate mental health condition, and there are currently no FDA-approved medications for treating NPD. Psychotherapy, or talk therapy, is likely the preferred treatment for NPD, although the evidence supporting it is mixed. ‘Transfered-focused therapy’, a specific type of therapy, may be more successful than others. People with NPD may also benefit from case management, which can provide support with income, housing, access to medical and mental health services, and other basic needs.
What else can Narcissistic Personality Disorder be?
Narcissistic Personality Disorder (NPD) should be considered if a person has a long-term pattern of rigid behaviors that are consistent across different situations and stimuli. It’s important to note that many behaviors related to NPD can also be symptoms of other mental health conditions. This means it’s crucial to determine if NPD is the only condition present, or if it exists alongside another mental health disorder.
For instance, some common symptoms like grandiosity, irritability, and high activity levels can also be seen during manic or hypomanic episodes in people with bipolar disorders. However, people with just NPD don’t usually have a reduced need for sleep. Furthermore, manic and hypomanic episodes are typically short-lived and can be relieved with medication, while NPD is a long-term, rigid condition that often doesn’t respond well to medication.
Other mental health conditions that can be mistaken for NPD include other “cluster B” personality disorders such as antisocial, histrionic, and borderline personality disorders. People with NPD don’t tend to display the impulsivity and self-destructive behaviors associated with borderline personality disorder. Also, unlike individuals with a histrionic personality disorder, they don’t often show overt emotional responses.
Antisocial personality disorder can sometimes seem similar to NPD due to shared traits like a lack of empathy and charming surface behavior. However, those with antisocial personality disorder typically lack a moral code, unlike those with NPD, and they often have had previous diagnoses of conduct disorder during their teenage years.
What to expect with Narcissistic Personality Disorder
Studies on narcissistic personality disorder (NPD) are limited, but most experts agree that it typically lasts a lifetime. Research using relatively old criteria found that people with NPD were less likely to have long-term difficulties in overall functioning compared to those with schizoid, antisocial, borderline, histrionic, and avoidant personality disorders.
Even though NPD might not completely go away on its own or with treatment, interventions aimed at improving the quality of life can help. These include measures to decrease related mental health issues and stabilize social circumstances, which are likely to improve the outlook for people with NPD.
Possible Complications When Diagnosed with Narcissistic Personality Disorder
Substance use disorders can often be seen with personality disorders. However, it’s still unclear which specific personality disorders are most likely to lead to a certain type of substance use disorder. It’s also worth noting that people with personality disorders show a higher risk of suicide and suicide attempts compared to those without such disorders. Particularly, individuals with Narcissistic Personality Disorder (NPD) require regular screening for signs of suicidal thoughts.
Key Facts:
- Substance use disorders are often seen with personality disorders.
- The connection between specific personality disorders and specific substance use disorders is not well understood.
- People with personality disorders have a higher risk of suicide and suicide attempts.
- Individuals with Narcissistic Personality Disorder (NPD) should frequently be checked for suicidal thoughts.
Preventing Narcissistic Personality Disorder
Treating Narcissistic Personality Disorder (NPD) heavily rests on building and preserving a trusting relationship, especially since these individuals might be extremely sensitive to suggestions or advice. Instead of doctors focusing solely on reducing unhealthy behaviors, patients are advised to openly share their symptoms or any societal or emotional stress they wish the medical team to help reduce.
Moreover, patients are urged to make good use of supportive relationships they still have. Including the patient’s family is also beneficial for monitoring the patient’s progress and teaching them how to provide consistent social support. Using standard measures to evaluate their quality of life can point out opportunities to better enhance their ability to cope in essential aspects of life.