| Narcissistic personality disorder | |
|---|---|
| Classification and external resources | |
Narcissus by Caravaggio. Narcissus gazing at his own reflection. |
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| ICD-10 | F60.8 |
| ICD-9 | 301.81 |
| MeSH | D010554 |
Narcissistic personality disorder (NPD) is a personality disorder[1] in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity.[2] Narcissistic personality disorder is closely linked to egocentrism.
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Symptoms of this disorder include, but are not limited to:
The symptoms of Narcissistic personality disorder can be similar to the traits of individuals with strong self-esteem and confidence, differentiation occurs when the underlying psychological structures of these traits are considered pathological. Narcissists have such an elevated sense of self-worth that they value themselves as inherently better than others. Yet, they have a fragile self-esteem and cannot handle criticism, and will often try to compensate for this inner fragility by belittling or disparaging others in an attempt to validate their own self-worth. It is this sadistic tendency that is characteristic of narcissism as opposed to other psychological conditions affecting level of self-worth. [4]
The cause of this disorder is unknown, according to Groopman and Cooper. However, they list the following factors identified by various researchers as possibilities:[5]
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.[6] Some psychotherapists believe that the etiology of the disorder is, in Freudian terms, the result of fixation to early childhood development.[7]
A 1994 study by Gabbard and Twemlow[8] reports that histories of incest, especially mother-son incest, are associated with NPD in some male patients.
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.[9] This belief is held below the person's conscious awareness; such a person would, if questioned, typically deny thinking such a thing. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognised their (perceived) defective nature, such people make strong attempts to control others’ views 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 and empathic attachment to them. This results in the child's perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.[10]
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.[11]
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.[12] To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility. In cases where the narcissistic personality-disordered individual feels a lack of admiration, adulation, attention and affirmation, he/she may also manifest a desire to be feared and to be notorious (narcissistic supply).
Although 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.[13] With narcissistic personality disorder, the individual's self-perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.
People who are diagnosed with narcissistic personality disorder use splitting as a central defense mechanism. According to psychoanalyst Kernberg, “the normal tension between actual self on the one hand, and ideal self and ideal object on the other, is eliminated by the building up of an inflated self concept within which the actual self and the ideal self and ideal object are confused. At the same time, the remnants of the unacceptable images are repressed and projected onto external objects, which are devalued.”[14] The merging of the "inflated self concept" and the "actual self" is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defense mechanisms of devaluation, idealization and denial.[15] Other people are either manipulated as an extension of one's own self, who serve the sole role of giving "admiration and approval"[16] or they are seen as worthless (because they are unable to collude with the narcissist's grandiosity).[17]
It has been suggested that narcissistic personality disorder may be related to defenses against shame.[18]
Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes.[19] He saw the "oblivious" subtype as being grandiose, arrogant, and thick-skinned and the "hypervigilant" subtype as being easily hurt, oversensitive, and ashamed. In his view, the oblivious subtype presents for admiration, envy, and appreciation a powerful, grandiose self that is the antithesis of a weak internalized self, which hides in shame, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers.
Dr. Jeffrey Young, who coined the term "Schema Therapy", a technique originally developed by psychiatrist Aaron T. Beck (1979), also links NPD and shame. He sees the so-called Defectiveness Schema as a core schema of NPD, along with the Emotional Deprivation and Entitlement Schemas.[20]
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:[1]
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.
The Personality and Personality Disorders Work Group has proposed[21] the elimination of NPD as a distinct disorder in DSM-5[22] as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains. Some clinicians have objected, characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice.[23]
The World Health Organization's ICD-10 lists narcissistic personality disorder under (F60.8) Other specific personality disorders.[24]
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Theodore Millon identified five subtypes of narcissist.[2][25] Any individual narcissist may exhibit none or one of the following:
Alexander Lowen has also specified five major subtypes from Phallic ("Skirtchasing") to Sociopathic (i.e., dissociative, capable of mayhem and murder) as outlined in his famous book, "Narcissism: Denial of the True Self".
Prominent clinical strategies are outlined by Heinz Kohut, Stephen M. Johnson and James F. Masterson, while Johns[10] discusses 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.[26] It is unusual for people to seek therapy for NPD. Unconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes.[27][28] Pharmacotherapy is rarely effective.
Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.[5][29]
Twenge and Campbell conducted studies suggesting that the incidence of NPD has more than doubled in the US in the last 10 years and now 1 in 16 of the population have experienced NPD.[30]
The history of narcissism predates the discovery of narcissistic personality disorder. The term "narcissistic personality structure" was introduced by Kernberg in 1967[31] and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.[32]
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."[33]
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