Those with a narcissistic personality disorder are likely to be preoccupied with:
Practice EssentialsNarcissistic personality disorder (NPD) is a cluster B personality disorder defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy. Show Signs and symptomsIn the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), [1] NPD is defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of the following 9 criteria:
In a proposed alternative model cited in DSM-5, NPD is characterized by moderate or greater impairment in personality functioning, manifested by characteristic difficulties in 2 or more of the following 4 areas [2] :
In addition, NPD is characterized by the presence of both grandiosity and attention seeking. NPD is not associated with any specific defining physical characteristics; however, physical consequences of substance abuse, with which NPD is often associated, may also be apparent on examination. Mental status examination may reveal depressed mood. Patients in the throes of narcissistic grandiosity may display signs of hypomania or mania. See Presentation for more detail. DiagnosisNPD must be distinguished from the other 3 cluster B personality disorders, which are as follows:
Patients with NPD may also meet criteria for separate axis I diagnoses. Alternatively, patients with only NPD may at times have symptoms that mimic those of axis I disorders. No specific laboratory studies are employed to diagnose NPD; however, it is wise to obtain a toxicology screen to rule out drugs and alcohol as possible causes of the pathology. Although there is some debate regarding their usefulness and reliability, personality tests such as the following may be administered to help elucidate character pathology and facilitate the diagnosis of NPD:
See Workup for more detail. ManagementLong-term, consistent outpatient care is the treatment approach of choice, usually involving a combination of psychotherapy and medication management. Options for psychotherapy include the following:
If the patient acutely decompensates or becomes a danger to self or others, inpatient treatment (for as short a period as possible) is warranted No psychiatric medications are tailored specifically toward the treatment of NPD. Nevertheless, patients with this disorder often benefit from the use of psychiatric medications to help alleviate certain symptoms associated with the disorder or to manage concomitant axis I diagnoses. Agents that may be indicated include the following:
See Treatment and Medication for more detail.  BackgroundNarcissistic personality disorder (NPD) is 1 of the 10 clinically recognized personality disorders listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition (DSM-5). It belongs to the subset of cluster B personality disorders, which are those marked by an intense degree of drama and emotionality. Historically, there has been much debate surrounding the exact definition of NPD, and competing theories exist regarding its etiology and optimal treatment. Diagnostic criteria (DSM-5)In DSM-5, NPD is defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of the following 9 criteria: [1]
These official diagnostic criteria are unchanged from the previous DSM edition. It should be noted, however, that there is currently a general inclination away from a strict criterion-based approach to diagnosis and toward a more “dimensional” model, as outlined in section III of DSM-5 (“Emerging Measures and Models”). In the subsection of section III entitled “Alternative DSM-5 Model for Personality Disorders,” NPD is newly characterized on the basis of (1) impairment in personality functioning and (2) pathologic personality traits. [2] Specifically, in this proposed new model, NPD is characterized by moderate or greater impairment in personality functioning, manifested by characteristic difficulties in 2 or more of the following 4 areas [2] :
In addition, NPD is characterized by the presence of both of the following pathologic personality traits [2] :
Pathophysiology and EtiologyThe exact mechanism by which NPD develops is unknown. Biologic, psychological, social, and environmental factors all probably play a role, but further research is necessary to confirm this supposition. Several psychodynamic theories point to an unhealthy early parent-child relationship as salient in the development of the disorder. To date, no genetic links to the disorder have been determined, but future research into the biologic basis of personality disorders may yield more information on the origins of NPD. From a psychoanalytic standpoint, the 2 main schools of thought regarding the origins of the disorder are the object-relations model described by Otto Kernberg and the self-psychology model developed by Heinz Kohut. Both models posit that an inadequate relationship between parent and child lays the groundwork for the eventual development of NPD. According to Kernberg, NPD is the result of a young child having an unempathetic and distant mother who is hypercritical and devaluing of her child. [3] As a defense against this perceived lack of love and to guard against emotional pain, the child creates an internalized grandiose self. Kernberg believed that this grandiose self was a combination of the following 3 elements:
In keeping with the object-relations model, on which Kernberg based much of his theory, the child eventually splits off the unlovable and needy image of himself or herself and relegates it to the unconscious, where it later forms the basis for the fragile self-esteem and sense of inferiority present in NPD. [3] By contrast, Heinz Kohut felt that NPD was the result of a developmental arrest in normal psychological growth. [3] He maintained that narcissism is a natural feature of the young child, who is bound to think of himself or herself as the center of the universe. According to Kohut, through the twin processes of mirroring (whereby the parent provides appropriate praise) and idealization (whereby the child effectively internalizes positive parental images), a child without narcissism can temper his or her former sense of being the center of the universe. However, if the parents do not offer effective mirroring or do not provide a basis for idealization, the child will be stuck with his or her initial grandiose, wholly unrealistic sense of self, and this developmental arrest will eventually lead to NPD. [3] EpidemiologyUnited States statisticsIt is estimated that NPD is present in 0.5% of the general United States population [4] and in 2-16% of those who seek help from a mental health professional. NPD is found in 6% of the forensic population, [5, 6] in 20% of the military population (the actual disorder as well as narcissistic traits), [7, 8, 6] and in 17% of first-year medical students. [9, 6] International statisticsOutside the United States, NPD is not recognized as a separate diagnostic entity. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) lists only 8 personality disorders (as opposed to the 10 found in DSM-5). What DSM-5 defines specifically as NPD falls under the ICD-10 heading of “Other Specific Personality Disorders” or “eccentric, impulsive-type, immature, passive-aggressive, and psychoneurotic personality disorders.” [10] Age-, sex-, and race-related demographicsNPD manifests by young adulthood (early to middle 20s) and may worsen in middle or old age as a consequence of the onset of physical infirmities or declining physical attractiveness. (In addition to feeling intellectually and socially superior to others, people who are narcissistic are often quite vain regarding their physical appearance.) Narcissistic traits can be exhibited by typical adolescents who are unlikely to go on to develop NPD. NPD is more commonly found in males than in females; of those diagnosed with the disorder, approximately 75% are male. No racial or ethnic predilection has been identified. PrognosisThe natural history of NPD, like those of all personality disorders, is unfavorable, and the condition is typically lifelong. However, many patients can and do show improvement with appropriate treatment. Research also suggests that corrective life events, such as new achievements, stable relationships, and manageable disappointments, can lead to considerable improvement in the level of pathologic narcissism over time. [11] Patients diagnosed with NPD are more likely to have comorbid axis I diagnoses, such as major depressive disorder, bipolar disorder, substance-related disorders (specifically related to cocaine and alcohol), anxiety disorders, and anorexia nervosa. [12, 13] Patient EducationIt is important to educate patients with NPD about the signs and symptoms of the disorder and explain to them in a supportive way that their behavior is a result of many different factors. During this psychoeducational phase of treatment, it is helpful to present patients with relevant reading material so that they may become aware of how the diagnosis specifically applies to them. [14] There are a myriad of Web sites for patients seeking lay information about NPD, of which the following are representative examples: In addition, the following resources are available to patients who may have questions about NPD: Family education is also important, in that relatives and loved ones of people with NPD are often profoundly affected by the illness as well. The following books may be helpful for those who may be in close contact with people who have NPD:
Author Sheenie Ambardar, MD Adult Psychiatrist, Private Practice Sheenie Ambardar, MD is a member of the following medical societies: American Psychiatric Association Disclosure: Nothing to disclose. Chief Editor Acknowledgements Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Acknowledgments Dr. Ambardar would like to thank Dr. Donald C. Fidler, Farnsworth Endowed Chair of Psychiatric Education at West Virginia University, for generously granting permission to use his video clip in the multimedia section of this article. |
