DSM-5

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Narcissistic personality disorder (NPD) is a personality disorder with a long-term pattern of abnormal behaviour characterized by exaggerated feelings of self-importance, an excessive need for admiration, and a lack of empathy. People affected by it often spend a lot of time thinking about achieving power or success, or about their appearance. They often take advantage of the people around them. The behaviour typically begins by early adulthood, and occurs across a variety of social situations.

The following is a cut-down version reproduced from Wikipedia:

Symptoms

The DSM-5 indicates that persons with NPD usually display some or all of the following symptoms, typically without the commensurate qualities or accomplishments:

• Grandiosity with expectations of superior treatment from other people
• Fixated on fantasies of power, success, intelligence, attractiveness, etc.
• Self-perception of being unique, superior, and associated with high-status people and institutions
• Needing continual admiration from others
• Sense of entitlement to special treatment and to obedience from others
• Exploitative of others to achieve personal gain
• Unwilling to empathize with the feelings, wishes, and needs of other people
• Intensely envious of others, and the belief that others are equally envious of them
• Pompous and arrogant demeanor

Background

Narcissistic personality disorder usually develops in adolescence or during early adulthood. It is not uncommon for children and adolescents to display some traits similar to those of NPD, but such occurrences usually are transient, and do not meet the criteria for a diagnosis of NPD. True symptoms of NPD are pervasive, apparent in varied situations, and rigid, remaining consistent over time. The NPD symptoms must be sufficiently severe to the degree that significantly impairs the person’s capabilities to develop meaningful human relationships. Generally, the symptoms of NPD also impair the person’s psychological abilities to function, either at work, or school, or important social settings. The DSM-5 indicates that the traits manifested by the person must substantially differ from cultural norms, in order to qualify as symptoms of NPD.

Associated features

People with NPD tend to exaggerate their skills and accomplishments as well as their level of intimacy with people they consider to be high-status. Their sense of superiority may cause them to monopolize conversations and to become impatient or disdainful when others talk about themselves. In the course of a conversation, they may purposefully or unknowingly disparage or devalue the other person by overemphasizing their own success. When they are aware that their statements have hurt someone else, they tend to react with contempt and to view it as a sign of weakness. When their own ego is wounded by a real or perceived criticism, their anger can be disproportionate to the situation, but typically, their actions and responses are deliberate and calculated. Despite occasional flare-ups of insecurity, their self-image is primarily stable (i.e., overinflated).

Pathological

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others’ needs and the effects of their behavior on others, and insist that others see them as they wish to be seen. Narcissistic individuals use various strategies to protect the self at the expense of others. They tend to devalue, derogate, insult and blame others, and they often respond to threatening feedback with anger and hostility. Since the fragile ego of individuals with NPD is hypersensitive to perceived criticism or defeat, they are prone to feelings of shame, humiliation and worthlessness over minor or even imagined incidents. They usually mask these feelings from others with feigned humility or by isolating themselves socially, or they may react with outbursts of rage, defiance, or by seeking revenge. 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 defence mechanisms of denial, idealization and devaluation.

Maladaptive

According to the DSM-5, “Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic personality disorder.” Due to the high-functionality associated with narcissism, some people may not view it as an impairment in their lives. Although overconfidence tends to make individuals with NPD ambitious, it does not necessarily lead to success and high achievement professionally. These individuals may be unwilling to compete or may refuse to take any risks in order to avoid appearing like a failure. In addition, their 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 relationships with superiors and colleagues.

Causes

The causes of narcissistic personality disorder are unknown. Experts tend to apply a biopsychosocial model of causation, meaning that a combination of environmental, social, genetic and neurobiological factors are likely to play a role in formulating a narcissistic personality.

Genetic

There is evidence that narcissistic personality disorder is heritable, and individuals are much more likely to develop NPD if they have a family history of the disorder.[15][16] Studies on the occurrence of personality disorders in twins determined that there is a moderate to high heritability for narcissistic personality disorder.

However the specific genes and gene interactions that contribute to its cause, and how they may influence the developmental and physiological processes underlying this condition, have yet to be determined.

Environment

Environmental and social factors are also thought to have a significant influence on the onset of NPD. In some people, pathological narcissism may develop from an impaired attachment to their primary caregivers, usually their parents.[18] This can result 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. Overindulgent, permissive parenting as well as insensitive, over-controlling parenting, are believed to be contributing factors.

According to Leonard Groopman and Arnold Cooper, the following factors have been identified by various researchers as possible factors that promote the development of NPD:

• An oversensitive temperament (personality traits) at birth.
• Excessive admiration that is never balanced with realistic feedback.
• Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood.
• Overindulgence and overvaluation by parents, other family members, or peers.
• Being praised for perceived exceptional looks or abilities by adults.
• Severe emotional abuse in childhood.
• Unpredictable or unreliable caregiving from parents.
• Learning manipulative behaviors from parents or peers.
• Valued by parents as a means to regulate their own self-esteem.
• Cultural elements are believed to influence the prevalence of NPD as well since NPD traits have been found to be more common in modern societies than in traditional ones.

Subtypes

While the DSM-5 regards narcissistic personality disorder as a homogeneous syndrome, there is evidence for variations in its expression. In a 2015 paper, two major presentations of narcissism are typically suggested, an “overt” or “grandiose” subtype, characterized by grandiosity, arrogance, and boldness, and a “covert” or “vulnerable” subtype characterized by defensiveness and hypersensitivity. Those with “narcissistic grandiosity” express behavior “through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism.” Psychiatrist Glen Gabbard described the subtype, which he referred to as the “oblivious” subtype as being grandiose, arrogant, and thick-skinned. The subtype of “narcissistic vulnerability” entails (on a conscious level) “helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behavior as being socially avoidant in situations where their self-presentation is not possible so they withdraw, or the approval they need/expect is not being met.” Gabbard described this subtype, which he referred to as the “hypervigilant” subtype as being easily hurt, oversensitive, and ashamed. In addition, a “high-functioning” presentation, where there is less impairment in the areas of life where those with a more severe expression of the disorder typically have difficulties in, is suggested.

Theodore Millon suggested five subtypes of narcissism. However, there are few pure variants of any subtype, and the subtypes are not recognized in the DSM or ICD.

Possible additional categories not cited by the current theory of Millon might include:

Will Titshaw also suggested three subtypes of narcissistic personality disorder which are not officially recognized in any editions of the DSM or the ICD.

Comorbidity

NPD has a high rate of comorbidity with other mental disorders. Individuals with NPD are prone to bouts of depression, often meeting criteria for co-occurring depressive disorders. In addition, NPD is associated with bipolar disorder, anorexia, and substance use disorders, especially cocaine. As far as other personality disorders, NPD may be associated with histrionic, borderline, antisocial, and paranoid personality disorders.

Treatment

Narcissistic personality disorder is rarely the primary reason for people seeking mental health treatment. When people with NPD enter treatment, it is typically prompted by life difficulties or to seek relief from another disorder, such as major depressive disorder, substance use disorders, bipolar disorder, or eating disorders, or at the insistence of relatives and friends. This is partly because individuals with NPD generally have poor insight and fail to recognize their perception and behavior as inappropriate and problematic due to their very positive self-image.

Psychotherapy

Treatment for NPD is centered around psychotherapy. In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time by outlining clinical strategies for using psychoanalytic psychotherapy with clients with NPD that they claimed were effective in treating the disorder. Contemporary treatment modalities commonly involve transference-focused, metacognitive, and schema-focused therapies. Some improvement might be observed through the treatment of symptoms related to comorbid disorders with psychopharmaceuticals, but as of 2016, according to Elsa Ronningstam, psychologist at Harvard Medical School, “Alliance building and engaging the patient’s sense of agency and reflective ability are essential for change in pathological narcissism.”

Pattern Change Strategies

Pattern change strategies performed over a long period of time are used to increase the ability of those with NPD to become more empathic in everyday relationships. To help modify their sense of entitlement and self-centeredness schema, the strategy is to help them identify how to utilize their unique talents and to help others for reasons other than their own personal gain. This is not so much to change their self-perception of their “entitlement” feeling but more to help them empathize with others. Another type of treatment would be temperament change.[31] Psychoanalytic psychotherapy may be effective in treating NPD, but therapists must recognize the patient’s traits and use caution in tearing down narcissistic defenses too quickly.[citation needed] Anger, rage, impulsivity, and impatience can be worked on with skill training. Therapy may not be effective because patients may receive feedback poorly and defensively. Anxiety disorders and somatoform dysfunctions are prevalent but the most common would be depression.

Group Treatment

Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted, but group therapy can also contradict itself as the patient may show “demandingness, egocentrism, social isolation and withdrawal, and socially deviant behavior”. Researchers originally thought group therapy among patients with NPD would fail because it was believed that group therapy required empathy that NPD patients lack. However, studies show group therapy does hold value for patients with NPD because it lets them explore boundaries, develop trust, increase self-awareness, and accept feedback. Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: “…effective expression, empathy, discussion and problem solving/conflict resolution”. Marital/relationship therapy is most beneficial when both partners participate.

No medications are indicated for treating NPD, but may be used to treat co-occurring mental conditions or symptoms that may be associated with it such as depression, anxiety, and impulsiveness if present.

Prognosis

The effectiveness of psychotherapeutic and pharmacological interventions in the treatment of narcissistic personality disorder has yet to be systematically and empirically investigated. Clinical practice guidelines for the disorder have not yet been created, and current treatment recommendations are largely based on theoretical psychodynamic models of NPD and the experiences of clinicians with afflicted individuals in clinical settings.[2]

The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates.[2]

References – Wikipedia https://en.wikipedia.org/wiki/Narcissistic_personality_disorder

Other Cluster B Personality Disorders:

• Antisocial
• Borderline
• Histrionic

They are not mutually exclusive, and many people exhibit patterns of several at the same time.

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