Narcissistic personality disorder (NPD) is a complex andheterogeneouspersonality disorder characterized by patterns ofgrandiosity,entitlement, low empathy, and interpersonal difficulties, which can manifest as either grandiose (“thick-skinned”) or vulnerable (“thin-skinned”) forms.[1][2] Grandiose individuals displayarrogance,social dominance, and exploitative behaviors, while vulnerable individuals show shame,inferiority,hypersensitivity, and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement. It is often comorbid with other mental disorders and associated with significant functional impairment andpsychosocialdisability.[1]
There is no standard treatment for NPD.[5][6] Its high comorbidity with other mental disorders influences treatment and outcomes.[5]Psychotherapeutic treatments generally fall into two categories:psychoanalytic/psychodynamic andcognitive behavioral therapy, with growing support for integration of both in therapy.[7][8] However, there are few studies on the effectiveness of treatments.[6] Treatment is frequently not sought; one's subjective experience of the mental disorder, as well as one's agreement to and level of engagement with treatment, are highly dependent on one's motivation to change.[9]
NPD’setiology is thought to be largely genetic and neurobiological, with structural and functional brain differences in areas related to self-processing and empathy. Assessment tools such as theNarcissistic Personality Inventory or Pathological Narcissism Inventory can help differentiate subtypes. NPD has historical roots inpsychoanalytic theory and remains a subject of controversy in psychiatric classification, while its manifestations continue to appear in literature and media as exemplars of extreme self-focus and entitlement.
Signs and symptoms
Individuals with narcissistic personality disorder may be grandiose or self-loathing, extraverted or socially isolated, captains of industry or unable to maintain steady employment, model citizens or prone to antisocial activities.[10]
NPD is complex and far from uniform in its presentation and consequences. Empirical evidence suggests several subtypes of NPD may exist (see the Subtypes section below), but in general, the disorder is known to have grandiose ("thick-skinned") and vulnerable ("thin-skinned") expressions.[10]
Grandiose, thick-skinned NPD patients show a sense of uniqueness or superiority, attitudes of entitlement, a belief that others envy their abilities or status, low empathy, social dominance, superficial charm, disdainfulness or snobbery, and an exploitative interpersonal style characterised by manipulation and selfishness.
Vulnerable, thin-skinned individuals with NPD also show entitlement, selfishness and low empathy, but uniquely, they demonstrate feelings of shame and inferiority, are envious of others' abilities or status, tend to be shy, paranoid, vindictive, and emotionally dependent on admiration, and show extreme rage and hostility in response to rejection and criticism.[11]
While vulnerable-type patients typically show extreme distress and dysfunction, grandiose variants tend to be associated withgreater psychological wellbeing,[12][13] often manifesting dysfunction by occupational conflict, harming others, antisocial behaviour or emotional strain resulting from perfectionism.[10][12][14][15]
It is often theorised that some patients may oscillate between grandiosity and vulnerability.[16] While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity,[16][17] most studies show the vulnerable individuals show occasional bouts ofgrandiosity, narcissistically grandiose individuals show few or no signs of vulnerability.[18][19][20][21]
Other features
NPD patients may have difficulty accepting help.[22] They may also exhibitvengeful fantasies,[23][24] as well as violent and antisocial behaviour.[25][15] They are more likely to try forms ofplastic surgery due to a desire to gain attention and to be seen as beautiful.[26][27]
Patients with NPD have an impaired ability to recognize facial expressions or mimic emotions, as well as a lower capacity foremotional empathy andemotional intelligence[28][29] but preserved capacity for cognitive empathy or an impairedtheory of mind.[30] People with NPD are less likely to engage inprosocial behavior.[31] They can still act in selfless ways to improve others' perceptions of them, advance theirsocial status, or if explicitly told to.[32] Despite these characteristics, they are more likely to overestimate their capacity for empathy.[33] Recent work, however, suggests narcissistic empathy deficits may be resolved (at least in part) by instructed perspective-taking.[34]
It is common for people with NPD to have difficult relationships.[35][36][37][38] They may disrespect others' boundaries oridealize and devalue them. They commonly keep people emotionally distant, andproject, deny,[39] orsplit. NPD individuals manifesting vulnerability tend to become enraged when rejected or criticised,[35][40][41] and may degrade, insult, or blame others who disagree with them.[42][43]
NPD may be associated with reduced insight into symptoms, especially in severe cases.[44] However, work on lower levels of narcissism suggests such individuals are not only aware of their traits but see them in a positive light, and strive to maintain them over time.[45] Given the high-function sociability associated withnarcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives.[46]
Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they refuse to take risks, in order to avoid failure or the appearance of failure.[2][27] Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism makes it difficult for persons with NPD to work cooperatively or to maintain long-term relationships.[47]
Causes
Aetiology
The cause of narcissistic personality disorder (NPD) is unclear, although there is evidence for a strong biological or genetic underpinning.[48][49][50][51] It is unclear if or how much a person's upbringing contributes to the development of NPD, although many speculative theories have been proposed.[48][52][53][54]
Evidence to support social factors in the development of NPD is limited.[48][54] Some studies have found NPD correlates with permissive and overindulgent parenting in childhood, while others have found correlations with harsh discipline, neglect or abuse.[48] Findings have been inconsistent, and scientists do not know if these correlations arecausal, as these studies do not control for geneticconfounding.[48][54]
This problem of genetic confounding is explained by psychologistSvenn Torgersen in a 2009 review:[54]
If parents treat their children badly, and the children develop personality disorders, it does not necessarily mean that the treatment of the children is the cause of the development. An alternative explanation may be that the parents themselves have some personality disorder traits, partly due to genes. These genetically influenced traits correlate with poor parenting, explaining the genetic influence on parenting. The children inherit the genes and subsequently develop personality disorders. The personality disorders might thus have developed in any case, independent of the childhood conditions.[54]
Twin studies allow scientists to assess the influence of genes and environment, in particular, how much of the variation in a trait is attributed to the "shared environment" (influences shared by twins, such as parents and upbringing) or the "unshared environment" (measurement error, noise, differing illnesses between twins, randomness in brain growth, and social or non-social experiences that only one twin experienced).[55][56][54] According to a 2018 review, twin studies of NPD have found little or no influence from the shared environment, and a major contribution of genes and the non-shared environment:[49]
Taken together, these studies have consistently demonstrated that genetic influence constitutes a major source of NPD. Non-shared environments also exert substantial influence on NPD. Notably, shared environments had no significant influence on NPD in any of these studies.
According to neurogeneticist Kevin Mitchell, a lack of influence from the shared environment indicates that the non-shared environmental influence may be largely non-social, perhaps reflecting innate processes such as randomness in brain growth.[56]
Pathophysiology
Neuroscientists have also studied the brains of people with NPD using structural imaging technology.[57] A 2021 review concluded the most consistent finding among NPD patients is lowered gray matter volume in themedial prefrontal cortex, previously associated with self-enhancement tendencies.[57] Studies of the occurrence of narcissistic personality disorder identified structural abnormalities in the brains of people with NPD, specifically, a lesser volume ofgray matter in the left, anteriorinsular cortex.[58] The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in theprefrontal cortex.[59] It has been suggested that empathic dysfunction and selfish behaviour in NPD may result from dysfunction in the brain'ssalience network (SN; consisting of the anterior insula and cingulate cortices), which switches between internally- and externally-focused cognition, to inhibit thedefault mode network (DMN), involved in self-related information-processing, during social interactions resulting in continued self-focus even when interacting with distressed others.[60] Consonantly, excessive selfishness in NPD appears to be related to decreased ability of the cingulate cortex to track motivational conflict between self-gain and other-pain.[61]
Grandiose and vulnerable expressions of NPD appear to relate differently to brain structure and function. Specifically, NPD patients with grandiose features show enhanced while those vulnerable features show reduced local efficiency in the DMN.[62] Vulnerable cases of NPD also appear to show increasedoxidative stress.[63]
Other aspects
Evolutionary models of NPD have also been proposed.[48] According to psychologist Marco Del Giudice,cluster B traits including NPD, predict increased mating success and fertility. NPD could potentially be an adaptive evolutionary phenomenon, though a risky one that can sometimes result in social rejection and failure to reproduce.[48] Another proposal is that NPD may result from an excess of traits which are only adaptive in moderate amounts (leadership success increases with moderate degrees of narcissism, but declines at the high end of narcissism).[48]
Research on NPD is limited, because patients are hard to recruit for study.[57] The cause of narcissistic personality disorder requires further research.[54][48]
Diagnosis
A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. Differential diagnosis is used in order to determine whether NPD is the most appropriate diagnosis.[medical citation needed]
In theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there are two frameworks for personality disorders,[64] with the categorical framework of previous editions having been retained as the main model,[66] and criteria remaining the same as in theDSM-IV-TR.[67] The categorical framework contains ten specific personality disorder categories, grouped into three clusters, with NPD belonging tocluster B, the disorders belonging to which often appear dramatic, emotional, or erratic.[2] NPD is defined by a subject meeting at least five of nine specified criteria.[2] In a 2018latent structure analysis, results suggested that the DSM-5 NPD criteria fail to distinguish some aspects of narcissism relevant to diagnosis of NPD and subclinical narcissism.[68]
Having initially been developed as a replacement for the categorical model, theAlternative DSM-5 Model for Personality Disorders (AMPD) is located inSection III of both the DSM-5 andDSM-5-TR due to the replacement having been rejected.[69] The AMPD defines six specific personality disorders – one of them being NPD[70] – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathologicalpersonality traits associated with the disorder (criterion B).[71]
General personality impairment in individuals with NPD, as described in the AMPD, involves a fragile or exaggerated self-image that depends on others' approval, leading to unstable self-esteem. Their personal goals are often shaped by a need for recognition, with standards that are either unrealistically high or based on entitlement. They struggle to recognize others’ feelings unless directly relevant to themselves and often misjudge their own impact on others. Relationships are typically superficial, serving self-enhancement rather than mutual connection. At least two of these elements must have a "moderate or greater impairment".[72]
The AMPD lists the following pathological traits, both of which are required: grandiosity and attention-seeking; each of these is followed by a description of how the trait manifests in NPD. The AMPD specifiers allow for additional traits to be specified; it suggests additional antagonistic traits for "malignant", and traits ofnegative affectivity for "vulnerable" manifestations of NPD.[72] Further requirements beyond traits and severity, for example relating todifferential diagnosis, are embodied in criteria C–G.[65]
TheWorld Health Organization'sICD-11 has replaced the categorical classification of personality disorders in theICD-10 with adimensional model containing a unifiedpersonality disorder (6D10) with severity specifiers, along with specifiers forprominent personality traits or patterns (6D11).[73] Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder,[74] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.[75]
Studies have shown that NPD corresponds well to the ICD-11 trait ofDissociality (6D11.2)[76][75] – especially self-centredness[75] (grandiosity, attention-seeking, entitlement and egocentricity;Dissociality also includes lack of empathy[73]), which "can be manifested as an expectation of others’ admiration, attention-seeking behaviours to ensure being the center of others’ focus, and anger or denigration of others when the admiration and attention that the individual expects are not granted."[75] Vulnerable features are associated withNegative Affectivity (6D11.0),[76] which "may characterize some individuals with vulnerable narcissism who are ruminating over perceived slights or insults from others, are overreactive to criticism, and have a low frustration tolerance that easily makes them become overtly or covertly upset over even minor issues."[75]
An ICD-11 case profile of a presentation aligning withanankastic andother specific (narcissistic) PD diagnoses in the ICD-10 could look like this.[73]
NPD also shows secondary links toAnankastia (6D11.4) andDisinhibition (6D11.3).[76] The connection toAnankastia may reflect perfectionistic traits that support grandiosity and competitiveness,[76][75] while the link toDisinhibition may involve impulsivity, overconfidence, and difficulty with long-term planning.[76] The complex and variable trait profile across ICD-11 domains reflects the diverse presentations of narcissism.[76] The involvement of multiple domains supports the traditional view that narcissistic pathology entails moderate to severe impairments in personality functioning.[76]
Borderline PD is characterized as having an instability in emotions, relationships, and self image.[78] The presence of BPD is also highly associated with traits such as grandiosity, lack of empathy, and praise-seeking behaviors which are characteristic of NPD. Research has shown that BPD does, in fact, have high comorbidity rates with NPD.[79] Antisocial Personality Disorder is similarly characterized by impulsivity and a lack of empathy, but also by a disregard for the rights of others and a tendency to manipulate others.[80] Additionally, both antisociality and narcissism are heavily correlated withpsychopathy, further suggesting an overlap between the two.[81]
NPD should also be differentiated frommania andhypomania as these cases can also present with grandiosity, but present with different levels of functional impairment.[2] It is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD.[82]
Normalcy must also be ruled out; as is stated in 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."[2] The person's manifested personality traits must substantially differ fromsocial norms.[2]
Subtypes
Although the DSM-5 diagnostic criteria for NPD has been viewed as homogeneous, there are a variety of subtypes used for classification of NPD.[1][83][84] There is poor consensus on how many subtypes exist, but there is broad acceptance that there are at least two: grandiose or overt narcissism, and vulnerable or covert narcissism.[7][83] However, none of the subtypes of NPD are recognized in the DSM-5 or in the ICD-11.
Empirically verified subtypes
Some research has indicated the existence of three subtypes of NPD,[85] which can be distinguished by symptom criteria, comorbidity and other clinical criteria. These are as follows:
Grandiose/overt: the group exhibitsgrandiosity, entitlement, interpersonal exploitativeness and manipulation, pursuit of power and control, lack of empathy and remorse, and marked irritability and hostility.[86] This group was noted for high levels of comorbidantisocial andparanoid personality disorders,substance abuse,externalizing, unemployment and greater likelihood of violence.[85][87] Of note, Russ et al. observed that this group "do not appear to suffer from underlying feelings of inadequacy or to be prone to negative affect states other than anger", an observation corroborated by recent research which found this variant to show strong inverse associations with depressive, anxious-avoidant, and dependant/victimised features.[87]
Vulnerable/covert: this variant is defined by feelings of shame, envy, resentment, and inferiority (which is occasionally "masked" by arrogance), entitlement, a belief that one is misunderstood or unappreciated, and excessive reactivity to slights or criticism. This variant is associated with elevated levels of neuroticism, psychological distress, depression, and anxiety. In fact, recent research suggests that vulnerable narcissism is mostly the product of dysfunctional levels ofneuroticism.[88] Vulnerable narcissism is sometimes comorbid with diagnoses ofavoidant,borderline anddependent personality disorders.[85][87]
High-functioning/exhibitionistic: A third subtype for classifying people with NPD, initially theorized by psychiatristGlen Gabbard, is termed high functioning or exhibitionistic.[89][85] This variant has been described as "high functioning narcissists [who] were grandiose, competitive, attention-seeking, and sexually provocative; they tended to show adaptive functioning and utilize their narcissistic traits to succeed."[83] This group has been found to have relatively few psychological issues and high rates ofobsessive-compulsive personality disorder, with excessive perfectionism posited as a potential cause for their impairment.[85]
Others
Oblivious/hypervigilant: Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes.[90][91][89] The first was the "oblivious" subtype of narcissist, equivalent to the grandiose subtype. This group was described as being grandiose, arrogant and thick-skinned, while also exhibiting personality traits of helplessness and emotional emptiness, low self-esteem and shame. These were observed in people with NPD to be expressed as socially avoidant behavior in situations where self-presentation is difficult or impossible, leading to withdrawal from situations where social approval is not given.
The second subtype Gabbard described was termed "hypervigilant", equivalent to the vulnerable subtype. People with this subtype of NPD were described as having easily hurt feelings, an oversensitivetemperament, and persistent feelings of shame.
Communal narcissism: A fourth type is the communal narcissist. Communal narcissism is a form of narcissism that occurs in group settings. It is characterized by an inflated sense of importance and a need for admiration from others. In relation to the grandiose narcissist, a communal narcissist is arrogant and self-motivating, and shares the sense of entitlement and grandiosity. However, the communal narcissist seeks power and admiration in the communal realm. They see themselves as altruistic, saintly, caring, helpful, and warm.[92][93] Individuals who display communal narcissism often seek out positions of power and influence within their groups.
Millon's subtypes
In the studyDisorders of Personality: DSM-IV-TM and Beyond (1996),Theodore Millon suggested five subtypes of NPD, although he did not identify specific treatments per subtype.[94]
Subtype
Traits
Unprincipled narcissist
Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive.
Amorous narcissist
Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclined to real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling. Tends to have many affairs, often with exotic partners.[citation needed]
Seeks to counteract or cancel out deep feelings ofinferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
Feels privileged and empowered by virtue of special childhood status and pseudo-achievements; entitled façade bears little relation to reality; seeks favored and good life; is upwardly mobile; cultivates special status and advantages by association.
Normal narcissist
Least severe and most interpersonally concerned and empathetic, still entitled and deficient in reciprocity; bold in environments, self-confident, competitive, seeks high targets, feels unique; talent in leadership positions; expecting recognition from others.
Masterson's subtypes (exhibitionist and closet)
In 1993,James F. Masterson proposed two subtypes for pathological narcissism, exhibitionist and closet.[95] Both fail to adequately develop an age- and phase- appropriate self because of defects in the quality of psychological nurturing provided, usually by the mother. A person with exhibitionist narcissism is similar to NPD described in theDSM-IV and differs from closet narcissism in several ways. A person with closet narcissism is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. A person with exhibitionist narcissism would be described as having an inflated, grandiose self-perception with little or no conscious awareness of feelings of emptiness. Such a person would assume that their condition was normal and that others were just like them. A person with closet narcissism is described to seek constant approval from others and appears similar to those withborderline personality disorder in the need to please others. A person with exhibitionist narcissism seeks perfect admiration all the time from others.[96]
Malignant narcissism, a term first coined inErich Fromm's 1964 bookThe Heart of Man: Its Genius for Good and Evil,[97] is asyndrome consisting of a combination of NPD,antisocial personality disorder, andparanoid traits. A person with malignant narcissism was described as deriving higher levels of psychologicalgratification from accomplishments over time, suspected to worsen the disorder. Because a person with malignant narcissism becomes more involved in psychological gratification, it was suspected to be a risk factor for developingantisocial,paranoid, andschizoid personality disorders. The termmalignant is added to the termnarcissist to indicate that individuals with this disorder have a severe form of narcissistic disorder that is characterized also by features of paranoia,psychopathy (anti-social behaviors), aggression, andsadism.[98]
Historical demarcation of grandiose and vulnerable types
Over the years, many clinicians and theorists have described two variants of NPD akin to the grandiose and vulnerable expressions of trait narcissism. Some examples include:[99]
Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using thenarcissistic personality inventory, an assessment tool originally developed in 1979, which has undergone multiple iterations with new versions in 1984, 2006 and 2014. It captures principally grandiose narcissism, but also seems to capture elements of vulnerability. A popular three-factor model has it that grandiose narcissism is assessed via the Leadership/Authority and Grandiose/Exhibitionism facets, while a combination of grandiose and vulnerable traits are indexed by the Entitlement/Exploitativeness facet.[100]
Pathological Narcissism Inventory
The Pathological Narcissism Inventory (PNI) was designed to measure fluctuations in grandiose and vulnerable narcissistic states, similar to what is ostensibly observed by some clinicians (though empirical demonstration of this phenomenon is lacking). While having both "grandiosity" and vulnerability scales, empirically both seem to primarily capture vulnerable narcissism.[100][101]
The PNI scales show significant associations withparasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.[102]
Five-Factor Narcissism Inventory
In 2013, the Five-Factor Narcissism Inventory (FFNI) was defined as a comprehensive assay of grandiose and vulnerable expressions of trait narcissism. The scale measures 11 traits of grandiose narcissism and 4 traits of vulnerable narcissism, both of which correlate with clinical ratings of NPD (with grandiose features of arrogance, grandiose fantasies, manipulativeness, entitlement and exploitativeness showing stronger relations).[103] Later analysis revealed that the FFNI actually measures three factors:[104]
Agentic Extraversion: an exaggerated sense of self-importance, grandiose fantasies, striving for greatness and acclaim, social dominance and authoritativeness, and exhibitionistic, charming interpersonal conduct.
Self-Centred Antagonism: disdain for others, psychological entitlement, interpersonally exploitative and manipulative behaviour, lack of empathy, anger in response to criticism or rebuke, suspiciousness, and thrill-seeking.
Narcissistic Neuroticism: shame-proneness, oversensitivity and negative emotionality to criticism and rebuke, and excessive need for admiration to maintain self-esteem.
Grandiose narcissism is a combination of agency and antagonism, and vulnerability is a combination of antagonism and neuroticism. The three factors show differential associations with clinically important variables. Agentic traits are associated with high self-esteem, positive view of others and the future, autonomous and authentic living, commitment to personal growth, sense of purpose in life and life satisfaction. Neurotic traits show precisely the opposite correlation with all of these variables, while antagonistic traits show more complex associations; they are associated with negative view of others (but not necessarily of the self), a sense of alienation from their 'true self', disinterest in personal growth, negative relationships with others, and all forms of aggression.[104][105]
The Millon Clinical Multiaxial Inventory (MCMI) is another diagnostic test developed byTheodore Millon. The MCMI includes a scale for narcissism. The NPI and MCMI have been found to be well correlated.[106] Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is ascreening tool. In other words, the NPI measures "normal" narcissism; i.e., most people who score very high on the NPI do not have NPD. Indeed, the NPI does not capture any sort of narcissism taxon as would be expected if it measured NPD.[107]
A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.[108]
Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist.[6][1] Therapy is complicated by the lack of treatment-seeking behavior in people with NPD, despitemental distress. Additionally, people with narcissistic personality disorders have decreased life satisfaction and lower qualities of life, irrespective of diagnosis.[111][112][113][114][115] People with NPD often present with comorbid mental disorders, complicating diagnosis and treatment.[1] NPD is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they often express seeking relief from a comorbid mental disorder, includingmajor depressive disorder, asubstance use disorder (drug addiction), orbipolar disorder.[27]
Prognosis
As of 2020[update], no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine efficacy forpsychotherapies andpharmacology.[6][7]Though there is no known single cure for NPD, there are some things one can do to lessen its symptoms. Medications such as antidepressants, which treat depression, are commonly prescribed by healthcare providers; mood stabilizers to reduce mood swings and antipsychotic drugs to reduce the prevalence of psychotic episodes.
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.[1] In this therapy, the goals often are examining traits and behaviors that negatively affect life, identifying ways these behaviors cause distress to the person and others, exploring early experiences that contributed to narcissistic defenses, developing new coping mechanisms to replace those defenses, helping the person see themselves and others in more realistic and nuanced ways, rather than wholly good or wholly bad, identifying and practicing more helpful patterns of behavior, developing interpersonal skills, and learning to consider the needs and feelings of others.[116]
Epidemiology
As of 2018[update], overall prevalence is estimated to range from 0.8% to 6.2%.[117][118] In 2008 under the DSM-IV, lifetime prevalence of NPD was estimated to be 6.2%, with 7.7% for men and 4.8% for women,[119] with a 2015 study confirming the gender difference.[120] In clinical settings, prevalence estimates range from 1% to 15%.[5][121]The same 2008 study presented a significantly higher prevalence of NPD among Black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults.[119]
The term "narcissism" comes from the first century (written in the year 8 AD)narrative poem theMetamorphoses by theRoman poetOvid. Book III of theMetamorphoses features amyth about two main characters,Narcissus andEcho. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects Echo, anymph cursed to onlyecho the sounds that others made, the goddessNemesis punishes him by making him fall in love with his own reflection in a pool of water. When Narcissus discovers that the object of his love cannot love him back, he slowly pines away and dies.[124]
The concept of excessiveselfishness has been recognized throughout history. In ancient Greece, the concept was understood ashubris. It is only since the late 1800s that narcissism has been defined in psychological terms:[125]
Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition in one of his patients.[125]
Ernest Jones (1913/1951) was the first to construe extreme narcissism as a character flaw.
Robert Waelder (1925) published the first case study of narcissism. His patient was a successful scientist with an attitude of superiority, an obsession with fostering self-respect, and a lack of normal feelings of guilt. The patient was aloof and independent from others and had an inability to empathize with others' situations, and was selfish sexually. Waelder's patient was also overly logical and analytical and valued abstract intellectual thought (thinking for thinking's sake) over the practical application of scientific knowledge.
Narcissistic personality was first described by the psychoanalystRobert Waelder in 1925.[127] The termnarcissistic personality disorder (NPD) was coined byHeinz Kohut in 1968.[128][129] Waelder's initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today[130]
Freudianism and psychoanalysis
Much of the early history of narcissism and NPD originates frompsychoanalysis. Regarding the adultneurotic's sense of omnipotence,Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy";[131] and concluded that: "we can detect an element of megalomania in most other forms ofparanoic disorder. We are justified in assuming that this megalomania is essentially of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations."[132]
Narcissistic injury andnarcissistic scar are terms used by Freud in the 1920s.Narcissistic wound andnarcissistic blow are other, almost interchangeable, terms.[133] When wounded in the ego, either by a real or a perceived criticism, a narcissistic person's displays of anger can be disproportionate to the nature of the criticism suffered;[82] but typically, the actions and responses of the NPD person are deliberate and calculated.[2] Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.[2]
InThe Psychology of Gambling (1957),Edmund Bergler considered megalomania to be a normal occurrence in the psychology of a child,[134] a condition later reactivated in adult life, if the individual takes up gambling.[135] InThe Psychoanalytic Theory of Neurosis (1946),Otto Fenichel said that people who, in their later lives, respond with denial to their own narcissistic injury usually undergo a similarregression to the megalomania of childhood.[136]
Narcissistic supply
Narcissistic supply was a concept introduced byOtto Fenichel in 1938, to describe a type ofadmiration,interpersonal support, or sustenance drawn by an individual from his or her environment and essential to theirself-esteem.[137] The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration that does not take into account the feelings, opinions, or preferences of other people.[138]
Narcissistic rage
The termnarcissistic rage was a concept introduced byHeinz Kohut in 1972. Narcissistic rage was theorised as a reaction to a perceived threat to a narcissist'sself-esteem or self-worth. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks.[139]
Narcissistic rage reactions are not necessarily limited to narcissistic personality disorder. They may also be seen incatatonic,paranoid delusion, and depressive episodes.[139]
Object relations
In the second half of the 20th century, in contrast to Freud's perspective of megalomania as an obstacle to psychoanalysis, in the US and UKKleinian psychologists used theobject relations theory to re-evaluate megalomania as adefence mechanism.[140] This Kleinian therapeutic approach built uponHeinz Kohut's view of narcissistic megalomania as an aspect of normal mental development, by contrast withOtto Kernberg's consideration of such grandiosity as a pathological distortion of normal psychological development.[140]
To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed individual who passes blame bypsychological projection and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of their behaviors, whilst insisting that people should see them as an ideal person.[141] The merging of the terms "inflated self-concept" and "actual self" is evident in later research on the grandiosity component of narcissistic personality disorder, along with incorporating the defence mechanisms ofidealization and devaluation and ofdenial.[142]
The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of theDiagnostic and Statistical Manual of Mental Disorders recommended the removal of Narcissistic Personality from the manual. A contentious three-year debate unfolded in the clinical community with one of the sharpest critics beingJohn Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual.[145]
TheAmerican Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in theDiagnostic and Statistical Manual of Mental Disorders, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That it is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns – at the expense of ... internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR.[46]
In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the DSM-5, and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains.[146][147] Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice.[148] Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.
Controversy
A 2011 study concluded that narcissism should be conceived as personality dimensions pertinent to the full range of personality disorders, rather than as a distinct diagnostic category.[149] In a 2012 literature review about NPD, the researchers concluded that narcissistic personality disorder "showsnosological inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field."[150]
In popular culture
Suzanne Stone-Maretto,Nicole Kidman's character in the filmTo Die For (1995), 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".[151]
Jay Gatsby, the eponymous character ofF. Scott Fitzgerald's novelThe Great Gatsby (1925), "an archetype of self-made American men seeking to joinhigh society", has been described by English professor Giles Mitchell as a "pathological narcissist" for whom the "ego-ideal" has become "inflated and destructive" and whose "grandiose lies, poor sense of reality, sense of entitlement, and exploitive treatment of others" conspire toward his own demise.[152][153]
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