Narccisistic Personality Disorder

Narcissistic Personality Disorder (NPD) is defined as in the American Heritage Dictionary as excessive love or admiration of oneself, a psychological condition characterized by self-preoccupation, lack of empathy, and unconscious deficits in self-esteem, erotic pleasure derived from contemplation or admiration of one’s own body or self, especially as a fixation on or a regression to an infantile stage of development, and the attribute of the human psyche characterized by admiration of oneself but within normal limits. Personality disorder is defined by the Fourth Edition Text Revision of the Diagnostic and Statistical Manual of Mental Disorders as “enduring patterns of perceiving, relating to and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts, and are inflexible and maladaptive and cause significant functional impairment or subjective distress. DSM-IV-TR specifies that these dysfunctional patterns must be regarded as nonconforming or deviant by the person’s culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance.

Narcissistic Personality Disorder is found in Axis III of the DSM-IV-TR in section 301.81 with personality disorders. Narcissistic Personality Disorder is categorized with the Cluster B personality disorders: Antisocial, borderline, histrionic, and narcissistic. Cluster B personality disorders are described as dramatic, emotional, or erratic. The diagnostic criteria for Narcissistic Personality disorder is a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following criteria. Has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). He or she is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Believes that he or she is “special” and unique and can only be understood by or should associate with, other special or high-status people. He or she requests excessive admiration. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatments or automatic compliance with his or her expectations. Hi or she is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. He or she lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. He or she is often envious of others or believes that others are envious of him or her. He or she shows arrogant, haughty behaviors or attitudes.

The term narcissistic is derived from an ancient Greek legend, the story of Echo and Narcissus. According to the legend, Echo, a woodland nymph, fell in love with Narcissus. He was an uncommonly handsome as well as an exceptionally vain young man. He disdainfully rejected her expressions of love. Echo pined away and died. The god Apollo was angered by Narcissus’ pride and self-satisfaction, and condemned him to die without ever knowing human love. One day, Narcissus was feeling thirsty, saw a pool of clear water nearby, and knelt beside it in order to dip his hands in the water and drink. He saw his face reflected on the surface of the water and fell in love with the reflection. Unable to win a response from the image in the water, Narcissus eventually died beside the pool.

Sigmund Freud wrote an essay in 1914 entitled On Narcissism. Freud introduced a distinction between primary and secondary narcissism. Freud thought that all human infants pass through a phase of primary narcissism, in which they assume they are the center of their universe. This phase ends when the baby is forced by the realities of life to recognize that it does not control its parents (or other caregivers) but is in fact entirely dependent on them. In normal circumstances, the baby gives up its fantasy of being all-powerful and becomes emotionally attached to its parents rather than itself. What Freud defined as secondary narcissism is a pathological condition in which the infant does not invest its emotions in its parents but rather redirects them back to itself. He thought that secondary narcissism developed in what he termed the pre-Oedipal phase of childhood; that is, before the age of three. From a Freudian perspective, narcissistic disorders originate in very early childhood development, and this early origin is thought to explain why they are so difficult to treat in later life.

There are two major theories about the origin and nature of Narcissistic Personality Disorder. Heinz Kohut’s theory regards Narcissistic Personality Disorder as a form of arrested psychological development while Otto Kernberg’s theory regards Narcissistic Personality Disorder as a young child’s defense against psychological pain. Kohut and Kernberg agree with Freud in tracing the roots of Narcissistic Personality Disorder to disturbances in the patient’s family of origin, specifically to problems in parent-child relationships before the child turned three. Kohut and Kernberg disagree is the nature of these problems. According to Kohut, the child grows out of primary narcissism through opportunities to be mirrored by (i.e., gain approval from) his or her parents and to idealize them, acquiring a more realistic sense of self and a set of personal ideals and values through these two processes. On the other hand, if the parents fail to provide appropriate opportunities for idealization and mirroring, the child remains “stuck” at a developmental stage in which his or her sense of self remains grandiose and unrealistic while at the same time he or she remains dependent on approval from others for self-esteem.

Kernberg views Narcissistic Personality Disorder as rooted in the child’s defense against a cold, unsympathetic parent, usually the mother. Emotionally hungry and angry at the depriving parents, the child withdraws into a part of the self that the parents value, whether looks, intellectual ability, or some other skill or talent. This part of the self becomes hyper inflated and grandiose. Any perceived weaknesses are “split off” into a hidden part of the self. Splitting gives rise to a lifelong tendency to swing between extremes of grandiosity and feelings of emptiness and worthlessness. In both accounts, the child emerges into adult life with a history of unsatisfactory relationships with others. The adult narcissist possesses a grandiose view of the self but has a conflict-ridden psychological dependence on others.

One dimension of Narcissistic Personality Disorder that must be considered is the social and historical context. Shortly after World War II older practitioners noticed a change in their patient population. Instead of seeing patients who suffered from obsessions and compulsions related to a harsh and punishing superego, psychiatrists were treating more patients with character disorders related to a weak sense of self. Instead of a judgmental and overactive conscience, these patients had a weak or nonexistent code of morals. They differed greatly from the patients that Freud treated, described, and analyzed. The next generation of psychiatrists began to interpret their patients’ character disorders in terms of narcissism. In the 1960s, historians and social critics drew the attention of the general public to narcissism as a metaphorical description of Western culture in general.

Psychiatrists saw several parallels between trends in the larger society and the personality traits of people diagnosed with narcissistic disorders. In short, they argued that the advanced industrial societies of Europe and the United States were contributing to the development of narcissistic disorders in individuals in a number of respects. Some of the trends they noted include the mass media’s preoccupation with “lifestyles of the rich and famous” rather than with ordinary or average people, the social approval of open displays of money, status, or accomplishments rather than modesty and self-restraint, preference for a leadership style that emphasizes the leader’s outward appearance and personality rather than his or her inner beliefs and values, the growth of large corporations and government bureaucracies that favor a managerial style based on “impression management” rather than objective measurements of performance, and social trends that encourage parents to be self-centered and to resent their children’s legitimate needs. Although discussion continues about the location and forms of narcissism in the larger society, no one denies that personality disorders both reflect and influence the culture in which they arise. Family therapists are reporting the treatment of families in which the children are replicating the narcissistic disorders of their parents. Kohut suggested the etiology of narcissism as a result of a developmental arrest; that is, a mismatch of the child’s normal narcissistic needs and the environment’s ability to adequately respond to them. Kernberg’s opinion regarding the etiology of narcissism as a result of an instinctual or structural conflict but in the case of narcissism, the conflict is not centered around the oedipal complex but rather on issues that predate the oedipal complex.

According to DSM-IV-TR, 2% to 16% of the clinical population and slightly less than 1% of the general population of the United States suffers from Narcissistic Personality Disorder. Between 50% and 75% of those diagnosed with Narcissistic Personality Disorder are males. These numbers could be disproportional as there are discrepancies in the diagnosis of personality disorders. For example, if a person has symptoms of Narcissistic Personality Disorder and has a substance abuse problem, some of the narcissistic behavior might be contributed to the mood-altering properties of certain narcotics.

Treatment options for Narcissistic Personality Disorder consist of psychoanalytical therapy, cognitive behavior therapy; group therapy, family therapy, and individual therapy are the preferred treatment options. The diagnosis of Narcissistic Personality Disorder does not in and of itself imply a given treatment. Because the range of narcissistic character pathology is broad and the capacities and circumstances of the patients varied, treatment must be tailored to each individual case. Motivation, insight, and life circumstances need to be taken into account in formulating a realistic treatment plan and treatment goals. Narcissistic personality disorder presents in a full range of severity, from episodically troublesome dysphoria to crippling existential emptiness and lack of meaningful relationships and goals, and treatment is prescribed accordingly. Treatment recommendations, therefore, are based on clinical experience. Although some form of individual psychotherapy is generally recommended, couples, family, and group therapy are useful in certain cases.

A University of Georgia study suggests that social networking websites such as Facebook and MySpace might be useful tools in determining whether someone is a narcissist. By examining three areas of a person’s profile untrained observers were able to identify a person with narcissistic tendencies. The untrained observers looked at the quantity of social interaction, attractiveness of the individual, and the degree of self-promotion of the individual’s main photograph. The number of friends and number of wall postings or comments that individuals have on their profile page positively correlate with narcissism. This behavior is consistent with narcissistic people in the real world, numerous, yet shallow and superficial relationships. Narcissists are more likely to use glamorous and self-promoting pictures for their main profile picture, where other people use snapshot or candid photographs.