Narcissistic personality disorder
From Wikipedia, the free encyclopedia
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| Narcissus, the mythical Greek youth, after whom narcissism is named, as depicted in John William Waterhouse's "Echo and Narcissus," ca. 1903. Narcissus might have been diagnosed as a classic, somatic narcissist. | |
| ICD-10 | F60.8 |
| ICD-9 | 301.81 |
Narcissistic personality disorder (NPD), a term first used by Heinz Kohut in 1971[1], is a form of pathological narcissism acknowledged in the Diagnostic and Statistical Manual of Mental Disorders in 1980, in the edition known as DSM III-TR. Narcissistic personality disorder is characterized by extreme focus on oneself, and is a maladaptive, rigid, and persistent condition that may cause significant distress and functional impairment.
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[edit] Classification
DSM-IV divides personality disorders into three clusters based on symptom similarities[2]:
- Cluster A (paranoid, schizoid, schizotypal): odd or eccentric disorders
- Cluster B (antisocial, borderline, histrionic, narcissistic): dramatic, emotional or erratic disorders
- Cluster C (avoidant, dependent, obsessive-compulsive): anxious or fearful disorders
Narcissistic personality disorder is a "cluster B" personality disorder.
The ICD-10 (International Classification of Mental and Behavioural Disorders, published by the World Health Organisation in Geneva 1992) regards narcissistic personality disorder (NPD) as "a personality disorder that fits none of the specific rubrics". It relegates it to the category known as "Other specific personality disorders", which also includes the eccentric, "haltlose", immature, passive-aggressive, and psychoneurotic personality disorders.
[edit] ICD-10 Criteria
While the ICD-10 does not specifically define the characteristics of this personality disorder, it is classified in the category "Other Specific Personality Disorders".
ICD-10 states that Narcissistic Personality Disorder is "a personality disorder that fits none of the specific rubrics F60.0-F60.7". That is, this personality disorder does not meet the diagnostic criteria for any of the following:
- F60.0 Paranoid Personality Disorder
- F60.1 Schizoid Personality Disorder
- F60.2 Dissocial (Antisocial) Personality Disorder
- F60.3 Emotionally unstable (borderline) Personality Disorder
- F60.4 Histrionic Personality Disorder
- F60.5 Anankastic (Obsessive-Compulsive) Personality Disorder
- F60.6 Anxious (Avoidant) Personality Disorder
- F60.7 Dependent Personality Disorder
[edit] Epidemiology
Narcissist Personality Disorder (NPD) is isolating, disenfranchising, painful, and formidable for those diagnosed with it and often those who are in a relationship with them. Distinctions need to be made among those who have NPD because not each and every person with NPD is the same. Even with similar core issues the way in which one's individual narcissism manifests itself in his or her relationships varies.
Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations. 50 to 75% of those with this diagnosis are men. [3]
[edit] Causes
The etiology of this disorder is unknown. [3]
Pathological narcissism is an infantile, defensive personality structure in response to abuse and trauma, usually developing in early childhood or early adolescence and is exhibited by disregard for the feelings of others (lack of empathy), grandiosity, obsessive self-interest, and the pursuit of primarily selfish goals. Narcissism is a maladaptive defense of the abused child's or adolescent's emotional splitting, resultant cognitive distortions, and negative/hostile worldview. Some think that caregiver deprivation at approximately 36 months of age is a major risk factor for the later development of this disorder.
[edit] Signs and symptoms
Johnson Template:Cite author=Stephen M. Johnson discusses Narcissism as constituting a spectrum, from a severe disorder with much in common with borderline personality disorder, to a much less severe, high-functioning form he calls "the narcissistic style."
People who have a narcissistic personality style rather than narcissistic personality disorder are relatively psychologically healthy, but may at times be arrogant, proud, shrewd, confident, self-centered and determined to be at the top. They may not, however, have an unrealistic image of their skills and worth and are not so strongly dependent on praise to sustain a healthy self-esteem.
Lack of empathy is a hallmark of narcissistic disorders, and sufferers find it extremely difficult to understand others' (and their own) emotional states and impact. This poses serious problems in maintaining close or intimate relationships. They may find it difficult to perceive or admit this flaw, or may reinterpret it as a virtue.
It is also worth noting that the individual expressions of grandiosity or arrogance vary with the person's value system. A person will generally attempt to display superiority as they define it.
- Overreacts to criticism, becoming angry or humiliated
- Uses others to reach goals
- Exaggerates own importance
- Entertains unrealistic fantasies about achievements, power, beauty, intelligence or romance
- Has unreasonable expectations of favorable treatment
- Seeks constant attention and positive reinforcement from others
- Is easily jealous [4]
- Has a sense of entitlement
- Is interpersonally exploitative
- Lacks empathy
- Displays arrogant behavior
- Displays haughty behavior
[edit] Diagnostic criteria
At least five of the following are necessary for a diagnosis (as with many DSM diagnoses, they must form a pervasive pattern; for example, a person who shows these criteria only in one or two relationships or situations would not properly be diagnosed with NPD):
- has a grandiose sense of self-importance
- 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 other special people
- requires excessive admiration
- strong sense of entitlement
- takes advantage of others to achieve his or her own ends
- lacks empathy
- is often envious or believes others are envious of him or her
- arrogant affect.
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- (see also full list in DSM-IV-TR, p. 717)
[edit] Prevalence, age, and gender features
According to DSM IV, the prevalence of NPD is less than 1% of the general population, though it manifests itself in 2-16% of psychiatric outpatients. Studies have not conclusively demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to NPD[5]. However, evidence for heritability greater than that of other personality disorders has been reported[6].
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. The disorder occurs 50 to 75 percent more frequently in men than in women. It has been suggested that NPD may be exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes[5].
[edit] Clinical experience
Pathological narcissism occurs in a spectrum of severity [7]. In its more extreme forms, it is narcissistic personality disorder. NPD is considered to result from a person’s belief that he or she is flawed in a way that makes the person fundamentally unacceptable to others [8]. This belief is held below the person’s conscious awareness; such a person would typically deny thinking such a thing if questioned. In order to protect themselves against the intolerably painful rejection and isolation they imagine would follow if others recognized their supposedly defective nature, such people make strong attempts to control others’ view of them and behavior towards them.
The common use of the term “narcissism” refers to some of the ways people defend themselves against this narcissistic dynamic: a concern with one’s own physical and social image, a preoccupation with one’s own thoughts and feelings, and a sense of grandiosity. There are, however, many other behaviors that can stem from narcissistic concerns, such as immersion in one’s own affairs to the exclusion of others, an inability to empathize with others’ experience, interpersonal rigidity, an insistence that one’s opinions and values are “right,” and a tendency to be easily offended and take things personally.
Psychologists commonly believe that pathological narcissism results 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, empathic attachment to them. This results in the child conceiving of themselves as unimportant and unconnected to others. The child typically comes to believe that he or she has some defect of personality which makes them unvalued and unwanted [7].
To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of other’s needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen [5]. They may also demand certain behavior from their children because they see the children as extensions of themselves, and need the children to represent them in the world in ways that meet the parents’ emotional needs [9]. (For example, a narcissistic father who was a lawyer demanded that his son, who had always been treated as the “favorite” in the family, enter the legal profession as well. When the son chose another career, the father rejected and disparaged him.)
These traits will lead overly narcissistic parents to be very intrusive in some ways, and entirely neglectful in others. The children are punished if they do not respond adequately to the parents’ needs. This punishment may take a variety of forms, including physical abuse, angry outbursts, blame, attempts to instill guilt, emotional withdrawal, and criticism. Whatever form it takes, the purpose of the punishment is to enforce compliance with the parents’ narcissistic needs[9].
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, real or imagined [10]. To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility.
There is a broad spectrum of pathologically narcissistic personalities, styles, and reactions -- from the very mild, reactive and transient, to the severe and inflexible narcissistic personality disorder.
Though 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 [11]. With narcissistic personality disorder, the person's perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.
The interpersonal relationships of patients with NPD are typically impaired due to the individual's lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention. They frequently select as mates, and engender in their children, "co-narcissism," which is a term coined to refer to a co-dependent personality style similar to co-alcoholism and co-dependency [9]. Co-narcissists organize themselves around the needs of others. They feel responsible for others, accept blame readily, are eager to please, defer to other's opinions, and fear being considered selfish if they act assertively.
[edit] True self, false self
Alexander Lowen describes pathological narcissism, and narcissistic personality disorder, as "the denial of the true self"[12]
Masterson describes the creation of a false self as:
- when a young child fails to separate her own self-image from that of her mother. This happens roughly between the ages of two and three, often because of a parent’s own emotional problems. A mother’s encouragement of a child’s self-assertion is vital. When the mother suffers from low self-esteem, she has difficulty encouraging her child’s emerging self. The child experiences this absence as a loss of self, creating feelings of abandonment that lead to depression. To deal with the depression, the child gives up efforts to support her emerging self. Instead, she relies on her mother’s approval to maintain the esteem of a "false self." [13]
[edit] Narcissistic personality disorder and shame
It has been suggested that Narcissistic personality disorder may be related to defences against shame. [14]
Gabbard suggested NPD could be broken down into two subtypes[15]. He saw the "oblivious" subtype as being grandiose, arrogant and thick skinned and the "hypervigilant" subtype as easily hurt, oversensitive and ashamed.
He suggested that the oblivious subtype presents a large, powerful, grandiose self to be admired, envied and appreciated, which is the antithesis of the weakened and internalised self that hides in a generic state of shame, in order to fend off devaluation, whereas the hypervigilant subtype, far from fending off devaluation, is obsessed with it, neutralising devaluation by seeing others as unjust abusers.
[edit] Treatment and prognosis
Though there is controversy in the profession, most psychiatrists and psychologists regard NPD as a relatively stable condition when experienced as a primary disorder [9]. James F. Masterson's A Therapist's Guide to the Personality Disorders: The Masterson Approach outlines a prominent approach to healing NPD, while [7] discusses a continuum of severity and the kinds of therapy most effective in different cases.
It is unusual for people to seek therapy for NPD. Subconscious fears of exposure of inadequacy are often met with defensive disdain of therapeutic processes [16], [17]
Pharmacotherapy is rarely used, though there is one unofficially documented observation of therapeutic response with the atypical anti-depressant bupropion (Wellbutrin). [1]
Because NPD contributes to negative, stressful life experiences characterized by the mental health field as "clinically significant distress" or "impairment", co-existing conditions of depression and anxiety are typical, and can ameliorate with pharmaceutical interventions.[citation needed] NPD sufferers are more likely to seek such treatment from primary care physicians for relief of immediate symptoms of distress / depression.[citation needed]
[edit] See also
- Narcissism (psychology)
- Malignant narcissism
- Megalomania
- Hubris
- Victory disease
- Peter Pan syndrome
- Dorian Gray syndrome
- Superiority complex
- Narcissus (mythology)
- Brian Blackwell
- Solipsism
[edit] References
- ^ Kohut, Heinz, The Analysis of the Self, 1971
- ^ DSM IV-TR, Diagnostic criteria for 301.81 Narcissistic Personality Disorder
- ^ a b Narcissistic Personality Disorder. Personality Disorders - Narcissistic Personality Disorder. Armenian Medical Network (2006). Retrieved on 2007-02-14.
- ^ Laura Stephens (apr 18 2006). Narcissistic Personality Disorder. Psychology Today's Diagnosis Dictionary. Psychology Today. Retrieved on 2007-02-14.
- ^ a b c American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 660
- ^ Livesley, W.J., Jang, K.L., Jackson, D.N. and P.A. Vernon (1993). "Genetic and environmental contributions to dimensions of personality disorder". American Journal of Psychiatry 150, 1826-1831. Abstract online. Accessed June 18, 2006.
- ^ a b c
- ^ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 19-20
- ^ a b c d Rappoport, Alan, Ph. D.Co-Narcissism: How We Adapt to Narcissistic Parents. The Therapist, in press
- ^ American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 659
- ^ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pages 22
- ^ Lowen, Alexander, M.D. (1997) Narcissism: Denial of the True Self Touchstone (New York), ISBN 0-7432-5543-7
- ^ Masterson, J, M.D. The Hollow Self
- ^ Wurmser L, Shame, the veiled companion of narcissism, in The Many Faces of Shame, edited by Nathanson DL. New York, Guilford, 1987, pp 64–92
- ^ Gabbard GO, subtypes of narcissistic personality disorder. Bull Menninger Clin 1989; 53:527–532
- ^ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, page 23
- ^ Kohut, Heinz, (1971). The Analysis of the Self.
[edit] External links
- DSM-IV-TR Narcissistic Personality Disorder Diagnostic Criteria Mentions two film depictions of persons with NPD and a few suggested books.
- The DSM Diagnostic Criteria The DSM Diagnostic criteria explained
Cluster A (Odd): Schizotypal, Schizoid, Paranoid
Cluster B (Dramatic): Antisocial, Borderline, Histrionic, Narcissistic
Cluster C (Anxious): Dependent, Obsessive-Compulsive, Avoidant
