Narcissistic personality disorder: Difference between revisions

Narcissistic personality disorder
Narcissistic personality disorder
Specialty	Psychiatry
Symptoms	Exaggerated feelings of self-importance, excessive craving for admiration, low levels of empathy
Usual onset	Early adulthood
Duration	Long term
Causes	Unknown
Differential diagnosis	Bipolar disorder, substance abuse, borderline personality disorder, histrionic personality disorder
Treatment	Psychotherapy, pharmaceuticals
Frequency	<1% of population

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Narcissistic personality disorder (NPD) or megalomania is a personality disorder characterized by a long-term pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and struggles with empathy.^[1]^[2] People with NPD often spend much time daydreaming about achieving power and success, and perceive injustice for failing to do so. This is a pattern of obsessive thoughts and unstable sense of identity, often to cope with a sub-par real life. People with the diagnosis in recent years have spoken out about its stigma in media, and possible links to abusive situations and childhood trauma.^[2] Such narcissistic behavior typically begins by early adulthood, and occurs across a broad range of situations.^[2]

The causes of narcissistic personality disorder are unknown, but theorized to be linked to certain types of traumas.^[3] The condition of NPD is included in the cluster B personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM).^[2] A diagnosis of NPD is made by a healthcare professional interviewing the person in question.^[1] The condition of NPD should be differentiated from mania and substance use disorder.^[2]

Treatments for narcissistic personality disorder have not been well studied.^[1] Therapy is difficult, because people with NPD usually do not consider their own issues as symptoms, despite mental distress. Additionally, people with narcissistic personality disorders have decreased life satisfaction and lower qualities of life, even when their narcissism is undiagnosed.^[4]^[5]^[6]^[7]^[8]^[9] People with NPD may have other comorbid psychiatric conditions as well, making it more difficult to identify the symptoms.^[1] About one percent of people are believed to be affected with NPD at some point in their lives.^[3] It occurs more often in men than women, and typically affects younger as opposed to older people.^[1]^[2] The narcissistic personality was first described by the psychoanalyst Robert Waelder in 1925. The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968.^[10]^[11]

Presentation

People with narcissistic personality disorder (NPD) are characterized by the personality traits of persistent grandiosity, an excessive need for admiration and recognition, and a personal disdain and lack of empathy for other people.^[12]^[13] As such, the person with NPD usually displays arrogance and a distorted sense of personal superiority, and seeks to establish abusive power and control over others.^[14] Self-confidence (a strong sense of self) is a personality trait different from the traits of NPD; thus, people with NPD typically value themselves over others, to the extent of openly disregarding the wishes and feelings of anyone else, and expect to be treated as superior, regardless of their actual status or achievements.^[12]^[15] Socially, the person with NPD usually exhibits a fragile ego (self-concept), intolerance of criticism, and a tendency to belittle other people, in order to validate their own feelings of superiority.^[15]

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5, 2013) indicates that a person with NPD possesses at least five of the following nine criteria, typically without possessing the commensurate personal qualities or accomplishments for which they demand respect and status:

A grandiose sense of self-importance (e.g. exaggerating achievements and talents, expecting to be recognized as superior without commensurate achievements)
Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
Believing that they are "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
Requiring excessive admiration
A sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with their expectations)
Being interpersonally exploitative (taking advantage of others to achieve their own ends)
Lacking empathy: unwilling to recognize or identify with the feelings and needs of others
Often being envious of others or believing that others are envious of them
Showing arrogant, haughty behaviors or attitudes^[12]^[15]

Narcissistic personality disorder usually develops either in youth or in early adulthood.^[12] It is common for children and youths 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.^[15] True symptoms of NPD are pervasive, apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person's mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person's psychological abilities to function socially, either at work or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person's manifested personality traits must substantially differ from social norms.^[12]

Associated features

People with NPD exaggerate their skills, accomplishments, and their degree of intimacy with people they consider high-status. Such a sense of personal superiority may cause them to monopolize conversations,^[15] or to become impatient and disdainful when other persons talk about themselves.^[12] This attitude connects to an overall worse functioning in areas of life like work and intimate romantic relationships.^[16]^[17]^[18]^[19]

"Narcissistic injury" and "narcissistic scar" are terms used by Sigmund Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms.^[20] When wounded in the ego, either by a real or a perceived criticism, the narcissist's displays of anger can be disproportionate to the nature of the criticism suffered;^[15] but typically, the actions and responses of the NPD person are deliberate and calculated.^[12] Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.^[12]

To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed control freak who passes blame by psychological 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.^[12] To protect their fragile self-concept, narcissists use psychosocial strategies, such as the tendency to devalue and derogate and to insult and blame other people, usually with anger and hostility towards people's responses to the narcissist's anti-social conduct.^[21] Narcissistic personalities are more likely to respond with anger or aggressiveness when presented with rejection.^[22]^[23]^[24] Because they are sensitive to perceived criticism or defeat, people with NPD are prone to feelings of shame, humiliation, and worthlessness over minor incidents of daily life and imagined, personal slights,^[15] and usually mask such feelings from people, either by way of feigned humility, or by responding with outbursts of rage and defiance, or by seeking revenge.^[12]^[13] The merging of the inflated self-concept and the actual self is evident in the grandiosity component of narcissistic personality disorder; also inherent to that psychological process are the defence mechanisms of idealization and devaluation and of denial.^[25]

The DSM-5 indicates that: "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."^[12] Given the high-function sociability associated with narcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives.^[26] 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.^[12]^[13] Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism, make it difficult for persons with NPD to work cooperatively or to maintain long-term, professional relationships with superiors and colleagues.^[27]

Some narcissists may have a limited or minimal capability to experience emotions.^[28]

Narcissistic supply

Narcissistic supply is a concept introduced into psychoanalytic theory by Otto Fenichel in 1938, to describe a type of admiration, interpersonal support or sustenance drawn by an individual from his or her environment and essential to their self-esteem.^[29] The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration in codependents and the orally fixated, that does not take into account the feelings, opinions or preferences of other people.^[30]

Narcissistic rage

Narcissistic rage is a reaction to a perceived threat to a narcissist's self-esteem or self-worth. The term narcissistic rage was coined by Heinz Kohut in 1972. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks.^[31]

Narcissistic rage reactions are not limited to personality disorders. They may also be seen in catatonic, paranoid delusion, and depressive episodes.^[31] It has been suggested that narcissists have two layers of rage. The first layer of rage can be thought of as a constant anger towards someone else, with the second layer being a self-aimed anger.^[32]

Comorbidity

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.^[33] People with NPD are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder.^[34] Moreover, the occurrence of NPD is further associated with the occurrence of bipolar disorder and substance use disorders,^[13] especially cocaine use disorder.^[12] In that vein, NPD also might be comorbid with the occurrence of other mental disorders, such as histrionic personality disorder, borderline personality disorder, antisocial personality disorder, or paranoid personality disorder.^[12]

Type theories

The DSM-5 indicates narcissistic personality disorder as a homogeneous syndrome.^[1] Since its inclusion in the DSM, NPD has been primarily conceptualized by overt and grandiose phenomena.^[35] This characterization has been criticized as not fully capturing all of the clinical phenomena^[36] and there has been much theoretical and empirical work suggesting that NPD is not a homogenous disorder but rather that subtypes exist.^[37] There is not consensus on how many subtypes exist, but there is broad acceptance that there are at least two.^[35]

None of the subtypes of NPD are currently recognized in the Diagnostic and Statistical Manual of Mental Disorders or in the International Statistical Classification of Diseases and Related Health Problems.

Grandiose and vulnerable narcissism theory

Grandiose narcissism is characterized by personality traits of grandiosity, arrogance, and boldness. The research indicates that people with grandiose narcissism express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."^[38]

Vulnerable narcissism is characterized by the personality traits of defensiveness and hypersensitivity.^[1]

Numerous studies (Miller & Campbell, 2008; Russ, Shedler, Bradley, & Westen, 2008; Wink, 1991) have demonstrated that narcissism has two or more variants: grandiose narcissism and vulnerable narcissism. The grandiose variant, which is usually measured using the NPI, is strongly linked to the DSM-IV conceptualization and is the variant associated with NPD, a Cluster B personality disorder which reflects traits related to self-importance, entitlement, aggression, and dominance. Vulnerable narcissism reflects a defensive and fragile grandiosity, which functions mainly as a cover for feelings of inadequacy. Vulnerable narcissism is characterized by hypersensitivity, defensiveness, and withdrawal and is strongly associated with BPD, which is characterized by the fear of abandonment, interpersonal and affective instability, impulsivity, chronic feelings of emptiness, suicidal ideation, and self-mutilation. Pathological narcissism is when both grandiose and vulnerable narcissism is concurrent, which is linked to poor self-esteem, lack of empathy, feelings of shame, interpersonal distress, aggression, and significant impairments in personality functioning across both clinical and non-clinical samples.

Pathological narcissism, as measured by the Pathological Narcissism Inventory (PNI), is embedded within the personality disorders organized at the borderline level, which include antisocial, borderline, narcissistic personality disorders. PNI scales exhibited significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.^[39] Despite the phenomenological and empirical distinction between vulnerable and grandiose narcissism, there is experimental evidence from studies that have employed direct or indirect ego-threat to suggest that grandiose narcissists have also a fragile, vulnerable core.^[40]

Oblivious and hypervigilant narcissism theory

In an inventory of the types of NPD, the psychiatrist Glen Gabbard described the "oblivious" subtype of narcissist as being a grandiose, arrogant, and thick-skinned person; and described the "narcissistic vulnerability" of the subtype of person who consciously exhibits the personality traits of helplessness and emotional emptiness, and of low self-esteem and shame, which usually are expressed as socially avoidant behavior in situations where the narcissist's self-presentation is impossible; therefore, they withdraw from situations wherein the needed or expected social approval is not given.^[38]

Gabbard also described the "hypervigilant" subtype of narcissist whose feelings are easily hurt, has an oversensitive temperament, and ashamed; and described the "high-functioning" subtype of narcissist as a person less functionally impaired in the areas of life where narcissists with a severe expression of NPD usually have difficulties in functioning as a normally-socialized person.^[1]

Malignant, fragile, and high functioning narcissism theory

Russ, Shedler, Bradley, and Westen characterized three subtypes among the NPD patients they studied: (a) grandiose/malignant; (b) fragile; and (c) high functioning/exhibitionistic.^[41] The researchers concluded that "Grandiose narcissists were characterized as angry, interpersonally manipulative, and lacking empathy and remorse; their grandiosity was seen as neither defensive nor compensatory. Fragile narcissists demonstrated grandiosity under threat (defensive grandiosity) and experienced feelings of inadequacy and anxiety, indicating that they vacillate between superiority and inferiority. High functioning narcissists were grandiose, competitive, attention-seeking, and sexually provocative; they tended to show adaptive functioning and utilize their narcissistic traits to succeed."^[35]

Millon's variations

In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of narcissist;^[42] however, there are few, pure subtypes of narcissist.

Subtype	Description
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.
Compensatory narcissist	Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
Elitist narcissist	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.

In 1996, Theodore Millon identified four variations of narcissist.^[43] Any individual narcissist may exhibit none or one of the variations.^{[inconsistent]}

unprincipled narcissist: including antisocial features. A charlatan – is a fraudulent, exploitative, amoral, disloyal, deceptive and unscrupulous individual.
amorous narcissist: including histrionic features. The Don Juan or Casanova of our times – is erotic, tantalizing, enticing; clever, glib and pathological lying.
compensatory narcissist: including negativistic (passive-aggressive), avoidant features: admirable, exceptional, noteworthy; creating illusions of being superior.
elitist narcissist: variant of pure pattern. Corresponds to Wilhelm Reich's "phallic narcissistic" personality type.

Masterson's subtypes (exhibitionist and closet)

In 1993, James F. Masterson proposed two categories for pathological narcissism, exhibitionist and closet.^[44] 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. The exhibitionist narcissist is the one described in DSM-IV and differs from the closet narcissist in several important ways. The closet narcissist is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. The exhibitionist narcissist would be described as having an inflated, grandiose self-perception with little or no conscious awareness of the emptiness within. Such a person would assume that this condition was normal and that others were just like him. The closet narcissist seeks constant approval from others and appears similar to the borderline in the need to please others. The exhibitionist narcissist seeks perfect admiration all the time from others.^{[citation needed]}

Malignant narcissism

Malignant narcissism, a term first coined in a book by Erich Fromm in 1964,^[45] is a syndrome consisting of a crossbreed of the narcissistic personality disorder, the antisocial personality disorder, as well as paranoid traits. The malignant narcissist differs from one suffering from a narcissistic personality disorder in that the malignant narcissist derives higher levels of psychological gratification from accomplishments over time (thus worsening the disorder). Because the malignant narcissist becomes more involved in this psychological gratification, in the context of the right conditions, the narcissist is apt to develop the antisocial, the paranoid, and the schizoid personality disorders. The term malignant is added to the term narcissist 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, and sadism according to Kernberg and colleagues.^[46]

Primordial narcissism

Psychiatrist Ernst Simmel first defined primordial narcissism in 1944.^[47] Simmel's fundamental thesis is that the most primitive stage of libidinal development is not the oral, but the gastrointestinal one. The mouth and anus are merely to be considered as the terminal parts of this organic zone. Simmel terms the psychological condition of prenatal existence "primordial narcissism." It is the vegetative stage of the pre-ego, identical with the id. At this stage, there is complete instinctual repose, manifested in unconsciousness. Satiation of the gastrointestinal zone, the representative of the instinct of self-preservation, can bring back this complete instinctual repose, which, under pathological conditions, can become the aim of the instinct. Contrary to Lasch, Bernard Stiegler argues in his book, Acting Out, that consumer capitalism is in fact destructive of what he calls primordial narcissism, without which it is not possible to extend love to others.^[48] In other words, he is referring to the natural state of an infant as a fetus and in the first few days of its life, before it has learned that other people exist besides itself, and therefore cannot possibly be aware that they are human beings with feelings, rather than having anything to do with actual narcissism.

Causes

The causes of narcissistic personality disorder are unknown.^[15]^[34] Researchers apply a biopsychosocial model of causation,^[33] whereby the occurrence and the expression of NPD – a pathological amplification of the traits of the narcissistic personality – are consequent to a combination of nature and nurture, of environmental and social, genetic and neurobiological factors.^[34]^[33]

Genetic

Narcissistic personality disorder is an inheritable psychological condition; research evidence indicates that a person is more likely to develop NPD if said personality disorder occurs in the medical history of his or her family.^[33]^[49] The results reported in A Twin Study of Personality Disorders (2000) indicate that the rate of occurrence of personality disorders in twins determined that there is a moderate-to-high likelihood of the heritability of NPD;^[49] and the research of The Genetic Epidemiology of Personality Disorders (2010) indicates that specific genes and genetic interactions (epistasis) contribute to the formation of NPD, and to the development of a narcissistic personality, yet how genetics influences the developmental and the physiologic processes underlying NPD remains undetermined.^[50]

Twin studies

Livesley et al. concluded, in agreement with other studies, that narcissism, as measured by a standardized test, was a common inherited trait.^[51] Additionally, in similar agreement with those other studies, it was found that there exists a continuum between normal and disordered personality. The study subjects were 175 volunteer twin pairs (ninety identical, eighty-five fraternal) drawn from the general population. Each twin completed a questionnaire that assessed eighteen dimensions of personality disorder. The authors estimated the heritability of each dimension of personality by standard methods, thus providing estimates of the relative contributions of genetic and environmental causation. Of the eighteen personality dimensions, narcissism was found to have the highest heritability (0.64), indicating that the concordance of this trait in the identical twins was significantly influenced by genetics. Of the other dimensions of personality, only four were found to have heritability coefficients of greater than 0.5: callousness, identity problems, oppositionality, and social avoidance

Environment

Environmental and social factors also exert significant influence upon the onset of NPD in a person.^[33] In some people, pathological narcissism may develop from an impaired emotional attachment to the primary caregivers, usually the parents.^[52] That lack of psychological and emotional attachment to a parental figure can result in the child's perception of themselves as unimportant and unconnected to other people, usually family, community and society. Typically, the child comes to believe that they have a personality defect that makes them an unvalued and unwanted person;^[53] in that vein, either overindulgent and permissive parenting or insensitive and over-controlling parenting are contributing factors towards the development of NPD in a child.^[15]^[34]

In Gabbard's Treatments of Psychiatric Disorders (2014), the following factors are identified as promoting the development of narcissistic personality disorder:^[54]

An oversensitive temperament (individual differences of behavior) at birth
Excessive admiration that is never balanced with realistic criticism
Excessive praise for good behaviors, or excessive criticism for bad behaviors in childhood
Overindulgence and overvaluation by family or peers
Being praised by adults for perceived exceptional physical appearance or abilities
Trauma caused by psychological abuse, physical abuse or sexual abuse in childhood
Unpredictable or unreliable parental caregiving
Learning the behaviors of psychological manipulation from parents or peers^[55]

Moreover, the research reported in "Modernity and Narcissistic Personality Disorders" (2014) indicates that cultural elements also influence the prevalence of NPD, because narcissistic personality traits more commonly occur in modern societies than in traditionalist conservative societies.^[33]

Pathophysiology

Studies of the occurrence of narcissistic personality disorder, such as Gray Matter Abnormalities in Patients with Narcissistic Personality Disorder (2013) and Narcissists' Lack of Empathy Tied to Less Gray Matter (2016) identified structural abnormalities in the brains of people afflicted with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex.^[56]^[57] The results of the study Brain Structure in Narcissistic Personality Disorder: A VBM and DTI Pilot Study (2015) associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex.^[58] The regions of the brain identified and studied – the insular cortex and the prefrontal cortex – are associated with the human emotions of empathy and compassion, and with the mental functions of cognition and emotional regulation. The neurologic findings of the studies suggest that NPD may be related to a compromised (damaged) capacity for emotional empathy and emotional regulation.^[59]

Measurement of narcissism

Narcissistic Personality Inventory

The Narcissistic Personality Inventory (NPI) is the most widely used measure of narcissism in social psychological research. Although several versions of the NPI have been proposed in the literature, a forty-item forced-choice version (Raskin & Terry, 1988) is the one most commonly employed in current research. Another shorter version, a sixteen-item version NPI-16 (Ames, Rose & Anderson, 2013) is also present. The NPI is based on the DSM-III clinical criteria for narcissistic personality disorder (NPD), although it was designed to measure these features in the general population. Thus, the NPI is often said to measure "normal" or "subclinical" (borderline) narcissism (i.e., in people who score very high on the NPI do not necessarily meet criteria for diagnosis with NPD).

Millon Clinical Multiaxial Inventory

The Millon Clinical Multiaxial Inventory (MCMI) is a widely used diagnostic test developed by Theodore Millon. The MCMI includes a scale for Narcissism. The NPI and MCMI have been found to be well correlated, r(146) = 0.55, p < 0.001.^[60] Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population. 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.^[61]

A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.^[62]

Classification

DSM-5

Within the DSM-5, NPD is a cluster B personality disorder.^[2] Individuals with cluster B personality disorders often appear dramatic, emotional, or erratic.^[2]

NPD was revised in the DSM-5. The general move towards a dimensional (personality trait-based) view of the personality disorders has been maintained.

Controversy

The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of the Diagnostic 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 being John Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual.^[63]

The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the Diagnostic 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.^[26]

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.^[64]^[65] 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.^[66] 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.

The Norwegian study, Validity Aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Narcissistic Personality Disorder Construct (2011) concluded that narcissism should be conceived as personality dimensions pertinent to the full range of personality disorders, rather than as a distinct diagnostic category.^[67] In the study Debates on the Narcissism Conundrum: Trait, Domain, Dimension, Type, or Disorder? (2012) examining the past literature about NPD, the researchers Renato Alarcón and Silvana Sarabia concluded that narcissistic personality disorder "shows nosological inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field."^[68]

ICD-10

The International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), of the World Health Organization (WHO), lists narcissistic personality disorder (NPD) under the category of "Other specific personality disorders". The ICD-10 requires that any personality-disorder diagnosis also meet and satisfy the General diagnostic criteria 2 used for determining that a person has a diagnosable personality disorder.^[69]

Treatment

Narcissistic personality disorder is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they usually are prompted by difficulties in their lives, or are seeking relief from some other disorder of their mental health, such as a major depressive disorder, a substance use disorder (drug addiction), or bipolar disorder.^[13] The reason for such an indirect path to psychotherapeutic treatment is partly because narcissists generally possess poor insight, and are unaware that their actions produced their mentally unhealthy circumstance, and so fail to recognize that their perceptions and behaviors are socially inappropriate and problematic, because of their very positive self-image (inflated self-concept).^[1]

In general, psychotherapy is the basis for treating narcissistic personality disorder.^[70] In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time^{[clarification needed]} with clinical strategies that applied psychoanalytic therapy to NPD clients, which, they claimed, effectively treated that personality disorder.^{[citation needed]} Contemporary psychotherapy treatments include transference-focused therapy; metacognitive therapy; and schema therapy, to treat the client's particular subtype of NPD.^{[medical citation needed]} Improvements to the mental health of patients with NPD are possible with psychopharmaceutical treatment of the symptoms of the comorbid disorders;^{[medical citation needed]} despite such drug therapy, the psychologist Elsa Ronningstam said that "alliance-building and engaging the patient's sense of agency and reflective ability are essential for [achieving] change in pathological narcissism."^[13]^{[medical citation needed]} Psychiatric medications usually are not indicated for treating NPD, but can be used to treat the co-occurring symptoms of psychological depression, anxiety, and impulsiveness, when present in the NPD client.^[70] In the field of relationship counseling mental health therapy is most beneficial when both partners participate in the treatments.^[71]

Prognosis

The effectiveness of psychotherapeutic and pharmacological interventions in the treatment of narcissistic personality disorder have 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.^[1]

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]

Epidemiology

The lifetime rates of narcissistic personality disorder are estimated at 1% in the general population; and between 2% and 16% in the clinical population.^[72] A 2010 review found rates of NPD of up to 6% in community samples,^[73] and that the yearly number of new cases of NPD in men is slightly greater than in women.^[74] A 2015 review found that the rates of NPD have been relatively stable for men and women throughout the thirty-year period in which data were collected.^[74]

History

The historical use of the term narcissism, to describe a person's excessive vanity and self-centeredness predates the modern medical classification of NPD (narcissistic personality disorder). The mental condition of narcissism is named after the mythological character Narcissus, a beautiful boy, born of a nymph, who became infatuated with his own reflection in a pool of water. At first, Narcissus did not understand that the image he saw in the pool of water was a reflection of himself; when he did understand that fact, he pined for the unattainable image and died of grief, for having fallen in love with someone who did not exist outside of himself.^[75]

Further conceptual developments and refinements of the mental condition of Narcissism produced the term narcissistic personality structure, which was introduced by Otto Friedmann Kernberg, in 1967;^[76] and the term narcissistic personality disorder, which was proposed by Heinz Kohut, in 1968.^[77]

Early Freudianism

Regarding the adult neurotic's sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy";^[78] and concluded that: "we can detect an element of megalomania in most other forms of paranoic 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."^[79]

In The Psychology of Gambling (1957), Edmund Bergler considered megalomania to be a normal occurrence in the psychology of a child,^[80] a condition later reactivated in adult life, if the individual takes up the vice of gambling.^[81] In The 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 similar regression to the megalomania of childhood.^[82]

Object relations

In the second half of the 20th century, in contrast to Freud's perspective that megalomania is an obstacle to psychoanalysis, in the US and UK, Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defence mechanism, a circumstance that offered the psychotherapist access to the patient for treatment.^[83] Such a Kleinian therapeutic approach built upon Heinz Kohut's view of narcissistic megalomania as an aspect of normal mental development, by contrast with Otto Kernberg's consideration of such grandiosity as a pathological distortion of normal psychological development.^[84]

Megalomania

The term megalomania first came into usage in the late 1800s and began to be used popularly by the public in the early 1900s.^[85] A former mental disorder, megalomania has since been removed from the DSM, and forged in with narcissistic personality disorder.^[86] In popular culture, narcissistic personality disorder (NPD) is also known as megalomania.^[72]^[87]

Narcissistic abuse

Some writers discuss 'narcissistic abuse' as a unique form of abuse, although the concept is not formally recognized in health care.^[88] Other scholars suggest there is little evidence to show psychological, financial, sexual or physical abuse manifests itself differently or more often in people with narcissistic traits or narcissistic personality disorder.^[89]

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Classification	D ICD-10: F60.8 ICD-9-CM: 301.81 MeSH: D010554
External resources	MedlinePlus: 000934

v t e Narcissism
Similar personality concepts	Egomania Egotism God complex Healthy narcissism Hubris Machiavellianism Messiah complex Narcissus (mythology) Superiority complex
In society	Collective narcissism Don Juanism In the workplace Leadership Me generation Parents
Pathological narcissism	Narcissistic personality disorder history Dark triad Malignant narcissism Manipulation (psychology) Narcissistic injury neurosis elation mortification supply withdrawal Narcissistic Personality Inventory
Related psychology concepts	Compensation Empathy Entitlement Grandiosity
Category