Narcissistic Personality Disorder

Essentials of Diagnosis

DSM-IV-TR Criteria

A. 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:

1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

3. 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 (or institutions)

4. requires excessive admiration

5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

6. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

7. lacks empathy: Is unwilling to recognize or identify with the feelings and needs of others

8. is often envious of others or believes that others are envious of him or her

9. shows arrogant, haughty behaviors or attitudes

(Reprinted, with permission, from the Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000.)

General Considerations

Epidemiology

Narcissistic personality disorder occurs in less than 1% in the general population. It is frequently comorbid in populations of psychiatric patients, being estimated at 2–16%. The disorder is somewhat more common in men than in women.

Etiology

Although the cause of narcissistic personality disorder is unknown, one hypothesis is that there has been a lack of clear parental appreciation of the child's accomplishments. This deficiency, or conversely, excessive attention and overgratification concerning accomplishments, is thought to lead the child, and later the adult to continually seek adoration, and to have difficulties in attaining self-esteem at realistic levels.

Clinical Findings

Signs & Symptoms

The hallmarks of the narcissistic personality disorder are grandiosity, a notable lack of empathy and of a lack of consideration for others. There also is hypersensitivity to evaluation by others. Narcissistic individuals exaggerate their accomplishments, act egotistical and are manipulative of those around them. They have an exaggerated sense of entitlement, being convinced that they deserve special treatment and admiration. Thus, individuals with narcissistic personality disorder are frequently boastful of their accomplishments and often appear haughty and irritating, although they can be outwardly charming. Usually they have little insight into their narcissism. They are often excessively self-centered and self-absorbed and have problems with commitment. They have an exaggerated sense of uniqueness, and show devaluation, disdain, contempt, and deprecation of others.

Narcissistic personality disorder patients are prone to attribute and externalize the source of their problems to people who they think do not appreciate, support, or defer to them. Because they are highly vulnerable to criticism, any negative statements about them provokes anger, disdain, counter arguments, and devaluation of the person making the statement. Some narcissistic individuals react to criticism by becoming enraged, sometimes with acute paranoid ideation and marked deterioration in judgment.

Given the narcissistic personality disorder patient's view on life, these patients are vulnerable to depressive episodes and social withdrawal following injury to their self-image. Linked to this, envy of others is a major feature characteristic of personality disorder patients. Such envy makes it difficult for these patients to appreciate what they actually have acquired or accomplished. Individuals with narcissistic personality disorder are especially prone to dislike growing old, and thus, may become more depressed and demanding during the fourth, fifth, and later decades of life.