Pathological narcissism is a life-long pattern of traits and behaviours
which signify infatuation and obsession with one's self to the exclusion of
all others and the egotistic and ruthless pursuit of one's gratification,
dominance and ambition.
As distinct from healthy narcissism which we all possess, pathological
narcissism is maladaptive, rigid, persisting, and causes significant
distress, and functional impairment.
Pathological narcissism was first described in detail by Freud in his essay
"On Narcissism" (1915). Other major contributors to the study of narcissism
are: Melanie Klein, Karen Horney, Franz Kohut, Otto Kernberg, Theodore
Millon, Elsa Roningstam, Gunderson, and Robert Hare.
What is Narcissistic Personality Disorder (NPD)?
The Narcissistic Personality Disorder (NPD) (formerly known as megalomania
or, colloquially, as egotism) is a form of pathological narcissism. It is a
Cluster B (dramatic, emotional, or erratic) personality disorder. Other
Cluster B personality disorders are the Borderline Personality Disorder
(BPD), the Antisocial Personality Disorder (APD), and the Histrionic
Personality Disorder (HPD). The Narcissistic Personality Disorder (NPD)
first appeared as a mental health diagnosis in the DSM III-TR (Diagnostic
and Statistical Manual) in 1980.
Diagnostic Criteria
The ICD-10, the International Classification of Diseases, published by the
World Health Organisation in Geneva [1992] regards the Narcissistic
Personality Disorder (NPD) as "a personality disorder that fits none of the
specific rubrics". It relegates it to the category "Other Specific
Personality Disorders" together with the eccentric, "haltlose", immature,
passive-aggressive, and psychoneurotic personality disorders and types.
The American Psychiatric Association, based in Washington D.C., USA,
publishes the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition, Text Revision (DSM-IV-TR) [2000] where it provides the diagnostic
criteria for the Narcissistic Personality Disorder (301.81, p. 717).
The DSM-IV-TR defines Narcissistic Personality Disorder (NPD) as "an
all-pervasive pattern of grandiosity (in fantasy or behaviour), need for
admiration or adulation and lack of empathy, usually beginning by early
adulthood and present in various contexts", such as family life and work.
The DSM specifies nine diagnostic criteria. Five (or more) of these criteria
must be met for a diagnosis of Narcissistic Personality Disorder (NPD) to be
rendered.
[My amendments do not constitute a part of the text of the DSM-IV-TR, nor is
the American Psychiatric Association (APA) associated with them in any way.]
Proposed Amended Criteria for the Narcissistic Personality Disorder
a.. Feels grandiose and self-important (e.g., exaggerates accomplishments,
talents, skills, contacts, and personality traits to the point of lying,
demands to be recognised as superior without commensurate achievements);
a.. Is obsessed with fantasies of unlimited success, fame, fearsome power
or omnipotence, unequalled brilliance (the cerebral narcissist), bodily
beauty or sexual performance (the somatic narcissist), or ideal,
everlasting, all-conquering love or passion;
a.. Firmly convinced that he or she is unique and, being special, can only
be understood by, should only be treated by, or associate with, other
special or unique, or high-status people (or institutions);
a.. Requires excessive admiration, adulation, attention and affirmation -
or, failing that, wishes to be feared and to be notorious (Narcissistic
Supply);
a.. Feels entitled. Demands automatic and full compliance with his or her
unreasonable expectations for special and favourable priority treatment;
a.. Is "interpersonally exploitative", i.e., uses others to achieve his or
her own ends;
a.. Devoid of empathy. Is unable or unwilling to identify with,
acknowledge, or accept the feelings, needs, preferences, priorities, and
choices of others;
a.. Constantly envious of others and seeks to hurt or destroy the objects
of his or her frustration. Suffers from persecutory (paranoid) delusions as
he or she believes that they feel the same about him or her and are likely
to act similarly;
a.. Behaves arrogantly and haughtily. Feels superior, omnipotent,
omniscient, invincible, immune, "above the law", and omnipresent (magical
thinking). Rages when frustrated, contradicted, or confronted by people he
or she considers inferior to him or her and unworthy.
Prevalence and Age and Gender Features
According to the DSM IV-TR, between 2% and 16% of the population in clinical
settings (between 0.5-1% of the general population) are diagnosed with
Narcissistic Personality Disorder (NPD). Most narcissists (50-75%, according
to the DSM-IV-TR) are men.
We must carefully distinguish between the narcissistic traits of
adolescents - narcissism is an integral part of their healthy personal
development - and the full-fledge disorder. Adolescence is about
self-definition, differentiation, separation from one's parents, and
individuation. These inevitably involve narcissistic assertiveness which is
not to be conflated or confused with Narcissistic Personality Disorder
(NPD).
"The lifetime prevalence rate of NPD is approximately 0.5-1 percent;
however, the estimated prevalence in clinical settings is approximately 2-16
percent. Almost 75 percent of individuals diagnosed with NPD are male (APA,
DSM IV-TR 2000)."
From the Abstract of Psychotherapeutic Assessment and Treatment of
Narcissistic Personality Disorder By Robert C. Schwartz,Ph.D., DAPA and
Shannon D. Smith, Ph.D., DAPA (American Psychotherapy Association, Article
#3004 Annals July/August 2002)
Narcissistic Personality Disorder (NPD) is exacerbated by the onset of aging
and the physical, mental, and occupational restrictions it imposes.
In certain situations, such as under constant public scrutiny and exposure,
a transient and reactive form of the Narcissistic Personality Disorder (NPD)
has been observed by Robert Milman and labelled "Acquired Situational
Narcissism".
There is only scant research regarding the Narcissistic Personality Disorder
(NPD), but studies have not demonstrated any ethnic, social, cultural,
economic, genetic, or professional predilection to it.
Comorbidity and Differential Diagnoses
Narcissistic Personality Disorder (NPD) is often diagnosed with other mental
health disorders ("co-morbidity"), such as mood disorders, eating disorders,
and substance-related disorders. Patients with Narcissistic Personality
Disorder (NPD) are frequently abusive and prone to impulsive and reckless
behaviours ("dual diagnosis").
Narcissistic Personality Disorder (NPD) is commonly diagnosed with other
personality disorders, such as the Histrionic, Borderline, Paranoid, and
Antisocial Personality Disorders.
The personal style of those suffering from the Narcissistic Personality
Disorder (NPD) should be distinguished from the personal styles of patients
with other Cluster B Personality Disorders. The narcissist is grandiose, the
histrionic coquettish, the antisocial (psychopath) callous, and the
borderline needy.
As opposed to patients with the Borderline Personality Disorder, the
self-image of the narcissist is stable, he or she are less impulsive and
less self-defeating or self-destructive and less concerned with abandonment
issues (not as clinging).
Contrary to the histrionic patient, the narcissist is
achievements-orientated and proud of his or her possessions and
accomplishments. Narcissists also rarely display their emotions as
histrionics do and they hold the sensitivities and needs of others in
contempt.
According to the DSM-IV-TR, both narcissists and psychopaths are
"tough-minded, glib, superficial, exploitative, and unempathic". But
narcissists are less impulsive, less aggressive, and less deceitful.
Psychopaths rarely seek narcissistic supply. As opposed to psychopaths, few
narcissists are criminals.
Patients suffering from the range of obsessive-compulsive disorders are
committed to perfection and believe that only they are capable of attaining
it. But, as opposed to narcissists, they are self-critical and far more
aware of their own deficiencies, flaws, and shortcomings.
Clinical Features of the Narcissistic Personality Disorder
The onset of pathological narcissism is in infancy, childhood and early
adolescence. It is commonly attributed to childhood abuse and trauma
inflicted by parents, authority figures, or even peers. Pathological
narcissism is a defense mechanism intended to deflect hurt and trauma from
the victim's "True Self" into a "False Self" which is omnipotent,
invulnerable, and omniscient.
The narcissist uses the False Self to regulate his or her labile sense of self-worth by extracting from his environment narcissistic supply (any form of attention, both positive and negative). There is a whole range of narcissistic reactions, styles, and personalities - from the mild, reactive and transient to the permanent personality disorder.
Patients with Narcissistic Personality Disorder (NPD) feel injured,
humiliated and empty when criticized. They often react with disdain
(devaluation), rage, and defiance to any slight, real or imagined. To avoid
such situations, some patients with Narcissistic Personality Disorder (NPD)
socially withdraw and feign false modesty and humility to mask their
underlying grandiosity. Dysthymic and depressive disorders are common
reactions to isolation and feelings of shame and inadequacy.
The interpersonal relationships of patients with Narcissistic Personality
Disorder (NPD) are typically impaired due to their lack of empathy,
disregard for others, exploitativeness, sense of entitlement, and constant
need for attention (narcissistic supply).
Though often ambitious and capable, inability to tolerate setbacks,
disagreement, and criticism make it difficult for patients with Narcissistic
Personality Disorder (NPD) to work in a team or to maintain long-term
professional achievements. The narcissist's fantastic grandiosity,
frequently coupled with a hypomanic mood, is typically incommensurate with
his or her real accomplishments (the "grandiosity gap").
Patients with Narcissistic Personality Disorder (NPD) are either "cerebral"
(derive their Narcissistic Supply from their intelligence or academic
achievements) or "somatic" (derive their Narcissistic Supply from their
physique, exercise, physical or sexual prowess and romantic or physical
"conquests").
Patients with Narcissistic Personality Disorder (NPD) are either "classic"
(meet five of the nine diagnostic criteria included in the DSM), or they are
"compensatory" (their narcissism compensates for deep-set feelings of
inferiority and lack of self-worth).
Some narcissists are covert, or inverted narcissists. As codependents, they
derive their narcissistic supply from their relationships with classic
narcissists.
Treatment and Prognosis
The common treatment for patients with Narcissistic Personality Disorder
(NPD) is talk therapy (mainly psychodynamic psychotherapy or
cognitive-behavioural treatment modalities). Talk therapy is used to modify
the narcissist's antisocial, interpersonally exploitative, and dysfunctional
behaviors, often with some success. Medication is prescribed to control and
ameliorate attendant conditions such as mood disorders or
obsessive-compulsive disorders.
The prognosis for an adult suffering from the Narcissistic Personality
Disorder (NPD) is poor, though his adaptation to life and to others can
improve with treatment.
a.. Goldman, Howard H., Review of General Psychiatry, fourth edition,
1995. Prentice-Hall International, London.
b.. Gelder, Michael, Gath, Dennis, Mayou, Richard, Cowen, Philip (eds.),
Oxford Textbook of Psychiatry, third edition, 1996, reprinted 2000. Oxford
University Press, Oxford.
c.. Vaknin, Sam, Malignant Self Love - Narcissism Revisited, seventh
revised impression, 1999-2006. Narcissus Publications, Prague and Skopje.
Sam Vaknin http://samvak.tripod.com is the author of Malignant Self Love - Narcissism Revisited and After the Rain - How the West Lost the East.
He served as a columnist for Global Politician, Central Europe Review,
PopMatters, Bellaonline, and eBookWeb, a United Press International (UPI)
Senior Business Correspondent, and the editor of mental health and Central
East Europe categories in The Open Directory and Suite101.
Until recently, he served as the Economic Advisor to the Government of
Macedonia.
Visit Sam's Web site at http://samvak.tripod.com
