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8.160: Narcissistic Personality Disorder

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    I ndividual diagnosed with Narcissistic PD discusses his disorder.

    DSM-IV-TR criteria

    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 (perfect marriage to the perfect spouse)
    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 (“You owe me because I’m that good”)
    6. is inter-personally 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

    Other Symptoms:

    • history of intense but short-term relationships with others; inability to make or sustain genuinely intimate relationships
    • a tendency to be attracted to leadership or high-profile positions or occupations
    • a pattern of alternating between unrealistic idealization of others and equally unrealistic devaluation of them
    • assessment of others in terms of usefulness
    • a need to be the center of attention or admiration in a working group or social situation
    • hypersensitivity to criticism, however mild, or rejection from others
    • an unstable view of the self that fluctuates between extremes of self-praise and self-contempt
    • preoccupation with outward appearance, “image,” or public opinion rather than inner reality
    • painful emotions based on shame (dislike of who one is) rather than guilt (regret for what one has done)

    Associated features

    Individuals with Narcissistic Personality Disorder are greatly lacking in empathy and are unwilling to recognize or identify with the feelings and needs of others. They see themselves as above others and feel a strong sense of entitlement and need for admiration. Narcissistic individuals do not perceive themselves as flawed and are not likely to seek treatment. Therefore, these individuals represent less than one percent of the clinical population.

    Some people who suffer from NPD also have mood disorders. Narcissistic patients only pursue relationships that will benefit them in some way. Their inflated sense of self results in a devaluation of others and their accomplishments. Patients with narcissistic personality disorder exaggerate their achievements and talents and are surprised when they do not receive the recognition they expect. These patients are prone to be more envious of other people who possess knowledge, a specific skill, or some kind of belonging that they do not possess. Patients are very self-absorbed and have a hard time responding to the needs of others. Narcissistic individuals often exhibit a history of intense but short-term relationships with others, an inability to make or sustain genuinely intimate relationships, and an unstable view of self that fluctuates between extremes of self-praise and self-contempt. Criticism may haunt them and leave them feeling humiliated, degraded, hollow, and empty, although they don’t show it. Because of the problems from entitlement and the need for admiration and their disregard for others, they have difficulty with interpersonal relationships. They may be unwilling to take part in situations in which there is risk and a possibility of defeat. NPD is also associated with anorexia nervosa, substance-related disorders, and other personality disorders.

    If parents are neglectful, and they show no empathy toward the child, or if they devalue the child, then the child will always be seeking out this ideal sense of self, a narcissistic viewpoint. The reverse of this treatment by parents has also received some support. Narcissistic Personality Disorder could arise from parental overindulgence that is relatively painless but research is a little scarce for that proposition.

    Hitler as an Example:

    • The first criterion for this disorder is the individual must have a lavish sense of self-importance, they over-estimate their abilities, and embellish their accomplishments. Hitler considered himself to be a very special person. He believed that he was an astounding artist and had no doubt that he was going to get into the art school in Vienna and when he didn’t he was astounded. He let the people around him believe that he had been accepted to the Viennese Academy of Fine Arts when in fact he was rejected twice.
    • The second criterion of Narcissistic Personality Disorder is the individual must be preoccupied with fantasies of unlimited success and power. In Hitler’s earlier years he had fantasies about becoming a great and powerful artist. Later he developed the fantasy of becoming the world’s greatest and most powerful leader by exterminating Jews.
    • The third criterion is that the individual believes that they are superior, special, or unique. Hitler believed that his opinions were more advanced than those around him. He insisted that everyone listen to him and he often quarreled with those who opposed him.
    • Hitler met the fourth criterion as well by needing excessive admiration. He was admired by many he came in contact with. He was able to string his friend Gustl around for so long because of the admiration Gustl had for Hitler.
    • The fifth criterion is the sense of entitlement. Hitler expected others to cater to his every need, especially his mother, sister, and aunt. Later in his life, he expected his servants and military men to serve and give him everything he wanted.
    • The sixth criterion and one of the ones Hitler showed most prominently is the exploitation of others. In his business deals, he did whatever he needed to, in order to benefit himself, even if that meant hanging others out to dry or throwing them under the bus so to speak.
    • The seventh criterion is the lack of empathy. Hitler had absolutely no empathy for what he was doing during World War II. Killing Jews and anyone who aided their survival was something easy and painless for Hitler. However, he did have empathy for his mother.
    • Envy is the eighth criteria. Individuals with Narcissistic Personality Disorder envy others and believe that others envy them as well. Hitler was very envious of Gustl’s acceptance into the Vienna Conservatoire to practice his Grand Piano.
    • The final criterion is an arrogant, snobbish, or patronizing attitude towards others. Adolf Hitler was to say the least arrogant, snobbish, and patronizing. He believed that he was the greatest artist, the smartest man, better than women, and anyone different from him was inferior.
    • It is evident that Hitler possessed characteristics that fall under all nine of the criteria so it could be possible that Hitler had Narcissistic Personality Disorder
    • (Kershaw, 2008)

    Subtypes of NPD

    • Personality Subtype
    • Age Group Subtype:
      • According to the Encyclopedia of mental disorders, ever since the 1950s, when psychiatrists began to notice an increase in the number of their patients that had narcissistic disorders, they have made attempts to define these disorders more precisely. NPD was introduced as a new diagnostic category in DSM-III , which was published in 1980. Prior to DSM-III , narcissism was a recognized phenomenon but not an official diagnosis. At that time, NPD was considered virtually untreatable because people who suffer from it rarely enter or remain in treatment; typically, they regard themselves as superior to their therapist, and they see their problems as caused by other people’s “stupidity” or “lack of appreciation.”
      • psychiatrists have proposed dividing narcissistic patients into two subcategories based roughly on age: those who suffer from the stable form of NPD described by DSM-IVTR , and younger adults whose narcissism is often corrected by life experiences.
      • This age group distinction represents an ongoing controversy about the nature of NPD—whether it is fundamentally a character disorder, or whether it is a matter of learned behavior that can be unlearned. Therapists who incline toward the first viewpoint are usually pessimistic about the results of treatment for patients with NPD.
    • Other psychiatrists have noted that patients who meet the DSM-IV-TR criteria for NPD reflect different clusters of traits within the DSM-IV-TR list. One expert in the field of NPD has suggested the following subcategories of narcissistic personalities:
      • Craving narcissists. These are people who feel emotionally needy and undernourished, and may well appear clingy or demanding to those around them.
      • Paranoid narcissists. This type of narcissist feels intense contempt for him- or herself, but projects it outward onto others. Paranoid narcissists frequently drive other people away from them by hypercritical and jealous comments and behaviors.
      • Manipulative narcissists. These people enjoy “putting something over” on others, obtaining their feelings of superiority by lying to and manipulating them.
      • Phallic narcissists. Almost all narcissists in this subgroup are male. They tend to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies, clothes, and overall “manliness.”

    Child vs. Adult Presentation

    • NPD has been seen in children, adolescents, and adulthood. There have been no further studies to determine the differences in age of this disorder. The presentation of the disorder in children and adolescents are similar the the adult presentation.

    Gender and Cultural Differences in Presentation

    • NPD is seen more in men than in women (7.7% for men and 4.8% for women) based on 34,653 face-to-face structured interviews that included DSM-IV diagnostic criteria. Black men and Hispanic women had higher rates compared with Hispanic men and Caucasians of either gender. 50%-75% of all patients are men.

    Epidemiology

    • The prevalence of Narcissistic Personality Disorder within the general population ranges from 2 to 16 percent in the general population, but is less than 1 percent in the clinical population. The fact that these individuals represent less than 1 percent of the clinical population is not surprising because these individuals rarely, if ever, seek out treatment. The reason is quite clear: These individuals see themselves (and their lives) as nearly perfect and do not see any need for change.
    • For NPD, there have been no known genetic or environmental factors. It is believed that this is seen when parents over-indulge in the amount of encouragement they display to their child, over-zealously praise the accomplishments of the child, tell their child that they are not responsible for their own wrongdoings or spoiling their child.
    • However,additional evidence suggests a genetic influence may be at play in determining the character of NPD. These inherited aspects include hypersensitivity, aggression, low frustration tolerance, and problems in affect regulation.
    • Some researchers believe that Narcissistic individuals don’t grow out of the period when they don’t see the viewpoint of others as a child.
    • In the clinical practice for substance abuse, 10 to 15% have Narcissistic Personality Disorder (SAMHSA, 2009).

    Etiology

    • The Encyclopedia states that at present there are two major theories about the origin and nature of NPD. One theory regards NPD as a form of arrested psychological development while the other regards it as a young child’s defense against psychological pain. The two perspectives have been identified with two major figures in psychoanalytic thought, Heinz Kohut and Otto Kernberg respectively
    • Both theories about NPD go back to Sigmund Freud’s pioneering work On Narcissism, published in1914. In this essay, Freud introduced a distinction which has been retained by almost all later writers—namely, the 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, then, 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.
    • Kohut and Kernberg agree with Freud in tracing the roots of NPD to disturbances in the patient’s family of origin—specifically, to problems in the parent-child relationship before the child turned three. Where they disagree is in their accounts of 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
    • In contrast, Kernberg views NPD as rooted in the child’s defense against a cold and unempathetic 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 hyperinflated 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. At present, however, psychiatrists do not agree in their description of the central defect in NPD; some think that the problem is primarily emotional while others regard it as the result of distorted cognition, or knowing. Some maintain that the person with NPD has an “empty” or hungry sense of self while others argue that the narcissist has a “disorganized” self. Still others regard the core problem as the narcissist’s inability to test reality and construct an accurate view of him- or herself

    Macrosocial Causes.

    • One dimension of NPD that must be taken into account is its social and historical context. Psychiatrists became interested in narcissism shortly after World War II (1939–45), when the older practitioners in the field noticed that their patient population had changed. Instead of seeing patients who suffered from obsessions and compulsions related to a harsh and punishing superego (the part of the psyche that internalizes the standards and moral demands of one’s parents and culture), the psychiatrists were treating more patients with character disorders related to a weak sense of self. Instead of having a judgmental and overactive conscience, these patients had a weak or nonexistent code of morals. They were very different from the patients that Freud had treated, described, and analyzed. The younger generation of psychiatrists then 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. These writers 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 following:
      • The mass media’s preoccupation with “lifestyles of the rich and famous” rather than with ordinary or average people.
      • Social approval of open displays of money, status, or accomplishments (“if you’ve got it, flaunt it”) 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.
      • Social trends that encourage parents to be self-centered and to resent their children’s legitimate needs.
      • The weakening of churches, synagogues, and other religious or social institutions that traditionally helped children to see themselves as members of a community rather than as isolated individuals

    Empirically Supported Treatments

    • For NPD, the treatment of choice is normally Psychotherapy, but this method may prove problematic because the patient may become envious of the therapist and not respond to them. Long -Term Care Individual Counseling for these patients is recommended to help manage not only the self-aggrandizement, hypersensitivity, and need for control and attention, but also their anger and depression.
    • Group Therapy is another option for patients, but the therapist should set down boundaries and limits on time, interruptions, the respect of others’ feeling, responding to other group members, and listening to others’ responses and feedback.
    • It’s important to obtain treatment as quickly as possible to avoid the onset of other disorders. Also, treatment should be continued for as long as allowed as personality traits are often very difficult to change. The inability to change is even more of a problem for the narcissistic type because, after all, they have the best personality already

    Psychotherapy

    • Several different approaches to individual therapy have been tried with NPD patients, ranging from classical psychoanalysis and Adlerian therapy to rationalemotive approaches and Gestalt therapy . The consensus that has emerged is that therapists should set modest goals for treatment with NPD patients. Most of them cannot form a sufficiently deep bond with a therapist to allow healing of early-childhood injuries. In addition, the tendency of these patients to criticize and devalue their therapists (as well as other authority figures) makes it difficult for therapists to work with them.
    • An additional factor that complicates psychotherapy with NPD patients is the lack of agreement among psychiatrists about the causes and course of the disorder. One researcher has commented that much more research is necessary to validate DSM-IV-TR ‘s description of NPD before outcome studies can be done comparing different techniques of treatment

    Hospitalization

    • Low-functioning patients with NPD may require inpatient treatment, particularly those with severe self-harming behaviors or lack of impulse control. Hospital treatment, however, appears to be most helpful when it is focused on the immediate crisis and its symptoms rather than the patient’s underlying long-term difficulties
    • Read more: www.minddisorders.com

    Medication

    • As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms. There are anecdotal reports in the medical literature that the selective serotonin reuptake inhibitors, or SSRIs, which are frequently prescribed for depression, reinforce narcissistic grandiosity and lack of empathy with others

    Prognosis

    • The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older within a youth-oriented culture and lose their looks and overall vitality. The retirement years are especially painful for patients with NPD because they must yield their positions in the working world to the next generation. In addition, they do not have the network of intimate family ties and friendships that sustain most older people

    Prevention

    • The best hope for prevention of NPD lies with parents and other caregivers who are close to children during the early preschool years. Parents must be able to demonstrate empathy in their interactions with the child and with each other. They must also be able to show that they love their children for who they are, not for their appearance or their achievements. And they must focus their parenting efforts on meeting the child’s changing needs as he or she matures, rather than demanding that the child meet their needs for status, comfort, or convenience

    Portrayed in Popular Culture

    • In Greek mythology, Narcissus was a very beautiful guy that all the girls wanted to date, but Narcissus wanted nothing to do with them. He would pass by the loveliest and the most beautiful girls, not even bothering to look at them. One of his spurned lovers prayed to the goddess Nemesis that “he who loves not others love himself”. Nemesis granted that prayer, and when Narcissus bent over a clear pool to get a drink of water, he saw a reflection of himself and fell in love with it. He could not leave his image, and so he pined away, leaning perpetually over the pool, fixed in one long gaze until he died. They say that when his spirit crossed the river that encircles the world of the dead, it leaned over the boat to catch one last glimpse of itself in the water (Hamilton, 1969).
    • Wall Street (1987)
    • To Die For (1995)
    • The Scarecrow from Batman
      • A psychiatrist himself, highly intellectual and generally condescending
    • Gilderoy Lockhart from Harry Potter
      • Self-indulgent and always expecting admiration and adoration, even where lacking

    DSM-V Changes

    (APA, 2010)

    Links

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