A chronic pattern of grandiosity, a desire for adulation, a lack of empathy, and an exaggerated feeling of self-importance are characteristics of narcissistic personality disorder (NPD). NPD sufferers may come across to others as conceited, haughty, or even unlikeable. A pattern of behaviour known as narcissistic personality disorder can cause severe impairments in social and occupational functioning over an extended period and in a range of circumstances or social contexts. Furthermore, NPD frequently co-occurs with other mental disorders, which might exacerbate independent functioning even more. Sadly, there aren’t many effective or widely available therapy options for NPD.
The Roman poet Ovid originally used the term “narcissism” in Metamorphoses: Book III. The main character in this tale is Narcissus, who is condemned to fall in love with his reflection. However, the term “narcissism” was not used to characterize a psychological state of mind until the late 1800s.
In 1898, psychologist Havelock Ellis used the term “narcissism” to describe the behaviours he saw in his patient, connecting it to the description of Narcissus. Soon afterward, in his book Three Essays on the Theory of Sexuality, Sigmund Freud classified “narcissistic libido.” Ernest Jones, a psychoanalyst, defined narcissism as a personal weakness. Pathological narcissism was originally documented in a case report published in 1925 by Robert Waelder, who coined the term “narcissistic personality.” NPD was left out of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) despite these advancements. Heinz Kohut did not coin the term “narcissism” until 1968, when the DSM II was being released.
Based on shared traits, personality disorders were grouped in the DSM, and this model is still in use in the fifth edition of the DSM (text review) (DSM-5-TR). Personality disorders are classified into three clusters:
Cluster A:
Personality disorders with odd or eccentric characteristics, including paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder.
Cluster B:
Personality disorders with dramatic, emotional, or erratic features, including antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.
Cluster C:
Personality disorders with anxious and fearful characteristics, including avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder.
The etiology of NPD has been the subject of very few studies. The strong heritability of NPD and other cluster B personality disorders has been shown by a few behavioral genetic investigations. Personality disorders or changes in personality are frequently linked to medical diseases, particularly those that may cause harm to neurons. Head trauma, cerebrovascular illnesses, brain tumors, epilepsy, Huntington’s disease, multiple sclerosis, endocrine disorders, heavy metal toxicity, neurosyphilis, and AIDS are just a few examples of the conditions that fall under this category.
Although psychoanalytic elements play a role in the development of personality disorders, narcissistic features are not inherently abnormal, as they represent a natural aspect of human growth. Around age 8, narcissism starts to show signs, intensifying in adolescence, and continuing into adulthood. However, those who exhibit high levels of narcissism early in life typically continue to do so as they age.
In order to reduce cognitive conflict resulting from internal urges and interpersonal anxiety, psychotherapist Wilhelm Reich defined “character armor” as defense mechanisms that emerge with personality types (e.g., individuals with narcissistic tendencies may exhibit fantasy, projection defense, and splitting processes). Negative childhood events, including being rejected, and early childhood ego fragility may play a role in the development of NPD in adults. Conversely, unwarranted adulation during childhood, along with the belief that the child possesses exceptional skills, can also lead to an enduring desire for unceasing praise and appreciation.
Each personality is distinct, even among those diagnosed with a personality disorder, as personality is a complex amalgam of biological, psychological, social, and developmental elements. A person’s personality is a pattern of actions that they specifically adjust to deal with ever-changing internal and external stimuli. This is often referred to as temperament, which is an intrinsic and heritable psychobiological trait. Adaptive etiological elements in personality development, including life experiences like trauma and socioeconomic circumstances, further modify temperament through epigenetic mechanisms. Harm avoidance, novelty seeking, reward dependency, and perseverance are examples of temperamental qualities.
EVALUATION
Longitudinal monitoring of a patient’s behaviours under various conditions is beneficial for diagnosing a personality disorder, as it provides a more comprehensive understanding of long-term functioning. Patients with cluster B personality disorders frequently reflect their past conflicts onto the physician, a behaviour known as transference. Counter-transference, or projecting unresolved problems onto the patient, is common among clinicians. This occurs often due to the way people with personality problems interact with their patients; they might be harsh, aggressive, or illogical. To eliminate any therapeutic bias that can affect the clinical care of a patient with NPD, clinicians need to be aware of counter-transference indicators when they arise.
The Five-Factor Narcissism Inventory, which examines the five facets of general personality, is one tool that may be used to gauge the severity of NPD. This measure consists of approximately 148 questions. The Narcissistic Personality Inventory is another tool that can be helpful. Individuals must meet the DSM-5-TR diagnostic criteria for NPD to receive a formal diagnosis, which is based on a compilation of data from psychometric tests, collateral material, mental state exams, and personal histories.
NPD DSM-5-TR Criteria
- Grandiose sense of self-importance: Exaggerating achievements and talents, expecting to be recognized as superior even without commensurate achievements.
- Preoccupation with fantasies of success, power, beauty, and idealization.
- Belief in being “special” and that they can only be understood by or associated with other high-status people (or institutions).
- Demanding excessive admiration.
- Sense of entitlement.
- Exploitation behaviours.
- Lack of empathy.
- Envy towards others or belief that others are envious of them.
- Arrogant, haughty behaviours and attitudes.
TREATMENT
Since NPD is often ego syntonic, individuals with the disorder might not be aware of their condition. The presentation is typically requested by a close friend or relative, usually after someone else has experienced stress due to maladaptive behaviours rather than the NPD person experiencing internal discomfort. Therefore, it is critical to evaluate the treatment objectives in each unique case of NPD. The goal of therapy may be to stabilize psychosocial functioning and lessen interpersonal conflict because NPD is not likely to resolve with or without treatment.
Unless there is a coexisting mental disorder, there is no evidence that medication aids in the treatment of NPD. There are no FDA-approved drugs for the treatment of NPD. Although there is also little evidence to support the effectiveness of psychotherapy, it is likely the best course of treatment for NPD. Compared to other therapeutic modalities, transfer-focused therapy could be more effective. In addition to assisting with other basic needs, case management may help individuals with NPD maintain their source of income, housing, and access to medical and mental health treatments.
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