Narcissistic personality disorder

Narcissistic personality disorder (NPD) is a personality disorder in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity. This condition affects one percent of the population. First formulated in 1968, it was historically called megalomania, and is severe egocentrism.

History
The use of the term "narcissism" to describe excessive vanity and self-centeredness predates by many years the modern medical classification of narcissistic personality disorder. The condition was named after a mythological Greek youth named Narcissus who became infatuated with his own reflection in a lake. He did not realize at first that it was his own reflection, but when he did, he died out of grievance for having fallen in love with someone that did not exist outside of himself.

The term "narcissistic personality structure" was introduced by Kernberg in 1967 and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.

Symptoms
Symptoms of this disorder, as defined by the DSM-IV-TR include:

In addition to these symptoms, the person may also display dominance, arrogance, show superiority, and seek power. The symptoms of narcissistic personality disorder can be similar to the traits of individuals with strong self-esteem and confidence; differentiation occurs when the underlying psychological structures of these traits are considered pathological. Narcissists have such an elevated sense of self-worth that they value themselves as inherently better than others. However, they have a fragile self-esteem and cannot handle criticism, and will often try to compensate for this inner fragility by belittling or disparaging others in an attempt to validate their own self-worth. It is this sadistic tendency that is characteristic of narcissism as opposed to other psychological conditions affecting level of self-worth.
 * Reacting to criticism with anger, shame, or humiliation
 * Taking advantage of others to reach own goals
 * Exaggerating own importance, achievements, and talents
 * Imagining unrealistic fantasies of success, beauty, power, intelligence, or romance
 * Requiring constant attention and positive reinforcement from others
 * Becoming jealous easily
 * Lacking empathy and disregarding the feelings of others
 * Being obsessed with self
 * Pursuing mainly selfish goals
 * Trouble keeping healthy relationships
 * Becoming easily hurt and rejected
 * Setting goals that are unrealistic
 * Wanting "the best" of everything
 * Appearing unemotional

In children, inflated self-views and grandiose feelings, which are characteristics of narcissism, are part of the normal self-development. Children typically cannot understand the difference between their actual and their ideal self, which causes an unrealistic perception of the self. After about age 8, views of the self, both positive and negative, begin to develop based on comparisons of peers, and become more realistic. Two factors that cause self-view to remain unrealistic are dysfunctional interactions with parents that can be either excessive attention or a lack thereof. The child will either compensate for lack of attention or act in terms of unrealistic self-perception.

The Childhood Narcissism Scale (CNS) measurements concluded that narcissistic children seek to impress others and gain admiration but do not have any interest in creating sincere friendships. CNS researchers have measured that childhood narcissism has become more prevalent in Western society; any types of activities that focus on overly praising the individual can raise narcissistic levels. More research is needed to find the reasons that promote or protect against narcissism.

Causes
The cause of this disorder is unknown, however Groopman and Cooper list the following factors identified by various researchers as possibilities:
 * An oversensitive temperament at birth
 * Excessive admiration that is never balanced with realistic feedback
 * Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood
 * Overindulgence and overvaluation by parents, other family members, or peers
 * Being praised for perceived exceptional looks or abilities by adults
 * Severe emotional abuse in childhood
 * Unpredictable or unreliable caregiving from parents
 * Valued by parents as a means to regulate their own self-esteem

Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood, they may intensify to the point where NPD is diagnosed. Some psychotherapists believe that the etiology of the disorder is, in Freudian terms, the result of fixation to early childhood development.

A 1994 study by Gabbard and Twemlow reports that histories of incest, especially mother–son incest, are associated with NPD in some male patients.

Theories
Pathological narcissism occurs in a spectrum of severity. In its more extreme forms, it is narcissistic personality disorder (NPD). NPD is considered to result from a person's belief that they are flawed in a way that makes them fundamentally unacceptable to others. This belief is held below the person's conscious awareness; such a person would, if questioned, typically deny thinking such a thing. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognized their (perceived) defective nature, such people make strong attempts to control others’ views of them and behavior towards them.

Pathological narcissism can develop from an impairment in the quality of the person's relationship with their primary caregivers, usually their parents, in that the parents could not form a healthy and empathic attachment to them. This results in the child's perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others' needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen.

Narcissistic individuals use various strategies to protect the self at the expense of others. They tend to devalue, derogate and blame others, and they respond to threatening feedback with anger and hostility.

People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight criticism, real or imagined. To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility. In cases where the narcissistic personality-disordered individual feels a lack of admiration, adulation, attention and affirmation, he or she may also manifest a desire to be feared and to be notorious (narcissistic supply).

Although individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements. With narcissistic personality disorder, the individual's self-perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.

Splitting
People who are diagnosed with narcissistic personality disorder use splitting as a central defense mechanism. According to psychoanalyst Kernberg, "the normal tension between actual self on the one hand, and ideal self and ideal object on the other, is eliminated by the building up of an inflated self-concept within which the actual self and the ideal self and ideal object are confused. At the same time, the remnants of the unacceptable images are repressed and projected onto external objects, which are devalued."

The merging of the "inflated self-concept" and the "actual self" is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defense mechanisms of devaluation, idealization and denial. Other people are either manipulated as an extension of one's own self, who serve the sole role of giving "admiration and approval" or they are seen as worthless (because they cannot collude with the narcissist's grandiosity).

Relationship to shame
It has been suggested that narcissistic personality disorder may be related to defenses against shame. Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes. He saw the "oblivious" subtype as being grandiose, arrogant, and thick-skinned and the "hypervigilant" subtype as being easily hurt, oversensitive, and ashamed. In his view, the oblivious subtype presents for admiration, envy, and appreciation of a powerful, grandiose self that is the antithesis of a weak internalized self, which hides in shame, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers. Dr. Jeffrey Young, who coined the term "Schema Therapy", a technique originally developed by psychiatrist Aaron T. Beck (1979), also links NPD and shame. He sees the so-called Defectiveness Schema as a core schema of NPD, along with the Emotional Deprivation and Entitlement Schemas.

Proposed removal from DSM-5
The Personality and Personality Disorders Work Group originally proposed the elimination of NPD as a distinct disorder in DSM-5 as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains.

Some clinicians objected to this, characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice.

In July 2011, the Work Group came back with a major revision to their original proposal. In this revision, NPD was reinstated with dramatic changes to its definition. The general move towards a dimensional (personality trait-based) view of the Personality Disorders has been maintained despite the reintroduction of NPD.

ICD-10
The World Health Organization's ICD-10 lists narcissistic personality disorder under  Other specific personality disorders.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Subtypes
Theodore Millon identified five narcissist subtypes, however, there are few pure variants of any subtype.

Other theorists have identified two types of narcissism. Those narcissists who have been diagnosed with narcissistic grandiosity express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism." Another type of narcissism is narcissistic vulnerability. It entails (on a conscious level) "helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behavior as being socially avoidant in situations where their self-presentation is not possible so they withdraw, or the approval they need/expect is not being met."

Treatment
Prominent clinical strategies are outlined by Heinz Kohut, Stephen M. Johnson and James F. Masterson, while Johns discusses a continuum of severity and the kinds of therapy most effective in different cases. Schema Therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD. It is unusual for people to seek therapy for NPD. Unconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes. Pattern change strategies, over a long period of time, are for the narcissist to work on increasing their ability to become more empathetic in everyday relationships. To help modify their sense of entitlement and self-centeredness schema is to help them identify how to utilize their unique talents and to help others rather than for their own personal gain. This is not going to change their self-perception of their "entitlement" feeling but more so help them empathize with others. Another type of treatment would be temperament change.

Anger, rage, impulsivity and impatience can be worked on with skill training. Medication can also be an effective addition if needed. Anxiety disorders and somatoma dysfunctions are prevalent but the most common would be depression. Medication can be extremely beneficial when treating the disorder with regular therapy. Medications to help reduce impulsivity, depression, and anger (along with skilled training) will help the person create interpersonal relationships, be less impulsive, be less angry, and treat the depression/anxiety.

Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted, but group therapy can also contradict itself as the patient may show "demandingness, egocentrism, social isolation and withdrawal, and socially deviant behavior." Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: "effective expression, empathy, discussion and problem solving/conflict resolution." Marital/relationship therapy is most beneficial when both partners participate.

Correlative associations
NPD is comorbid with mood disorders, eating disorders, substance-related disorders and four personality disorders: antisocial, borderline, histrionic and paranoid. NPD is also comorbid with DSM Axis I major depressive disorders.

Eating disorders
The study of Narcissism and the Narcissistic Defenses in the Eating Disorders was concerned with the correlation between eating pathology and narcissism. Two types of narcissism were observed: core narcissism, having extremely positive (high) self-esteem combined with delusions about the level and ability of achievement; and narcissistic defenses, defenses that are triggered when self-esteem is threatened. Such narcissists maintain self-esteem by seeing themselves as misunderstood and a subject to intolerable demands.

Two types of narcissistic defenses that were measured with eating pathology were "poisonous pedagogy" and "narcissistically abused". Poisonous pedagogy is one who places blame on others and is overly critical of others' inadequacies. The narcissistically abused are those who put others’ needs before theirs yet see themselves as being poorly treated ("poor me"). Two groups were measured: Clinical ( 83 women and one male with the mean age of 28.4) and Non Clinical ( 70 women mean age of 23.2). BMI of groups did not significantly vary. They filled out a questionnaire that was measured by eating characteristic and narcissism levels by the OMNI (O’Brien Multiphasic Narcissism Inventory) and the EDE-Q (Eating Disorder Examination Questionnaire). OMNI measures pathological narcissism of narcissistic personality, poisonous pedagogy, and narcissistically abused personality. EDE-Q measures the common eating disorders: restraint, eating concern, body shape concern, and body weight concern.

The basic summaries of the questionnaire’s findings were the poisonous pedagogy defenses was related to restrictive mind-set; narcissistically abused defense related to restraint, eating concern, body shape concern, and body weight concern. The only main difference between the groups was the role of core narcissism in the clinical women’s levels of eating concerns. Further research is needed to better understand the relationship approaches in both groups.

Professional attainment
In 2005, Board and Fritzon published the results of a study in which they interviewed senior business managers, assessing them for the presence of personality disorder. Comparing their findings to three samples of psychiatric patients, they found that their senior business managers were as likely to demonstrate narcissistic traits as the patient population, although were less physically aggressive.

Anecdotal evidence suggests that narcissists may be particularly common in the financial sector as they "are able to make quick, bold decisions without any thought for the consequences these might have on other people". One financier with experience of NPD claimed to know a recruitment consultant who actively sought to recruit narcissists.

Epidemiology
Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.

In 2009, Twenge and Campbell conducted studies suggesting that the incidence of NPD had more than doubled in the US in the prior 10 years, and that 1 in 16 of the population have experienced NPD.

Cultural depictions
In the film To Die For, Nicole Kidman's character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder."