Narcissistic Personality Disorder

Although NPD is not curable, it is amenable to treatment. The challenge is narcissists don’t see themselves as the cause of their problems.

NPD occurs in 1% – 6.2% of the population and up to 16% in the clinical population; males exceed females at a ratio of 3:2.

Mythology

Narcissus was a young Greek man in a tragic story told by the Roman poet Ovid in Metamorphoses. To punish Narcissus for his arrogance, the goddess Nemesis sentenced him to a life without human love. He fell in love with his own reflection instead.

What is Narcissistic Personality Disorder?

“Narcissism” ranges from self-centeredness, in the colloquial usage of the term, to subclinical narcissism, describing someone with narcissistic traits that are insufficient to establish Narcissistic Personality Disorder (“NPD”). Narcissism is also viewed on a continuum from healthy narcissism in mature individuals who can idealize romantic partners, express their talents and skills, and accomplish their goals to immature people who are highly sensitive to wounding, employ destructive, psychotic defenses and have unstable relationships.[i]

NPD occurs in 1 to 6.2 percent of the population and up to 16 percent in the clinical population; males exceed females at a ratio of 3:2.[ii] It wasn’t categorized as a disorder by the American Psychiatric Association until 1987, because it was felt that too many people shared some of the traits and it was difficult to diagnose.

Symptoms and Diagnosis of NPD

The symptoms are laid out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.[iii] NPD begins by early adulthood with a pervasive pattern of grandiosity (sometimes only in fantasy), a constant need for admiration, and lack of empathy, as indicated by the presence of at least 5 of the following:

  1. A grandiose sense of self-importance
  2. Fantasies of unlimited success, power, brilliance, beauty, or ideal love
  3. A belief 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. A need for excessive admiration
  5. A sense of entitlement
  6. Exploitation or taking advantage of other people
  7. Lack of empathy
  8. Envy of others or a belief that others are envious of him or her
  9. Arrogance

NPD ranges in severity from people satisfying only five of the criteria with mild behavior to “malignant” narcissists, who demonstrate all nine and are malicious, vindictive, and exhibit more anti-social behavior, similar to sociopathy, or people with an anti-social personality disorder.

Types of Narcissists

All subtypes of narcissists meet the required criteria for NPD but emphasize different personality traits. “Exhibitionist narcissists” are extroverted and fit the common stereotype. There are also “introverted,” “covert” or “closet narcissists,” who may act humble or shy, and have an inadequate self-perception. Yet, they still lack empathy, are self-centered, and entitled. Their grandiosity may be hidden in martyrdom or unfilled dreams of greatness.

Other sub-types classified by psychologist Theodore Millon include the “unprincipled narcissist,” who is dishonest and acts without morality; the amorous narcissist,” who are seductive and exploitative of the opposite sex; the “compensatory narcissist,” who is the center of his or her imaginary world and seeks admiration for fabricated or exaggerated accomplishments; and the “elitist narcissist,” who is a competitive opportunist, constantly self-aggrandizing to climb the social or corporate ladder, while trampling over other people.

Etiology

How NPD develops is still unknown, but it may be caused by a combination of genetic, psychological, and environmental factors. Several psychodynamic theories focus on the parent-child relationship, particularly with the mother. Otto Kernberg believed NPD resulted from a child having had an envious, hostile, or distant mother who is hypercritical and devaluing of her child. According to Heinz Kohut, NPD reflects arrested psychological development due to inadequate, unempathic mirroring. Another theory suggests that it derives from extreme closeness with an overly indulgent mother. Twin studies reveal a 64-percent correlation of narcissistic behaviors, suggesting a genetic component.[iv]

Treatment

Although NPD is not curable, it is amenable to treatment. However, narcissists don’t see themselves as the cause of their problems and rarely enter treatment, except to manage an external problem, such as a divorce or work-related issue, or following a major blow to their fragile self. Sometimes they come because their spouse insists on conjoint counseling. Occasionally, they seek treatment for loneliness and depression. Medication has not been shown to be effective, except to treat associated depression or anxiety.

Individual Psychotherapy. Although narcissism is difficult to treat, progress can be made over time in talk therapy. Weekly sessions over a shorter term can improve patients’ functioning and adaptation to reality by gaining some control over their defenses and behavior. They can learn to better tolerate criticism, accept realistic goals and limitations, collaborate with others, and manage their anger, rage, and impulsivity. Some therapists believe depth work should be avoided not only because the narcissist’s difficulties emanating from the outside, but also because they need to strengthen their defenses against primitive feelings.[v] On the other hand, psychoanalysis and psychoanalytic psychotherapy are generally used for treating the disorder itself and would entail examining early trauma. Ultimately, effectiveness depends on the patient’s motivation and capacity to introspect and take responsibility for his or her behavior.

Although narcissists may feign empathy in order to get close or win others’ approval, subclinical narcissists have been taught empathy, through using their imagination (put themselves in another’s shoes).[vi]

Conjoint Therapy. In relationships with narcissists, underlying vulnerability and shame can provoke escalating cycles of defensive maneuvers involving forms of attack and withdrawal. Destructive defenses further deteriorate perceptions of one another. In conjoint therapy, couples can be educated that such tactics erode good feelings and damage their relationship. They can build self-awareness and learn how they protect themselves when they’re hurt, what they need and want from each other, and the impact of their current behaviors. This can open a dialogue between them about feelings, wishes, and needs, the way communicate, and its effect on one another. Partners can attain more realistic and understanding views of one another and to tolerate each other’s failure to meet their needs and expectations. Even if a narcissist cannot empathize with feelings, they do have the emotional intelligence that can be tapped to educate them to behave in ways that will better get their needs met.[vii]

It’s important when seeking treatment to find a psychotherapist or psychoanalyst experienced in treating NPD, who can be empathetic, yet not be intimidated or manipulated by the narcissistic patient. Symptoms, diagnoses, and primary relationships, including parental relationships, should be discussed and goals established. Many narcissists have addictions. Abstinence or sobriety should be the initial focus in therapy.

References

[i] Solomon, M. F. (1989). Narcissism and Intimacy. New York: W.W. Norton & Co., Inc.

[ii] Dhawan, N. K. (2010). Prevalence and treatment of narcissistic personality disorder in the community: a systematic review. Comprehensive Psychiatry 51.4, 333-339. McClean, J. (October 2007). Psychotherapy with a Narcissistic Patient Using Kohut’s Self Psychology Model. Psychotherapy Rounds, 40-47.

[iii] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders V. Washington, DC: American Psychiatric Publishing, Inc.

[iv] Livesley, W. J., Jang, K. L., Jackson, D. N., & Vernon, P. A. (December 1993). Genetic and environmental contributions to dimensions of personality disorder. The American Journal of Psychiatry 150 (12), pp. 1826-31.

[v] Russell, G. A. (1985). Narcissism and the narcissistic personality disorder: A comparison of the theories of Kohut and Kernberg. British Journal of Medical Psychology, 58, 137-148.

[vi] Hepper, E., Hart, C., & Sedikides, C. (May, 2014). Moving Narcissus: Can Narcissists Be Empathic? Personality and Social Psychology Bulletin.

[vii] Lancer, D. (July, 2015). “The Problem of Narcissists,” The Therapist, pp. 7-12. Lancer, D. (2015). Dealing with a Narcissist. Los Angeles: Carousel Books.