What is a Narcissistic Personality Disorder ? What is a Taker?

Narcissistic personality disorder (NPD) is a mental disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, a diminished ability to empathize with others’ feelings, and interpersonally exploitative behavior. A narcissistic personality disorder is one of the subtypes of the broader category known as personality disorders.^[1][2] It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.^[1]

Personality disorders are a class of mental disorders characterized by enduring and inflexible maladaptive patterns of behavior, cognition, and inner experience exhibited across many contexts and deviating from those accepted by any culture. These patterns develop by early adulthood and are associated with significant distress or impairment.^[4][5][6] Criteria for diagnosing personality disorders are listed in the fifth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association‘s Diagnostic and Statistical Manual of Mental Disorders (DSM).

There is no standard treatment for NPD.^[7][8] Its high comorbidity with other mental disorders influences treatment choice and outcomes.^[7] Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for the integration of both in therapy.^[9][10] However, there is an almost complete lack of studies determining the effectiveness of treatments.^[8]

Signs and symptoms

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes NPD as possessing at least five of the following nine criteria.^[2]

• A grandiose sense of self-importance
• Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• Believing that they are “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
• Requiring excessive admiration
• A sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with their expectations)
• Being interpersonally exploitative (taking advantage of others to achieve their own ends)
• Lacking empathy (unwilling to recognize or identify with the feelings and needs of others)
• Often being envious of others or believing that others are envious of them
• Showing arrogant, haughty behaviors or attitudes

Within the DSM-5, NPD is a cluster B personality disorder.^[2] Individuals with cluster B personality disorders often appear dramatic, emotional, or erratic.^[2] A narcissistic personality disorder is a mental disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and a diminished ability to empathize with others’ feelings.^[1][2]

A diagnosis of NPD, like other personality disorders, is made by a qualified healthcare professional in a clinical interview. The process of diagnosis often involves asking the client to describe people emotionally close to them, which can reveal extreme arrogance or a lack of empathy.^[1]

Narcissistic personality disorder usually develops either in youth or in early adulthood.^[2] True symptoms of NPD are pervasive, apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person’s mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person’s psychological abilities to function socially, either at work or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptomatic of NPD, the person’s manifested personality traits must substantially differ from social norms.^[2]

ICD-11 and ICD-10

In the International Statistical Classification of Diseases and Related Health Problems, 11th Edition ICD-11 of the World Health Organization (WHO), all personality disorders are diagnosed under a single title called “personality disorder”. The criteria for diagnosis are mainly concerned with assessing dysfunction, distress, and maladaptive behavior as opposed to attributing specific personality traits.

In the previous edition, the ICD-10, narcissistic personality disorder (NPD) is listed under the category of “other specific personality disorders”. This means similarly to the ICD-11, the ICD-10 required that cases otherwise described as NPD in the DSM-5 would only need to meet a general set of diagnostic criteria.^[11]

Associated features

People with NPD exaggerate their skills, accomplishments, and their degree of intimacy with people they consider high-status. A sense of personal superiority may lead them to monopolize conversations, look down on others^[12], or become impatient and disdainful when other people talk about themselves.^[2] This behavior correlates to overall worse functioning in areas of life like work and intimate romantic relationships.^{[13][14][15][16]}

People with NPD have been observed to use psychosocial strategies, such as the tendency to devalue and derogate and to insult and blame other people, usually with anger and hostility towards people’s responses to their anti-social behavior.^[17] Narcissistic personalities are more likely to respond with anger or aggressiveness when presented with rejection.^[18][19][20] Because they are sensitive to perceived criticism or defeat, people with NPD are prone to feelings of shame, humiliation, and worthlessness over minor incidents of daily life and imagined, personal slights,^[12] and usually mask such feelings from people, by feigning humility, responding with outbursts of rage and defiance, or seeking revenge.^[2][21]

The DSM-5 indicates that: “Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting, and cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder.”^[2] Given the high-function sociability associated with narcissism, some people with NPD might not view such a diagnosis as a functional impairment to their lives.^[22] Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they refuse to take risks, in order to avoid failure or the appearance of failure.^[2][21] Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism, makes it difficult for persons with NPD to work cooperatively or to maintain long-term, professional relationships with superiors and colleagues.^[23]

Differential diagnosis

The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.^[24] People with NPD are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring depressive disorder.^[25] NPD is associated with the occurrence of bipolar disorder and substance use disorders,^[1][21], especially cocaine use disorder.^[2] NPD may also be comorbid or differentiated from the occurrence of other mental disorders, including histrionic personality disorder, borderline personality disorder, antisocial personality disorder, or paranoid personality disorder.^[2] NPD should also be differentiated from mania and hypomania as these cases can also present with grandiosity, but present with different levels of functional impairment.^[2] Narcissistic personality disorder differs from self-confidence which is associated with a strong sense of self.^[2][12] It is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient and register below the clinical criteria for a formal diagnosis of NPD.^[12]

Subtypes

Although the DSM-5 diagnostic criteria for NPD have been viewed as homogeneous, there are a variety of subtypes used for the classification of NPD.^[1][26][27] There is poor consensus on how many subtypes exist, but there is broad acceptance that there are at least two: grandiose or overt narcissism, and vulnerable or covert narcissism.^[9][26] However, none of the subtypes of NPD are recognized in the DSM-5 or in the ICD-11.

Grandiose/overt and vulnerable/covert

Similar to the definition of NPD in the DSM-IV, Grandiose narcissism is defined by an inflated sense of self-worth and high self-esteem, interpersonal exploitativeness, social dominance and assertiveness, shamelessness, and a sense of entitlement derived from feelings of superiority or prestige.^[28]

The counterpart to grandiose narcissism is vulnerable narcissism, characterized by the personality traits of defensiveness, fragility, social withdrawal, and sensitivity to criticism.^[1]

Oblivious and hypervigilant

The psychiatrist and psychoanalyst Glen Gabbard described two subtypes of NPD in 1989, later referred to as equivalent to, the grandiose and vulnerable subtypes.^[29][30][31] The first was the “oblivious” subtype of narcissism, equivalent to the grandiose subtype. It was described as being grandiose, arrogant, and thick-skinned, while also exhibiting personality traits of helplessness and emotional emptiness, low self-esteem, and shame. These were observed in people with NPD to be expressed as socially avoidant behavior in situations where self-presentation is difficult or impossible, leading to withdrawal from situations where social approval is not given.

The second subtype Gabbard described was termed “hypervigilant”, equivalent to the vulnerable subtype. People with this subtype of NPD were described as having easily hurt feelings, an oversensitive temperament, and persistent feelings of shame.

High-functioning or exhibitionist

Those, competitive, attention-seeking, and sexually provocative; they tended to show adaptive functioning and utilize their narcissistic traits to succeed.”[26]rd subtype for classifying people with NPD, also initially theorized by Gabbard, is termed high functioning or exhibitionistic. ^[31][32] It has been described as “high functioning narcissists [who] were grand.

Millon’s subtypes

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In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), Theodore Millon suggested five subtypes of NPD, although they did not identify specific treatments per subtype.^[6]

Masterson’s subtypes (exhibitionist and closet)

In 1993, James F. Masterson proposed two subtypes of pathological narcissism, exhibitionist and closet.^[33] Both fail to adequately develop an age- and phase-appropriate self because of defects in the quality of psychological nurturing provided, usually by the mother. A person with exhibitionist narcissism is similar to NPD described in the DSM-IV and differs from closet narcissism in several ways. A person with closet narcissism is more likely to be described as having a deflated, inadequate self-perception and greater awareness of emptiness within. A person with exhibitionist narcissism would be described as having an inflated, grandiose self-perception with little or no conscious awareness of feelings of emptiness. Such a person would assume that their condition was normal and that others were just like them. A person with closet narcissism is described to seek constant approval from others and appears similar to those with borderline personality disorder in the need to please others. A person with exhibitionist narcissism seeks perfect admiration all the time from others.^[34]

Malignant narcissism[edit]

Malignant narcissism, a term first coined in Erich Fromm‘s 1964 book The Heart of Man: It’s Genius for Good and Evil,^[35] is a syndrome consisting of a combination of NPD, antisocial personality disorder, and paranoid traits. A person with malignant narcissism was described as deriving higher levels of psychological gratification from accomplishments over time, suspected to worsen the disorder. Because a person with malignant narcissism becomes more involved in psychological gratification, it was suspected to be a risk factor for developing antisocial, paranoid, and schizoid personality disorders. The term malignant is added to the term narcissist to indicate that individuals with this disorder have a severe form of the narcissistic disorder that is characterized also by features of paranoia, psychopathy (anti-social behaviors), aggression, and sadism.^[36]

Assessment and screening

Narcissistic Personality Inventory

Risk factors for NPD and grandiose/overt and vulnerable/covert subtypes are measured using the narcissistic personality inventory, an assessment tool originally developed in 1979, which has undergone multiple iterations with new versions in 1984, 2006, and 2014. The subtype is also assessed with the pathological narcissism inventory (PNI).^[37] The PNI is a screening tool for antisocial, borderline, and narcissistic personality disorders. The PNI scales exhibited significant associations with parasuicidal behavior, suicide attempts, homicidal ideation, and several aspects of psychotherapy utilization.^[38] Pathological narcissism is a term for concurrent grandiose and vulnerable narcissism, which is linked to poor self-esteem, lack of empathy, feelings of shame, interpersonal distress, aggression, and significant impairments in personality functioning across both clinical and non-clinical samples. Despite the phenomenological and empirical distinction between vulnerable and grandiose narcissism, some theories suggest that grandiose narcissists also have fragile personality traits.^[27] There are a number of other assessment tools for narcissism and NPD subtypes.^[39]

Millon Clinical Multiaxial Inventory

The Millon Clinical Multiaxial Inventory (MCMI) is another diagnostic test developed by Theodore Millon. The MCMI includes a scale for narcissism. The NPI and MCMI have been found to be well correlated.^[40] Whereas the MCMI measures narcissistic personality disorder (NPD), the NPI measures narcissism as it occurs in the general population; the MCMI is a screening tool. In other words, the NPI measures “normal” narcissism; i.e., most people who score very high on the NPI do not have NPD. Indeed, the NPI does not capture any sort of narcissism taxon as would be expected if it measured NPD.^[41]

A 2020 study found that females scored significantly higher on vulnerable narcissism than males, but no gender differences were found for grandiose narcissism.^[42]

Causes

Although there are no specific causes for NPD, it is described using the biopsychosocial model which describes a combination of risk factors from biological, psychological, and socio-environmental factors.^[7][43] This includes but is not limited to genetics, neurobiology, trauma, abuse, and parenting.

Genetic

Evidence suggests there is a high heritability of NPD, with a number of genetic influences indicating varying rates of heritability based on subtype.^{[43][24][44][45]} A number of twin studies historically suggested the heritability of NPD, including personality disorders in general.^[46][47]

Environment

Environmental and social factors also influence the development of NPD.^[24] In some people, pathological narcissism may develop from an impaired emotional attachment to primary caregivers (usually parents).^[48] That lack of psychological and emotional attachment to a parental figure can result in the child’s perception of themselves as unimportant and unconnected to other people, usually, family, community, and society. Typically, the child comes to believe that they have a personality defect that makes them unvalued and unwanted;^[49] overindulgent, permissive parenting or insensitive and over-controlling parenting are risk factors for the development of NPD in a child.^[12][25]

In Gabbard’s Treatments of Psychiatric Disorders (2014), the following factors are identified as promoting the development of narcissistic personality disorder:^[50]

• An oversensitive temperament (individual differences of behavior) at birth
• Excessive admiration that is never balanced with realistic criticism
• Excessive praise for good behaviors, or excessive criticism for bad behaviors in childhood
• Overindulgence and overvaluation by family or peers
• Being praised by adults for perceived exceptional physical appearance or abilities
• Trauma caused by psychological abuse, physical abuse, or sexual abuse in childhood
• Unpredictable or unreliable parental caregiving
• Learning the behaviors of psychological manipulation from parents or peers^[51]

Moreover, the research reported in “Modernity and Narcissistic Personality Disorders” (2014) indicates that cultural elements also influence the prevalence of NPD, because narcissistic personality traits more commonly occur in modern societies than in traditionalist conservative societies.^[24]

Pathophysiology

Studies of the occurrence of narcissistic personality disorder identified structural abnormalities in the brains of people with NPD, specifically, a lesser volume of gray matter in the left, anterior insular cortex.^[52][53] The results of a 2015 study associated the condition of NPD with a reduced volume of gray matter in the prefrontal cortex.^[54] The regions of the brain identified and studied – the insular cortex and the prefrontal cortex – are associated with the human emotions of empathy and compassion, and with the mental functions of cognition and emotional regulation. The neurologic findings of the studies suggest that NPD may be related to a compromised (damaged) capacity for emotional empathy and emotional regulation.^[55]

Management

Treatment for NPD is primarily psychotherapeutic; there is no clear evidence that psychopharmacological treatment is effective for NPD, although it can prove useful for treating comorbid disorders.^[9][56] Psychotherapeutic treatment falls into two general categories: psychoanalytic/psychodynamic and cognitive behavioral. Psychoanalytic therapies include schema therapy, transference-focused psychotherapy, mentalization-based treatment, and metacognitive psychotherapy. Cognitive behavioral therapies include cognitive behavioral therapy and dialectical behavior therapy. Formats also include group therapy and couples therapy.^[10] The specific choice of treatment varies based on individual presentations.^[57]

Management of narcissistic personality disorder has not been well studied, however many treatments tailored to NPD exist.^[8][1] Therapy is complicated by the lack of treatment-seeking behavior in people with NPD, despite mental distress. Additionally, people with narcissistic personality disorders have decreased life satisfaction and lower quality of life, irrespective of diagnosis.^{[58][59][60][61][62]} People with NPD often present with comorbid mental disorders, complicating diagnosis and treatment.^[1] NPD is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they often express seeking relief from a comorbid mental disorder, including major depressive disorder, a substance use disorder (drug addiction), or bipolar disorder.^[21]

Prognosis

As of 2020, no treatment guidelines exist for NPD and no empirical studies have been conducted on specific NPD groups to determine the efficacy of psychotherapies and pharmacology.^[8][9]

The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates.^[1]

Epidemiology

As of 2018, the overall prevalence is estimated to range from 0.8% to 6.2%.^[63][64] In 2008 under the DSM-IV, the lifetime prevalence of NPD was estimated to be 6.2%, with 7.7% for men and 4.8% for women,^[65] with a 2015 study confirming the gender difference.^[66] In clinical settings, prevalence estimates range from 1% to 15%.^[7][3] The occurrence of narcissistic personality disorder presents a high rate of comorbidity with other mental disorders.^[24]

History

The term “narcissism” comes from a first-century (written in the year 8 AD) book by the Roman poet Ovid. Metamorphoses Book III is a myth about two main characters, Narcissus and Echo. Narcissus is a handsome young man who spurns the advances of many potential lovers. When Narcissus rejects the nymph Echo, named this way because she was cursed to only echo the sounds that others made, the gods punish him by making him fall in love with his own reflection in a pool of water. When Narcissus discovers that the object of his love cannot love him back, he slowly pines away and dies.^[67]

The concept of excessive selfishness has been recognized throughout history. In ancient Greece, the concept was understood as hubris. It is only since the late 1800s that narcissism has been defined in psychological terms:^[68]

• Havelock Ellis (1898) was the first psychologist to use the term when he linked the myth to the condition of one of his patients.^[68]
• Sigmund Freud (1905-1953) used the term “narcissistic libido” in his Three Essays on the Theory of Sexuality.^[69][68]
• Ernest Jones (1913/1951) was the first to construe extreme narcissism as a character flaw.
• Robert Waelder (1925) published the first case study of narcissism. His patient was a successful scientist with an attitude of superiority, an obsession with fostering self-respect, and a lack of normal feelings of guilt. The patient was aloof and independent from others and had the inability to empathize with others’ situations, and was selfish sexuality. Waelder’s patient was also overly logical and analytical and valued abstract intellectual thought (thinking for thinking’s sake) over the practical application of scientific knowledge.

A narcissistic personality was first described by the psychoanalyst Robert Waelder in 1925.^[70] The term narcissistic personality disorder (NPD) was coined by Heinz Kohut in 1968.^[71][72] Waelder’s initial study has been influential in the way narcissism and the clinical disorder Narcissistic personality disorder are defined today^[73]

Freudianism and psychoanalysis

Much early history of narcissism and NPD originates from psychoanalysis. Regarding the adult neurotic‘s sense of omnipotence, Sigmund Freud said that “this belief is a frank acknowledgment of a relic of the old megalomania of infancy“;^[74] and concluded that: “we can detect an element of megalomania in most other forms of the paranoic disorder. We are justified in assuming that this megalomania is essential of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations.”^[75]

Narcissistic injury and narcissistic scar are terms used by Freud in the 1920s. Narcissistic wound and narcissistic blow are other, almost interchangeable, terms.^[76] When wounded in the ego, either by real or perceived criticism, a narcissistic person’s displays of anger can be disproportionate to the nature of the criticism suffered;^[12] but typically, the actions and responses of the NPD person are deliberate and calculated.^[2] Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.^[2]

In The Psychology of Gambling (1957), Edmund Bergler considered megalomania to be a normal occurrence in the psychology of a child,^[77] a condition later reactivated in adult life if the individual takes up gambling.^[78] In The Psychoanalytic Theory of Neurosis (1946), Otto Fenichel said that people who, in their later lives, respond with denial to their own narcissistic injury usually undergo a similar regression to the megalomania of childhood.^[79]

Narcissistic supply

Narcissistic supply was a concept introduced by Otto Fenichel in 1938, to describe a type of admiration, interpersonal support, or sustenance drawn by an individual from his or her environment and essential to their self-esteem.^[80] The term is typically used in a negative sense, describing a pathological or excessive need for attention or admiration in codependents and the orally fixated, that does not take into account the feelings, opinions, or preferences of other people.^[81]

Narcissistic rage

The term narcissistic rage was a concept introduced by Heinz Kohut in 1972. Narcissistic rage was theorized as a reaction to a perceived threat to a narcissist’s self-esteem or self-worth. Narcissistic rage occurs on a continuum from aloofness, to expressions of mild irritation or annoyance, to serious outbursts, including violent attacks.^[82]

Narcissistic rage reactions are not necessarily limited to NPD. They may also be seen in catatonic, paranoid delusion, and depressive episodes.^[82] It was later suggested that narcissistic people have two layers of rage; the first layer of rage is directed at constant anger toward someone else, with the second layer being self-deprecating.^[83]

Object relations

In the second half of the 20th century, in contrast to Freud’s perspective of megalomania as an obstacle to psychoanalysis, in the US and UK Kleinian psychologists used the object relations theory to re-evaluate megalomania as a defense mechanism.^[84] This Kleinian therapeutic approach is built upon Heinz Kohut‘s view of narcissistic megalomania as an aspect of normal mental development, in contrast with Otto Kernberg‘s consideration of such grandiosity as a pathological distortion of normal psychological development.^[85]

To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed individual who passes blame by psychological projection and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of their behaviors, whilst insisting that people should see them as an ideal person.^{[citation needed]} The merging of the terms “inflated self-concept” and “actual self“ is evident in later research on the grandiosity component of narcissistic personality disorder, along with incorporating the defense mechanisms of idealization and devaluation, and of denial.^[86]

Comparison to borderline personality disorder

NPD shares properties with borderline personality disorder, including social stigma, unclear causes, and prevalence rates. In a 2020 study, it was argued that NPD is following a similar historical trend to borderline personality disorder: “In the past three decades, enormous progress has been made to elucidate the psychopathology, longitudinal course, and effective treatment for BPD. NPD, which remains as similarly stigmatized and poorly understood as BPD once was, now carries the potential for a new wave of investigation and treatment development.”^[87]

Controversy

The extent of controversy about narcissism was on display when the committee on personality disorders for the 5th Edition (2013) of the Diagnostic and Statistical Manual of Mental Disorders recommended the removal of Narcissistic Personality from the manual. A contentious three-year debate unfolded in the clinical community with one of the sharpest critics being John Gunderson, who led the DSM personality disorders committee for the 4th edition of the manual.^[88]

The American Psychiatric Association‘s (APA) formulation, description, and definition of narcissistic personality disorder, as published in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed., Text Revision (DSM-IV-TR, 2000), was criticized by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That it is excessively focused upon “the narcissistic individual’s external, symptomatic, or social interpersonal patterns – at the expense of … internal complexity and individual suffering”, which reduced the clinical utility of the NPD definition in the DSM-IV-TR.^[22]

In revising the diagnostic criteria for personality disorders, the work group for the list of “Personality and Personality Disorders” proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the DSM-5, and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains.^[89][90] Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an “unwieldy conglomeration of disparate models that cannot happily coexist”, which is of limited usefulness in clinical practice.^[91] Despite the reintroduction of the NPD entry, the APA’s re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.

A 2011 study concluded that narcissism should be conceived as a personality dimension pertinent to the full range of personality disorders, rather than as a distinct diagnostic category.^[92] In a 2012 literature review about NPD, the researchers concluded that narcissistic personality disorder “shows nosological inconsistency and that its consideration as a trait domain needed further research would be strongly beneficial to the field.”^[93] In a 2018 latent structure analysis, results suggested that the DSM-5 NPD criteria fail to distinguish some aspects of narcissism relevant to the diagnosis of NPD and subclinical narcissism.^[94]