Pathological Narcissism

Pathological narcissism is a life-long pattern of traits and behaviours. It is an infatuation and obsession with one's self and the egotistic and ruthless pursuit of one's gratification, dominance and ambition.

We all possess healthy narcissism, which is adaptative, flexible, realistic, and helps our functioning. In contrast, pathological narcissism is maladaptive, rigid, persisting, and causes significant distress, and functional impairment.

Pathological narcissism was first described in detail by Freud in his essay "On Narcissism" (1915). Other major contributors to the study of narcissism are: Melanie Klein, Karen Horney, Franz Kohut, Otto Kernberg, Theodore Millon, Elsa Roningstam, Gunderson, and Robert Hare.

The Legend of Narcissus According to the Ancient Greek legend of Narcissus, Narcissus fell in love with his own reflection in a pond. He rejected the advances of the nymph Echo and was punished by Nemesis, consigned to pine away as he fell in love with his own reflection.

What is Narcissistic Personality Disorder (NPD)? The Narcissistic Personality Disorder (NPD) is a Cluster B (dramatic, emotional, or erratic) personality disorder. Other Cluster B personality disorders are the Borderline Personality Disorder (BPD), the Antisocial Personality Disorder (APD), and the Histrionic Personality Disorder (HPD). The Narcissistic Personality Disorder (NPD) was first included as a mental health diagnosis in the DSM III-TR (Diagnostic and Statistical Manual) in 1980.

Types of Narcissistic Personality Disorder (NPD) Narcissists are either "Cerebral" (derive their narcissistic supply from their intelligence or academic achievements) - or "Somatic" (derive their narcissistic supply from their physique, exercise, physical or sexual prowess and romantic or physical "conquests"). Narcissists are "Classic", "Compensatory", or "Inverted". The classic narcissist is self-confident, the compensatory narcissist covers up in his haughty behavior for a deep-seated deficit in self-esteem, and the inverted type is a co-dependent who caters to the emotional needs of a classic narcissist. Other typologies have been suggested (for instance, the phallic vs. non-phallic narcissist). Based on a survey of 1201 therapists and psychologists in clinical practice, Prof. Drew Westen of Emory University postulated the existence of three subtypes of narcissists: 1. High functioning or Exhibitionist: "(H)as an exaggerated sense of self-importance, but is also articulate, energetic, outgoing, and achievement oriented." (The equivalent of the Cerebral narcissist). 2. Fragile: "(W)ants to feel important and privileged to ward off painful feelings of inadequacy and loneliness" (The equivalent of the Compensatory narcissist). 3. Grandiose or Malignant: "(H)as an exaggerated sense of self-importance, feels privileged, exploits others, and lusts after power." (The equivalent of the Classic narcissist).

Prevalence and Age and Gender Features According to the DSM IV-TR, between 2% and 16% of the population in clinical settings (between 0.5-1% of the general population) are diagnosed with Narcissistic Personality Disorder (NPD). A slight majority of narcissists (50-75%, according to the DSM-IV-TR) are men. Narcissistic traits are common among adolescents, but few go on to develop the full-fledge disorder. The disorder becomes more acute a the narcissist grows older and is exacerbated by the onset of aging and the physical, mental, and occupational restrictions. Robert Milman suggested that under constant public scrutiny and exposure, a transient and reactive form of the Narcissistic Personality Disorder (NPD) can develop. He labelled it "Acquired Situational Narcissism". Studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to NPD.

Characteristics and Traits A person diagnosed with the Narcissistic Personality Disorder (NPD) feels grandiose and self-important. He tends to exaggerates his accomplishments, talents, skills, contacts, and personality traits to the point of lying. He also demands to be recognized as superior without commensurate achievements. Narcissists are obsessed with fantasies of unlimited success, fame, fearsome power or omnipotence, unequalled brilliance (the cerebral narcissist), bodily beauty or sexual performance (the somatic narcissist), or ideal, everlasting, all-conquering love or passion. They are firmly convinced that he or she is unique and, being special, can only be understood by, should only be treated by, or associate with, other special or unique, or high-status people (or institutions). The narcissist requires excessive admiration, adulation, attention and affirmation - or, failing that, wishes to be feared and to be notorious. Such feedback is known as narcissistic supply and the narcissist uses it to regulate his labile sense of self-worth. The narcissist feels entitled. He demands automatic and full compliance with his unreasonable expectations for special and favorable priority treatment. A a result, he is often "interpersonally exploitative", i.e., uses others to achieve his or her own ends; Narcissists lack empathy. They are unable or unwilling to identify with, acknowledge, or accept the feelings, needs, preferences, priorities, and choices of others. They are constantly envious of others and seek to hurt or destroy the objects of their resulting frustration. They suffer from persecutory (paranoid) delusions because they believe that others feel the same about them - seething with envy and resentment - and are likely to act on these negative sentiments. The narcissist is arrogant and haughty. He feels superior, omnipotent, omniscient, invincible, immune, "above the law", and omnipresent (magical thinking). Rages when frustrated, contradicted, or confronted by people he considers inferior to him and unworthy.

Clinical Features of the Narcissistic Personality Disorder The onset of pathological narcissism is in infancy, childhood and early adolescence. It is commonly attributed to childhood abuse and trauma inflicted by parents, authority figures, or even peers. There are indications that heredity may be involved as well. Pathological narcissism is a defense mechanism intended to deflect hurt and trauma from the victim's "True Self" into a "False Self" which is omnipotent, invulnerable, and omniscient. The narcissist uses the False Self to regulate his or her labile sense of self-worth by extracting from his environment narcissistic supply (any form of attention, both positive and negative). Narcissistic supply is outside attention - usually positive (adulation, affirmation, fame, celebrity) - used by the narcissist to regulate his labile sense of self-worth. There is a whole range of narcissistic reactions, styles, and personalities – from the mild, reactive and transient to the permanent personality disorder. Patients with Narcissistic Personality Disorder (NPD) feel injured, humiliated and empty when criticized. They often react with disdain (devaluation), rage, and defiance to any slight, real or imagined. To avoid such situations, some patients with Narcissistic Personality Disorder (NPD) socially withdraw and feign false modesty and humility to mask their underlying grandiosity. Dysthymic and depressive disorders are common reactions to isolation and feelings of shame and inadequacy. The interpersonal relationships of patients with Narcissistic Personality Disorder (NPD) are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (narcissistic supply). Though often ambitious and capable, inability to tolerate setbacks, disagreement, and criticism make it difficult for patients with Narcissistic Personality Disorder (NPD) to work in a team or to maintain long-term professional achievements. The narcissist's fantastic grandiosity, frequently coupled with a hypomanic mood, is typically incommensurate with his or her real accomplishments (the "grandiosity gap"). Patients with Narcissistic Personality Disorder (NPD) are either "cerebral" (derive their Narcissistic Supply from their intelligence or academic achievements) or "somatic" (derive their Narcissistic Supply from their physique, exercise, physical or sexual prowess and romantic or physical "conquests"). Patients with Narcissistic Personality Disorder (NPD) are either "classic" (meet five of the nine diagnostic criteria included in the DSM), or they are "compensatory" (their narcissism compensates for deep-set feelings of inferiority and lack of self-worth). Some narcissists are covert, or inverted narcissists. As codependents, they derive their narcissistic supply from their relationships with classic narcissists.

Comorbidity and Differential Diagnoses Narcissistic Personality Disorder (NPD) is often diagnosed with other mental health disorders ("co-morbidity"), such as mood disorders, eating disorders, and substance-related disorders. Patients with Narcissistic Personality Disorder (NPD) are frequently abusive and prone to impulsive and reckless behaviours ("dual diagnosis"). Narcissistic Personality Disorder (NPD) is commonly diagnosed with other personality disorders, such as the Histrionic, Borderline, Paranoid, and Antisocial Personality Disorders. The personal style of those suffering from the Narcissistic Personality Disorder (NPD) should be distinguished from the personal styles of patients with other Cluster B Personality Disorders. The narcissist is grandiose, the histrionic coquettish, the antisocial (psychopath) callous, and the borderline needy. As opposed to patients with the Borderline Personality Disorder, the self-image of the narcissist is stable, he or she are less impulsive and less self-defeating or self-destructive and less concerned with abandonment issues (not as clinging). Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt. According to the DSM-IV-TR, both narcissists and psychopaths are "tough-minded, glib, superficial, exploitative, and unempathic". But narcissists are less impulsive, less aggressive, and less deceitful. Psychopaths rarely seek narcissistic supply. As opposed to psychopaths, few narcissists are criminals. Patients suffering from the range of obsessive-compulsive disorders are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical and far more aware of their own deficiencies, flaws, and shortcomings.

Treatment and Prognosis The common treatment for patients with Narcissistic Personality Disorder (NPD) is talk therapy (mainly psychodynamic psychotherapy or cognitive-behavioural treatment modalities). Talk therapy is used to modify the narcissist's antisocial, interpersonally exploitative, and dysfunctional behaviors, often with some success. Medication is prescribed to control and ameliorate attendant conditions such as mood disorders or obsessive-compulsive disorders. The prognosis for an adult suffering from the Narcissistic Personality Disorder (NPD) is poor, though his adaptation to life and to others can improve with treatment.

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