Narcissism sits on a continuum. We need to have a certain level of confidence and a certain level of self-esteem to function and be productive on a daily basis. Narcissistic Personality Disorder (NPD) is an extreme manifestation of narcissism. Criteria:
- grandiose sense of self-importance – Someone needs to be recognized as superior even though there is no evidence to support this superior standing and if that recognition doesn’t occur, sometimes frustration and sadness can set in for that person. They expect to be recognized as being superior.
- preoccupation with unlimited success and with this manifestation we can see a lot of different occurrences. One would be, kind of a fantasy, and no real, clear way that that would be achievable. It’s not always unrealistic, but most of the time.
- someone is too special to be understood by regular people – People can’t understand how good he/she is, how special they are. They are complex to such a degree that normal individual just can’t comprehend, but certain special people could and often times this takes the shape of famous people.
- needs excessive admiration and this points to kind of an interesting topic of self-esteem – There are a few different theories about self-esteem and individuals with NPD, including theory that suggests they actually have a high self-esteem. In DSM-V and in practice it’s not the case that we see high self-esteem, but rather, almost all the time, we see low self-esteem, a particularly fragile self-esteem for people with this disorder. They often look for compliments in normal conversation.
- sense of entitlement
- highly manipulative
- exploiting relationship – They are very nice when they need you, but they will disregard you if they don’t need you without hesitation.
- lack of empathy – This is an element which is shared between NPD and Antisocial Personality Disorder. With NPD this and Antisocial Personality Disorder, it’s an inability for the most part to recognize the feelings and goals of other people. They can’t pick up affect somebody has. They are self-centered and don’t care for others, even if they can feel empathy.
- envious of others and they believe that other people are envious of them. It’s chronic. They tend to devalue the contributions of other people.
- arrogance
- they are condescending and they always accuse others of being incompetent
- they respond poorly to criticism – No amount of praise can compensate for criticism, sometimes.
- rage – If they don’t get what they want, feel they deserve, if they are offended, their rage is huge. There is an explanation regarding that rage and it’s about ”narcissistic wound”. According to that theory, they build ‘walls’ around their fragile ego while they are children and later in life we can see those walls; beautiful mansions, expensive cars, expensive clothes, nice-looking partners etc. Actually, they protect themselves by hiding their deep insecurity behind the walls. If they can’t afford it, they will use intellect or something different. Supporters of this theory believe that children who are humiliated, criticized, not good enough to their parents or one parent whatever they do, might develop NPD. And what about narcissistic wound? When they feel that someone humiliates, offends, hurts them, all pain, anger, rage from childhood will overwhelm them.
- low agreeableness – Agreeableness is a personality trait with several facets: trust, altruism, kindness, affection and other prosocial behaviors. They are more likely to be empathetic and tend to be more cooperative. People with NPD value competition more than cooperation.
- tendency to blame other people when something goes wrong. They don’t take a responsibility.
- pathological lying
- poor listener – Sometimes they appear to listen to you, but they are calculating what to say about themselves.
- tendency to be engaged in extramarital affairs – fantasy of an ideal love with money, power… also, tendency to be bored, they have a lower amount of tolerance in general…
- they never ask for help for NPD. They go to clinicians when they have to (court order). They feel great, unless they are anxious or have some other mental condition, but people around them suffer.
Other illnesses that are comorbid (simultaneously present in a patient, relating to medical conditions) with NPD would be anorexia nervosa (often referred to simply as anorexia) and substance use disorder, especially cocaine. Also, borderline, histrionic, antisocial and paranoid are comorbid with NPD.
DSM – 5, criteria:
In interpersonal settings, there is a pervasive pattern of grandiosity, need for admiration, and lack of empathy. This pattern of behaviors onsets in early adulthood and persists through various contexts. Clinical features include at least 5 of the following:
- Having a grandiose sense of self-importance, such as 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 behaviors
- Lack of empathy
- Envy towards others or belief that others are envious of them
- Arrogant, haughty behaviors and attitudes
They are generally unable to handle criticism from peers or staff and frequently become enraged. Individuals with NPD have difficulty following rules (or believing rules apply to them). Descriptions of empathy are limited when discussing failed relationships. Although many individuals with NPD deny feelings of depression or any signs of perceived weakness, they often suffer symptoms of depression due to an underlying fragile ego perpetuated by socio-occupational impairment from their maladaptive behaviors. There are 2 proposed subtypes of NP: grandiose NPD and vulnerable NPD. The grandiose subtype includes overt grandiosity, aggression, a profound lack of empathy, exploitation, and boldness. The vulnerable subtype presents with hypersensitivity and defensiveness and may be overlooked; these individuals may be more susceptible to affective disorders due to a fragile ego.
Clothing, accessories, hairstyles, or tattoos that are provoking may suggest NPD, as there is a sense of grandiosity and attention-seeking behavior characteristic of the disorder. The clinician should monitor for disinhibited behaviors, grandiose postures, smirking, and scoffing. The context of the patient’s cooperation should be paid particular attention to, as it may vary greatly depending on who the individual interacts with (depending on their perceived status). NPD may present with an increased amount of speech due to feelings of needing to prove oneself or brag about achievements and friendships, but there are no expected concerns with speech initiation, volume, or vocabulary. Affect is highly variable but may fluctuate greatly depending on the conversation topic, particularly if the patient with NPD feels challenged or threatened by the interviewer. More lability is expected than usual, with more frequent irritability. It is essential to assess for delusions in patients with NPD. The level of grandiose thought may border between non-delusional grandiose thoughts and delusional (psychotic) grandiose thoughts. Although this distinction does not impact the treatment plan, it does help the clinician assess the severity of NPD. The thought process in NPD is generally concrete, with grandiosity being unchallengeable. Still, individuals with NPD have the capability for linear and logical thought, often used to achieve their initial accomplishments (higher education, careers, relationships of status). General cognition and orientation are not expected to be impaired in NPD but should be evaluated to rule out other psychiatric conditions. NPD is an egosyntonic disorder; therefore, a patient’s understanding of their NPD is generally poor. Accepting self-deficit is usually not congruent with NPD. The severity of NPD will impact a patient’s judgment. This can often be assessed by inquiring of the patient’s legal and relationship histories. Reward dependence describes the amount of desire to cater to behaviors in response to social reward cues. Individuals with NPD have high reward dependence, to the point of demanding praise when completing tasks or forming new relationships. Individuals with NPD try to be social but for the sake of receiving praise or being seen in association with others of high status, which provides them with internal reward and validation. Harm avoidance involves a bias towards inhibiting behavior that would result in punishment or non-reward. Individuals with NPD have relatively low harm avoidance; instead, they may act in general disregard for the consequences of their actions or view the potential gain from risky behavior as far outweighing the gamble of any potential harm that may result. Further, individuals with NPD are generally outgoing and have few social inhibitions. The underlying temperament of NPD is classic for high reward dependence and low harm avoidance behaviors, which generally results in poor impulse control. This can also be assessed by inquiring about past legal and relationship history. Persistence describes the ability to maintain behaviors despite frustration, fatigue, and limited reinforcement. Interestingly, individuals with NPD are quite persistent, with an extreme desire to seek out a reward. They will persist in certain behaviors; however, this is generally one of their most major maladaptive traits, particularly when combined with their tendency for low harm avoidance. These individuals strive for higher accomplishments and social status worthy of praise. Novelty seeking describes an inherent desire to initiate novel activities likely to produce a reward signal. Individuals with NPD have moderate-to-high novelty-seeking behaviors. They tend to be hot-tempered and social; some are thrill-seeking.
NPD can cause significant social and occupational impairment and often has complications of comorbid psychiatric and substance use disorders.
Mitra P, Torrico TJ, Fluyau D. Narcissistic Personality Disorder. [Updated 2024 Mar 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556001/