Thursday, October 30, 2014

8. Narcissistic personality disorder

Narcissistic personality disorder takes its name from the myth of Narcissus, a beautiful youth who fell in love with his own reflection. In narcissistic personality disorder the person has a grandiose sense of self-importance, a sense of entitlement, and a need to be admired. He or she is envious of others and expects them to be the same of him or her. He or she lacks empathy and readily exploits others to achieve his or her goals. To others he or she may seem self-absorbed, controlling, intolerant, selfish, and insensitive. If he or she feels slighted or ridiculed, he or she may be provoked into a fit of destructive anger and revenge-seeking. Such ‘narcissistic rage’ can have disastrous consequences for all those involved.

Narcissistic Personality Disorder is characterized by a long-standing pattern of grandiosity (either in fantasy or actual behavior), an overwhelming need for admiration, and usually a complete lack of empathy toward others. People with this disorder often believe they are of primary importance in everybody’s life or to anyone they meet. While this pattern of behavior may be appropriate for a king in 16th Century England, it is generally considered inappropriate for most ordinary people today.
People with narcissistic personality disorder often display snobbish, disdainful, or patronizing attitudes. For example, an individual with this disorder may complain about a clumsy waiter’s “rudeness” or “stupidity” or conclude a medical evaluation with a condescending evaluation of the physician.
In laypeople terms, someone with this disorder may be described simply as a  “narcissist” or as someone with “narcissism.” Both of these terms generally refer to someone with narcissistic personality disorder.
A personality disorder is an enduring pattern of inner experience and behavior that deviates from the norm of the individual’s culture. The pattern is seen in two or more of the following areas: cognition; affect; interpersonal functioning; or impulse control. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. It typically leads to significant distress or impairment in social, work or other areas of functioning. The pattern is stable and of long duration, and its onset can be traced back to early adulthood or adolescence.

Symptoms of Narcissistic Personality Disorder

In order for a person to be diagnosed with narcissistic personality disorder (NPD) they must meet five or more of the following  symptoms:
  • Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
  • Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  • Believes 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)
  • Requires excessive admiration
  • Has a very strong sense of entitlement, e.g., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
  • Is exploitative of others, e.g., takes advantage of others to achieve his or her own ends
  • Lacks empathy, e.g., is unwilling to recognize or identify with the feelings and needs of others
  • Is often envious of others or believes that others are envious of him or her
  • Regularly shows arrogant, haughty behaviors or attitudes
take-narcissistic-quiz-nowBecause personality disorders describe long-standing and enduring patterns of behavior, they are most often diagnosed in adulthood. It is uncommon for them to be diagnosed in childhood or adolescence, because a child or teen is under constant development, personality changes and maturation. However, if it is diagnosed in a child or teen, the features must have been present for at least 1 year.
Narcissistic  personality disorder is more prevalent in males than females, and is thought to occur in up to 6.2 percent of the general population.
Like most personality disorders, narcissistic   personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.
Learn more about the symptoms and characteristics of someone with narcissitic personality disorder.

How is Narcissistic Personality Disorder Diagnosed?

Personality disorders such as narcissistic personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or  psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose personality disorder.
Many people with narcissistic personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.
A diagnosis for narcissistic  personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Narcissistic Personality Disorder

Researchers today don’t know what causes  narcissistic personality disorder.  There are many theories, however, about the possible causes of  narcissistic personality disorder.  Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of  are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk   for this disorder to be “passed down” to their children.

Treatment of  Narcissistic Personality Disorder

Treatment of narcissistic personality disorder  typically involves long-term psychotherapy with a therapist that has experience in treating this kind of personality disorder. Medications may also be prescribed to help with specific troubling and debilitating symptoms. For more information about treatment, please see narcissistic personality disorder treatment.
Narcissistic Personality Disorder Resources
 What is a personality disorder?
[from Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994, commonly referred to as DSM-IV, of the American Psychiatric Association. European countries use thediagnostic criteria of the World Health Organization.]An enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.
A personality disorder is a pattern of deviant or abnormal behavior that the person doesn't change even though it causes emotional upsets and trouble with other people at work and in personal relationships. It is not limited to episodes of mental illness, and it is not caused by drug or alcohol use, head injury, or illness. There are about a dozen different behavior patterns classified as personality disorders by DSM-IV. All the personality disorders show up as deviations from normal in one or more of the following:
(1) cognition -- i.e., perception, thinking, and interpretation of oneself, other people, and events;
(2) affectivity -- i.e., emotional responses (range, intensity, lability, appropriateness);
(3) interpersonal functions;
(4) impulsivity.

Narcissistic Personality Disorder
While grandiosity is the diagnostic hallmark of pathological narcissism, there isresearch evidence that pathological narcissism occurs in two forms, (a) a grandiose state of mind in young adults that can be corrected by life experiences, and (b) the stable disorder described in DSM-IV, which is defined less by grandiosity than by severely disturbed interpersonal relations.
     The preferred theory seems to be that narcissism is caused by very early affective deprivation, yet the clinical material tends to describe narcissists asunwilling rather than unable, thus treating narcissistic behaviors as volitional -- that is, narcissism is termed a personality disorder, but it tends to be discussed as a character disorder. This distinction is important to prognosis and treatmentpossibilities. If NPD is caused by infantile damage and consequent developmental short-circuits, it probably represents an irremediable condition. On the other hand, if narcissism is a behavior pattern that's learned, then there is some hope, however tenuous, that it's a behavior pattern that can be unlearned. The clinical literature on NPD is highly theoretical, abstract, and general, with sparse case material, suggesting that clinical writers have little experience with narcissism in the flesh. There are several reasons for this to be so:
-- The incidence of NPD is estimated at 1% in the general population, though I haven't been able to discover the basis of this estimate.
-- Narcissists rarely enter treatment and, once in treatment, progress very slowly. We're talking about two or more years of frequent sessions before the narcissist can acknowledge even that the therapist is sometimes helpful. It's difficult to keep narcissists in treatment long enough for improvement to be made -- and few people, narcissists or not, have the motivation or the money to pursue treatment that produces so little so late.
-- Because of the influence of third-party payers (insurance companies), there has been a strong trend towards short-term therapy that concentrates on ameliorating acute troubles, such as depression, rather than delving into underlying chronic problems. Narcissists are very reluctant to open up and trust, so it's possible that their NPD is not even recognized by therapists in short-term treatment. Purely anecdotal evidence from correspondents and from observations of people I know indicates that selective serotonin-reuptake inhibitors, such as Prozac, aggravate narcissists' grandiosity and lack of social inhibition. It has also been suggested that self-help literature about bolstering self-esteem and getting what you want out of life or that encourages the feeling of victimization has aggravating effects on NPD thinking and behavior.
-- Most clinical writers seem unaware that narcissists' self-reports are unreliable. This is troubling, considering that lying is the most common complaint about narcissists and that, in many instances, defects of empathy lead narcissists to wildly inaccurate misinterpretations of other people's speech and actions, so that they may believe that they are liked and respected despite a history of callous and exploitative personal interactions.
[from Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994, commonly referred to as DSM-IV, of the American Psychiatric Association. European countries use thediagnostic criteria of the World Health Organization.]A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.[jma: NPD first appeared in DSM-III in 1980; before that time there had been no formal diagnostic description. Additionally, there is considerable overlap between personality disorders and clinicians tend to diagnose mixes of two or more. Grandiosity is a special case, but lack of empathy and exploitative interpersonal relations are not unique to NPD, nor is the need to be seen as special or unique. The differential diagnosis of NPD is made on the absence of specific gross behaviors. Borderline Personality Disorder has several conspicuous similarities to NPD, but BPD is characterized by self-injury and threatened or attempted suicide, whereas narcissists are rarely self-harming in this way. BPD may include psychotic breaks, and these are uncharacteristic of NPD but not unknown. The need for constant attention is also found in Histrionic Personality Disorder, but HPD and BPD are both strongly oriented towards relationships, whereas NPD is characterized by aloofness and avoidance of intimacy. Grandiosity is unique to NPD among personality disorders, but it is found in other psychiatric illnesses. Psychopaths display pathological narcissism, including grandiosity, but psychopathy is differentiated from NPD by psychopaths' willingness to use physical violence to get what they want, whereas narcissists rarely commit crimes; the narcissists I've known personally are, in fact, averse to physical contact with others, though they will occasionally strike out in an impulse of rage. It has been found that court-ordered psychotherapy for psychopaths actually increases their recidivism rate; apparently treatment teaches psychopaths new ways to exploit other people. Bipolar illness also contains strong elements of grandiosity. See more on grandiosity and empathy and its lack below.]The disorder begins by early adulthood and is indicated by at least five of the following:
Translation: Narcissistic Personality Disorder (NPD) is a pattern of self-centered or egotistical behavior that shows up in thinking and behavior in a lot of different situations and activities. People with NPD won't (or can't) change their behavior even when it causes problems at work or when other people complain about the way they act, or when their behavior causes a lot of emotional distress to others (or themselves? none of my narcissists ever admit to being distressed by their own behavior -- they always blame other people for any problems). This pattern of self-centered or egotistical behavior is not caused by current drug or alcohol use, head injury, acute psychotic episodes, or any other illness, but has been going on steadily at least since adolescence or early adulthood.
     NPD interferes with people's functioning in their occupations and in their relationships:
Mild impairment when self-centered or egotistical behavior results in occasional minor problems, but the person is generally doing pretty well.
Moderate impairment when self-centered or egotistical behavior results in: (a) missing days from work, household duties, or school, (b) significant performance problems as a wage-earner, homemaker, or student, (c) frequently avoiding or alienating friends, (d) significant risk of harming self or others (frequent suicidal preoccupation; often neglecting family, or frequently abusing others or committing criminal acts).
Severe impairment when self-centered or egotistical behavior results in: (a) staying in bed all day, (b) totally alienating all friends and family, (c) severe risk of harming self or others (failing to maintain personal hygiene; persistent danger of suicide, abuse, or crime).
1. An exaggerated sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) 
Translation: Grandiosity is the hallmark of narcissism. So what is grandiose?
The simplest everyday way that narcissists show their exaggerated sense of self-importance is by talking about family, work, life in general as if there is nobody else in the picture. Whatever they may be doing, in their own view, they are the star, and they give the impression that they are bearing heroic responsibility for their family or department or company, that they have to take care of everything because their spouses or co-workers are undependable, uncooperative, or otherwise unfit. They ignore or denigrate the abilities and contributions of others and complain that they receive no help at all; they may inspire your sympathy or admiration for their stoicism in the face of hardship or unstinting self-sacrifice for the good of (undeserving) others. But this everyday grandiosity is an aspect of narcissism that you may never catch on to unless you visit the narcissist's home or workplace and see for yourself that others are involved and are pulling their share of the load and, more often than not, are also pulling the narcissist's share as well. An example is the older woman who told me with a sigh that she knew she hadn't been a perfect mother but she just never had any help at all -- and she said this despite knowing that I knew that she had worn out and discarded two devoted husbands and had lived in her parents' pocket (and pocketbook) as long as they lived, quickly blowing her substantial inheritance on flaky business schemes. Another example is claiming unusual benefits or spectacular results from ordinary effort and investment, giving the impression that somehow the narcissist's time and money are worth more than other people's. [Here is an article about recognizing and coping with narcissism in the workplace; it is rather heavy on management jargon and psychobabble, but worth reading. "The Impact of Narcissism on Leadership and Sustainability" by Bruce Gregory, Ph.D. "When the narcissistic defense is operating in an interpersonal or group setting, the grandiose part does not show its face in public. In public it presents a front of patience, congeniality, and confident reasonableness."]
In popular usage, the terms narcissismnarcissist, and narcissistic denote absurd vanity and are applied to people whose ambitions and aspirations are much grander than their evident talents. Sometimes these terms are applied to people who are simply full of themselves -- even when their real achievements are spectacular. Outstanding performers are not always modest, but they aren't grandiose if their self-assessments are realistic; e.g., Muhammad Ali, then Cassius Clay, was notorious for boasting "I am the greatest!" and also pointing out that he was the prettiest, but he was the greatest and the prettiest for a number of years, so his self-assessments weren't grandiose. Some narcissists are flamboyantly boastful and self-aggrandizing, but many are inconspicuous in public, saving their conceit and autocratic opinions for their nearest and dearest. Common conspicuous grandiose behaviors include expecting special treatment or admiration on the basis of claiming (a) to know important, powerful or famous people or (b) to be extraordinarily intelligent or talented. As a real-life example, I used to have a neighbor who told his wife that he was the youngest person since Sir Isaac Newton to take a doctorate at Oxford. The neighbor gave no evidence of a world-class education, so I looked up Newton and found out that Newton had completed his baccalaureate at the age of twenty-two (like most people) and spent his entire academic career at Cambridge. The grandiose claims of narcissists are superficially plausible fabrications, readily punctured by a little critical consideration. The test is performance: do they deliver the goods? (There's also the special situation of a genius who's also strongly narcissistic, as perhaps Frank Lloyd Wright. Just remind yourself that the odds are that you'll meet at least 1000 narcissists for every genius you come across.) [More ongrandiosity.]
2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
Translation: Narcissists cultivate solipsistic or "autistic" fantasies, which is to say that they live in their own little worlds (and react with affront when reality dares to intrude).
3. Believes he is "special" and can only be understood by, or should associate with, other special or high-status people (or institutions)
Translation: Narcissists think that everyone who is not special and superior is worthless. By definition, normal, ordinary, and average aren't special and superior, and so, to narcissists, they are worthless.
4. Requires excessive admiration
Translation: Excessive in two ways: they want praise, compliments, deference, and expressions of envy all the time, and they want to be told that everything they do is better than what others can do. Sincerity is not an issue here; all that matter are frequency and volume.
5. Has a sense of entitlement
Translation: They expect automatic compliance with their wishes or especially favorable treatment, such as thinking that they should always be able to go first and that other people should stop whatever they're doing to do what the narcissists want, and may react with hurt or rage when these expectations are frustrated.
6. Selfishly takes advantage of others to achieve his own ends
Translation: Narcissists use other people to get what they want without caring about the cost to the other people.
7. Lacks empathy
Translation: They are unwilling to recognize or sympathize with other people's feelings and needs. They "tune out" when other people want to talk about their own problems.
    In clinical terms, empathy is the ability to recognize and interpret other people's emotions. Lack of empathy may take two different directions: (a) accurate interpretation of others' emotions with no concern for others' distress, which is characteristic of psychopaths; and (b) the inability to recognize and accurately interpret other people's emotions, which is the NPD style. This second form of defective empathy may (rarely) go so far as alexithymia, or no words for emotions, and is found with psychosomatic illnesses, i.e., medical conditions in which emotion is experienced somatically rather than psychically. People with personality disorders don't have the normal body-ego identification and regard their bodies only instrumentally, i.e., as tools to use to get what they want, or, in bad states, as torture chambers that inflict on them meaningless suffering. Self-described narcissists who've written to me say that they are aware that their feelings are different from other people's, mostly that they feel less, both in strength and variety (and which the narcissists interpret as evidence of their own superiority); some narcissists report "numbness" and the inability to perceive meaning in other people's emotions.
8. Is often envious of others or believes that others are envious of him
Translation: No translation needed.
9. Shows arrogant, haughty, patronizing, or contemptuous behaviors or attitudes
Translation: They treat other people like dirt.

Narcissistic personality disorder facts

  • Narcissistic personality disorder is a mental disorder that is characterized by an established pattern of being fixated on oneself, permeating the thoughts, feelings, and actions of the sufferer, and their relationships with others.
  • People with narcissistic personality disorder tend to alternate between feeling omnipotent and devalued.
  • Narcissistic personality disorder has been found to occur as often as in 6% of adults, more often in men than in women.
  • Like most mental illness, narcissistic personality disorder tends to have biological, psychological, and environmental risk factors that contribute to its development.
  • People with narcissistic personality disorder demonstrate a pervasive pattern of significantly inflated self-esteem, a need to be admired, and lack of empathy for others that begins by early adulthood and manifests in a number of different aspects of their life.
  • While the primary treatment for narcissistic personality disorder is talk therapy rather than medication, medication may be appropriate to address some co-occurring symptoms.
  • One of the major obstacles to a good prognosis for narcissistic individuals is their perception that their problems are caused by others rather than by their own self-centered tendencies.

What is narcissistic personality disorder?

In order to understand narcissistic personality disorder, the concept of personality is important. As with normal personality, that of the person with narcissistic personality disorder (NPD) has a pervasive way of thinking, feeling, and interacting with others that tends to be fairly established and fixed by the time the individual reaches adulthood. A narcissist is someone who has therefore established a pattern of being fixated on him- or herself that permeates their thoughts, feelings, actions, and relationships.
The word narcissism comes from the story of Narcissus, a hunter in Greek mythology, who was well known for his beauty and for being completely in love with himself. His all-consuming self-love resulted in his eventual death, caused by his becoming so attracted to his own reflection in a pool that he was unable to stop staring at his image.
People with narcissistic personality disorder tend to interact with others and the world in general by distorting things such that they alternate between feeling omnipotent or devalued. Narcissistic personality disorder has an average occurrence rate of about 1% of the population but has been found to occur as often as in 6% of adults.
Narcissistic personality disorder is diagnosed more often in men than in women. It is also more often found in people who are involved with the court system compared to the general public. Antisocial personality disorderis an illness that commonly co-occurs with narcissistic personality disorder.

What are causes and risk factors for narcissistic personality disorder?

As with most mental-health disorders, narcissistic personality disorder does not have one single definitive cause. Rather, people with this illness tend to have biological, psychological, and environmental risk factors that contribute to its development. Biologically, narcissists are thought to have a tendency to have a smaller part of the brain that is related to having empathy for others.
Psychologically, individuals with narcissistic personality disorder tend to have trouble having opposing self-images of excessive admiration and devaluing in their minds and in their relationships. They are thought to be excessively emotionally sensitive.
Early psychoanalytic theory on the emotional motivations for the development of narcissistic personality disorder focused on the relationship between mothers and sons. Specifically, it was thought that men develop this disorder as the result of having an excessively close relationship with their mother that is contingent upon always doing what she wants, with a resulting paranoid fear of being retaliated against by their father and humiliated or abandoned by their mother. Since those early theories, the social risk factors for developing NPD have been expanded to include excessive admiration or neglect by either parent.
In addition to receiving excessive, unrealistic admiration, praise, and overindulgence, or excessive criticism for misbehavior during childhood, theories about other social risk factors of narcissistic personality disorder include emotional abuse, unpredictable parental care, and learning manipulation from caregivers.

What are narcissistic personality disorder symptoms and signs?

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In order to be assessed with the diagnosis of narcissistic personality disorder, an individual must demonstrate a pervasive pattern of significantly inflated self esteem (grandiosity), a need to be admired and lack of empathy for others that begins by early adulthood and is present in a number of different aspects of their life. Specific symptoms and signs of this illness can include the following:
  • An excessive sense of self importance, with an expectation of being seen as superior for no reason
  • Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or love
  • Excessive belief that he or she is special or unique
  • A need for excessive admiration
  • A sense of entitlement to special treatment or compliance with their wishes
  • A tendency to take advantage of others to achieve their own goals
  • Lacking empathy for the needs and feelings of others
  • Frequently envious of others or thinking others are envious of him or her
  • Exhibits arrogant thoughts or behaviors
Individuals who have some symptoms of narcissistic personality disorder but not enough for the diagnosis to be assigned are often described as having narcissistic traits.

How is narcissistic personality disorder diagnosed?

Many providers of health care may help make the diagnosis of narcissistic personality disorder, including pediatricians, primary-care providers, licensed mental-health therapists, psychiatrists, psychologists, psychiatric nurses, and social workers. As part of this examination, the sufferer will likely be referred for a full physical examination and laboratory tests in an attempt to rule out any medical condition that may contribute to the symptoms described. The person with NPD may be asked a series of questions from a standardized questionnaire or self-test to help assess the presence of the illness. Thorough exploration for any history or presence of mental-health symptoms will be conducted such that narcissistic personality disorder can be distinguished from other personality disorders like histrionic personality disorder, borderline personality disorder, or antisocial personality disorder. The mental-health professional will also explore whether other forms of mental illness are present, since narcissism is often also associated with depression or perfectionism. In addition to demonstrating a pattern of grandiose thoughts or behaviors, need for admiration, and lack of empathy for others characterized by at least five of the previously described symptoms, other diagnostic criteria for narcissistic personality disorder include the sufferer's pattern of such behaviors being pervasive throughout the person's life, as well as stable, longstanding symptoms that are not better explained by another mental illness, the effects of a substance, or a medical condition.

What is the treatment for narcissistic personality disorder?

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The primary treatment for narcissistic personality disorder is talk therapy (psychotherapy) rather than medication. However, medication may be appropriate to address some co-occurring mental-health symptoms like depression, irritability, oranxiety. Psychotherapy tends to focus on how the person with the disorder interacts with the therapist during therapy, examining and changing grandiose and excessively vulnerable thinking, teaching the sufferer ways to regulate their emotions, and correcting self-centered behaviors to more prosocial ways of interacting with others.

What is the prognosis of narcissistic personality disorder?

How well or poorly people with narcissistic personality disorder progress over time seems to be influenced by how severe the disorder is at the time that treatment starts, the state of the individual's current personal relationships, whether or not the sufferer has a history of being abused as a child, as well as whether or not the person receives appropriate treatment. Simultaneously suffering from other mental-health problems has been found to be associated with a lower likelihood of symptoms of NPD being alleviated with treatment. One of the major obstacles to treatment and therefore to a good prognosis for narcissistic individuals is the perception by these individuals that their problems are caused by others rather than by their own self-centered tendencies.

Is it possible to prevent narcissistic personality disorder?

Societal interventions like prevention of child abusedomestic violence, and substance abuse in families can help decrease the occurrence of a number of very different mental-health problems, including narcissistic personality disorder.
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