Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

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 sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
Lacks empathy: 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.
Shows arrogant, haughty behaviors or attitudes.

Associated Features:

Depressed Mood
Dramatic or Erratic or Antisocial Personality

Differential Diagnosis

Some disorders have similar or even the same symptom. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis.

Histrionic Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Schizotypal Personality Disorder
Paranoid Personality Disorder
Manic Episodes
Hypomanic Episodes
Personality Change Due to a General Medical Condition;
Symptoms that may develop in association with chronic substance use.

Cause:

The cause of Narcissistic Personality Disorder is unknown at this time, but several theories are being investigated. There is some evidence that genetic predisposition and other biological or biochemical factors are involved for some people. Psychological factors are also involved for most people.

Treatment:

Treatment of Narcissistic Personality Disorder usually consists of individual, group or family therapy, structure (scheduling one's time so that there are no long periods of unplanned time), support, medications, limit-setting, consistent rules, education about the illness, social skills training, behavior modification and learning more effective communication and coping skills. Inpatient or day hospitalization may be necessary when symptoms make the patient a danger to self or others

Counseling and Psychotherapy [ See Therapy Section ]:

Most psychiatrists will, as a practical matter, treat most of their severely narcissistic patients for symptoms related to crises and relatively external Axis I diagnoses, rather than in an effort to address the personality disorder itself. The therapist must be aware of the importance of narcissism to the contiguity of the patient's psyche, refrain from confronting the need for self-aggrandizement, and help the patient use his or her narcissistic characteristics to reconstitute an intact self-image. Positive transference and therapeutic alliance should not be relied upon, since the patient may not be able to acknowledge the real humanness of the therapist but may have to see him/her as either superhuman or devalued.

Group Therapy

The goals are to help the patient develop a healthy individuality (rather than a resilient narcissism) so that he or she can acknowledge others as separate persons, and to decrease the need for self-defeating coping mechanisms. The first step toward developing a working alliance is empathy with the surprise and hurt that the patient experiences as a result of confrontations within the group. The external structuring group therapy provides can control destructive behavior in spite of ego weakness. In groups, the therapist is less authoritative (and less threatening to the patient's grandiosity); intensity of emotional experience is lessened; and regression is more controlled, creating a better setting for confrontation and clarification.