Narcissistic Personality Disorder
Leonard C. Groopman, M.D.
Arnold M. Cooper, M.D.
Narcissism has stood at the center of the last 30 years of psychoanalytic exploration and controversy. Investigations into both healthy and pathological narcissism have occasioned significant developments and debates in psychoanalytic theory and psychotherapeutic technique. As Narcissus has assumed a place alongside Oedipus in the pantheon of developmental and pathogenic myths, the domain of practice has expanded to include disorders once believed to be untreatable. The therapist has been confronted with a rich, if at times contradictory and confusing, variety of phenomenological descriptions, etiological explanations, transference and countertransference phenomena, and technical recommendations for treating primary disturbances of the self. The treatment in such patients is widely recognized to be highly challenging as well as potentially highly rewarding.
As the domain of narcissism and its pathologies has expanded, nosologists have sought to define narcissistic personality disorder clearly with a set of agreed-on phenomenological criteria. These efforts to define and empirically test criteria that would diminish the overlap between narcissistic personality disorder and other personality disorders, while improving the fit between the phenomenological diagnosis and the entity described in the clinical literature, have led to the evolving DSM terms for narcissistic personality disorder. The DSM-IV (American Psychiatric Association 1994) criteria represent one consensus in the ongoing attempt to sharpen the specificity and improve the sensitivity of the diagnosis and meaning of narcissistic personality disorder.
Lifetime prevalence is estimated at 1 % in the general population and 2% to 16% in clinical populations.
Fifty to 75% of those with this diagnosis are men.
The etiology of this disorder is unknown.
Researchers have identified childhood developmental factors and parenting behaviors that may contribute to the disorder:
- An oversensitive temperament at birth
- Overindulgence and overvaluation by parents
- Valued by parents as a means to regulate their own self-esteem
- Excessive admiration that is never balanced with realistic feedback
- Unpredictable or unreliable caregiving from parents
- Severe emotional abuse in childhood
- Being praised for perceived exceptional looks or talents by adults
- Learning manipulative behaviors from parents
Phenomenology and Diagnosis
The challenge of understanding and treating narcissistic personality disorder has been compounded by the multiple, wide-ranging, and often ambiguous meanings of the terms narcissism and narcissistic pathology. As Cooper (1984) has written, "The fuzziness of the term reflects the complexity of the concepts, while the persistence of the term reflects their central importance" (p. 39). At the same time, he continues, "[W]e remain with more ambiguity than is desirable or useful" (p. 43).
The history of the concept of narcissism has been reviewed elsewhere (Cooper 1986; Pulver 1970). Recent literature recognizes that narcissism is a healthy, normal, and necessary component of psychological development and psychic life, thereby avoiding the pejorative connotation that the term narcissistic has often assumed (Stone 1997). Narcissistic traits, moreover, appear in all forms of character pathology. A constellation of certain pathological traits that dominate the life history and the transference relationship distinguishes narcissistic personality disorder from other forms of personality disturbance.
Narcissistic pathology assumes a wide range of clinical and functional forms. Clinically, these forms range from the arrogant, boastful individual who steals the spotlight to the shy, easily slighted person who avoids center stage (Akhtar 1989; Cooper 1982, 1997; Gabbard 1989). Functionally, they may range from the prominent businessperson and political leader to the malignant narcissist and premeditating murderer (Kernberg 1989; Stone 1989).
Three overlapping systems have evolved for diagnosing narcissistic personality disorder, differentiating it from other character pathology, and capturing the diversity of its clinical presentation. Narcissistic personality disorder can be diagnosed 1) according to DSM criteria; 2) according to a pattern of intrapsychic affects, defenses, and object relationships; and 3) according to the forms of transference that develop in therapy. Clearly, the linear model of first formulating a diagnosis and then planning and implementing a treatment cannot always be followed with patients with narcissistic personality disorder because the diagnosis may become apparent only after a period of psychotherapy or an extended evaluation.
History and Mental Status Examination
People with narcissistic personality disorder demonstrate an apparently paradoxical combination of self-centeredness and worthlessness. Their sense of self-importance is generally extravagant, and they demand attention and admiration. Concern or empathy for others is typically absent. They often appear arrogant, exploitative, and entitled. However, despite their inflated sense of self. below their brittle facade lies low self-esteem and intense envy of those whom they regard as more desirable, worthy, or able.
The grandiosity of narcissism can be differentiated from the grandiosity of bipolar disorder by the presence of characteristic mood symptoms in bipolar disorder.
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