Introduction Narcissism has stood at the center of the last 30 years of psychoanalytic exploration and controversy.
Medically reviewed byGerald Hurowitz, M.D.Updated 2 July 20107 min read
Key points
Narcissism has stood at the center of the last 30 years of psychoanalytic exploration and controversy.
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.
Lifetime prevalence is estimated at 1 % in the general population and 2% to 16% in clinical populations.
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.
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.
Epidemiology
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.
Etiology
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.
Clinical Manifestations
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.
Differential Diagnosis
The grandiosity of narcissism can be differentiated from the grandiosity of bipolar disorder by the presence of characteristic mood symptoms in bipolar disorder.
References
Akhtar S: Narcissistic personality disorder: descriptive features and differential diagnosis. Psychiatr Clin North Am 12:505-530, 1989
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
Baker HS, Baker MN: Heinz Kohut's psychology of the self: an overview. Am J Psychiatry 144:1-9, 1987
Bird HW, Martin PA, Schuman A: The marriage of the "collapsible" man of prominence. Am J Psychiatry 140:290-295, 1983
Bromberg PM: The mirror and the mask: on narcissism and psychoanalytic growth. Contemporary Psychoanalysis 19:359-387, 1983
Chessick RD: The two-woman phenomenon revisited. J Am Acad Psychoanal 17:293-304, 1989
Cooper AM: Narcissistic disorders within psychoanalytic theory, in Psychiatry 1982: The American Psychiatric Association Annual Review, Vol 1. Edited by Grinspoon L. Washington, DC, American Psychiatric Press, 1982, pp 487-497
Cooper AM: Narcissism in normal development, in Character Pathology. Edited by Zales M. New York, Brunner/Mazel, 1984, pp 39-56
Cooper AM: Narcissism, in Essential Papers on Narcissism. Edited by Morrison AP. New York, New York University Press, 1986, pp 112-143
Cooper AM: The narcissistic-masochistic character, in Masochism: Current Psychological Perspectives. Edited by Glick RA, Meyers DI. Hillside, NJ, Analytic Press, 1988, pp 117-138
Cooper AM: Paranoia: a part of most analyses. J Am Psychoanal Assoc 41:423-442, 1993
Cooper AM: Further developments in the clinical diagnosis of narcissistic personality disorder, in Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by Ronningstam EF. Washington, DC, American Psychiatric Press, 1997, pp 53-74
Gabbard GO: Two subtypes of narcissistic personality disorder. Bull Menninger Clin 53:527-532, 1989
Gabbard GO: Transference and countertransference in the treatment of narcissistic patients, in Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by Ronningstam EF. Washington, DC, American Psychiatric Press, 1997, pp 125-145
Glassman M: Kernberg and Kohut: a test of competing psychoanalytic models of narcissism. J Am Psychoanal Assoc 36:597-625, 1988
Gunderson JG, Ronningstam EF, Smith LE: Narcissistic personality disorder: a review of data on DSM-III-R descriptions. J Personal Disord 5:167-177, 1991
Hibbard S: Narcissism, shame, masochism, and object relations: an exploratory correctional study. Psychoanalytic Psychology 9:489-508, 1992
Horowitz MJ: Clinical phenomenology of narcissistic pathology. Psychiatr Clin North Am 12:531-540, 1989
Horwitz L: Indications for group psychotherapy with borderline and narcissistic patients. Bull Menninger Clin 51:248-260, 1987
Jones SA: Family therapy with borderline and narcissistic patients. Bull Menninger Clin 51:285-295, 1987
Kernberg OF: Factors in the psychoanalytic treatment of narcissistic personalities. J Am Psychoanal Assoc 18:51-85, 1970
Kernberg OF: Further contributions to the treatment of narcissistic personalities. Int J Psychoanal 55:215-240, 1974
Kernberg OF: Severe Personality Disorders: Psychotherapeutic Strategies. New Haven, CT, Yale University Press, 1984
Kernberg OF: The narcissistic personality disorder and the differential diagnosis of antisocial behavior. Psychiatr Clin North Am 12:553-570, 1989
Kohut H: How Does Analysis Cure? Edited by Goldberg A, Stepansky P. Chicago, IL, University of Chicago Press, 1984
Kohut H, Wolf ES: The disorders of the self and their treatment: an outline. Int J Psychoanal 59:413-425, 1978
Leszcz M: Group psychotherapy of the characterologically difficult patient. Int J Group Psychother 39:311-335, 1989
Malcolm RR: Technical problems in the analysis of a pseudo-compliant patient. Int J Psychoanal 62:477-484, 1981
Miller A: Prisoners of Childhood. Translated by Ward R. New York, Basic Books, 1981
Oldham JH: Treatment planning: brief treatment of narcissistic personality disorder. J Personal Disord 2:88-90, 1988
Ornstein PH: On the psychoanalytic psychotherapy of primary self pathology, in Psychiatry 1982: The American Psychiatric Association Annual Review, Vol 1. Edited by Grinspoon L. Washington, DC, American Psychiatric Press, 1982, pp 498-509
Pulver SE: Narcissism: the term and the concept. J Am Psychoanal Assoc 18:319-341, 1970
Roth BE: Narcissistic patients in group psychotherapy: containing affects in the early group, in Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by Ronningstam EF. Washington, DC, American Psychiatric Press, 1997, pp 221-237
Solomon MF: Manifestations of narcissistic disorders in couples therapy: identification and treatment, in Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by Ronningstam EF. Washington, DC, American Psychiatric Press, 1997, pp 269-293
Stone MH: Murder. Psychiatr Clin North Am 12:643-652, 1989
Stone MH: Normal narcissism: an etiological and ethological perspective, in Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by Ronningstam EF. Washington, DC, American Psychiatric Press, 1997, pp 7-28
Svrakic DM: Emotional features of narcissistic personality disorder. Am J Psychiatry 142:720-724, 1985
Wink P: Two faces of narcissism. J Pers Soc Psychol 61:590-597, 1991
Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic Books, 1975
Young J, Flanagan C: Schema-focused therapy for narcissistic patients, in Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by Ronningstam EF. Washington, DC, American Psychiatric Press, 1997, pp 239-268
