Author: Dr. Helen Okoye, MD, MBA, MS-Epi













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Narcissistic Personality Disorder DSM-5 301.81 (F60.81)

DSM-5 Category: Personality Disorders

Introduction

Narcissistic personality disorder (NPD), a cluster B personality disorder, is considered to be one of the least identified personality disorders (Pies, 2011). On the other hand, a good number of patients with narcissistic traits present at the psychiatrist's office with other types of issues such as anxiety or depression. A common finding in clinical practice, NPD frequently coexists with other psychiatric disorders. NPD is a relatively recent diagnostic category. Its origins stem from a great effort between psychoanalysts and psychoanalytic psychotherapists to recognize a cluster of predominantly difficult patients who could not be classified as psychotic, not typically neurotic and overall not responsive to conventional psycho therapeutic treatment options (Gildersleeve, 2012).

NPD appears to be more widespread in males than females for unknown reasons. In the past there has been some speculation that the limited spotlight on grandiosity likely adds to the extensive discrepancy that is seen with small NPD prevalence rates in epidemiological research and elevated occurrences of NPD seen in clinical practice (Campbell, Miller, & Widiger, 2010).

The most important characteristics of NPD are grandiosity, seeking excessive admiration, and a lack of empathy (Ronningstam & Weinberg, 2013). These identifying features can result in a negative impact on an individual’s interpersonal affairs and life general. In most cases, on the exterior, these patients act with an air of right and control, dismissing others, and frequently showcasing condescending or denigrating attitudes. Nevertheless, internally, these patients battle with strong feelings of low self esteem issues and inadequacy. Even though the typical NPD patient may achieve great achievements, ultimately their functioning in society can be affected as these characteristics interfere with both personal and professional relationships. A large part of this is as result of the NPD patient being incapable of receiving disapproval or rebuff of any kind, in addition to the fact that the NPD patient typically exhibits lack of empathy and overall disrespect for others.

Symptoms of Narcissistic Personality Disorder

The definition of NPD states that it comprises of a persistent manner of grandiosity, a continuous desire for admiration, along with a lack of empathy. It starts by early adulthood and occurs in a range of situations, as signified by the existence of any 5 of the next 9 standards (American Psychiatric Association, 2013):

A grandiose logic of self-importance

A fixation with fantasies of infinite success, control, brilliance, beauty, or idyllic love

A credence that he or she is extraordinary and exceptional and can only be understood by, or should connect with, other extraordinary or important people or institutions

A desire for unwarranted admiration

A sense of entitlement

Interpersonally oppressive behavior

No form of empathy

Resentment of others or a conviction that others are resentful of him or her

A display of egotistical and conceited behaviors or attitudes

Another model, characterizes NPD as having fair or superior impairment in personality functioning, apparent by characteristic troubles in at least 2 of the following 4 areas (American Psychiatric Association, 2013):

Individuality Self-direction Empathy Closeness

No actual physical characteristics are seen with NPD, but patients may have concurrent substance abuse, which may be seen in the clinical examination.

Epidemiology

Narcissistic Personality Disorder is more prevalent in males, with about 18 percent of males presenting with NPD, compared to six percent of females (Ronningstam & Weinberg, 2013). Within the general population, the prevalence rate is less than one percent, yet within the clinical population, this number rises to about 2 to 16 percent.

Differential Diagnosis

NPD has similar characteristics with the other 3 cluster B personality disorders, and thus should be differentiated accordingly. These are Antisocial personality disorder (ASPD), Borderline personality disorder (BPD) and Histrionic personality disorder (HPD). Additionally individuals with NPD may also meet the definition for also having axis I disorder, or exhibits features that similar to axis I disorders (CITE).

While no particular laboratory tests help with the diagnosis of NPD, a urine toxicology screen may be important to exclude substance abuse such as alcohol and drugs as likely reasons of the pathology.

Co-morbidity

Several comorbid disorders occur with NPD, with the most common being major depressive disorder, seen in about 45 to 50 percent of NPD patients (Ronningstam & Weinberg, 2013). Bipolar disorder presents in 5 to 11 percent of NPD patients (Ronningstam & Weinberg, 2013). On the other hand, the most prevalent comorbidity seen is that of substance abuse. Approximately 24 to 64.2 percent of NPD patients have substance abuse disorders (Ronningstam & Weinberg, 2013).

Treatment for Narcissistic Personality Disorder

The treatments for NPD are forms of therapy, as well as pharmacologic (Narcissistic Personality Disorder, 2011). The core of treatment lies with individual psychotherapy, which consists mainly of psychoanalytic psychotherapy. In addition, other types of therapy may be utilized, such as family, group, couples therapies, plus cognitive-behavioral therapy (CBT). Since NPD patients commonly have other psychiatric ailments like depression, anxiety or other mood disorders, certain psychotropic medications may also be administered.

While treatment for NPD largely remains outpatient, an indication for inpatient stay should occur if the patient severely worsens or becomes a threat to their own safety as well as others. Even with inpatient care, it is best to opt for shorter hospital times, as extended stays have not been reported to transform the course of the illness. The use of hospitalization ought to only be used as a short-term method which facilitates either the stabilization of environmental stressors, and/or regulation of drug dosages .

Psychotherapy

With individual psychoanalytic psychotherapy, much debate exists between the 2 key school of thoughts Kernberg and Kohut, both offering conflicting methods regarding the therapist’s role in treating NPD patients. Kernberg advocates a direct confrontation of the NPD patient during therapy, with the goal of eliminating or weakening the patient’s grandiosity. On the other hand, Kohut supports a more empathic role, that encourages the patient’s grandiosity, thus strengthening the patient’s naturally deficient self image (Gildersleeve, 2012). In therapy, a common form of treatment is a combination of both.

Other Forms of Therapy

Some speculate that NPD patients may experience difficulty handing group sessions, since they lack the traits needed for group therapy like patience, connectivity, and empathy. Research maintains that the use of long-term group therapy offers NPD patients the avenue to improve trust with others and other crucial relationship aspects in a safe and controlled environment (Ronningstam & Weinberg, 2013).

The use of Cognitive Behavioral Therapy (CBT) in treating NPD mainly involves the particular form of CBT recognized as schema-focused therapy, that focuses on fixing narcissistic schemas and the flawed moods and coping mechanisms (Matusiewicz, Hopwood, Banducci, & Lejuez, 2011).

Pharmacologic Therapy

No actual medications are indicated for the treatment of NPD. Given that patients may have other co-morbid psychiatric issues, these patients sometimes benefit from using medications such as antidepressants, antipsychotics, as well as mood stabilizers (Ronningstam & Weinberg, 2013).

Long-Term Monitoring

It is important for NPD patients to receive close long-term monitoring as there may be a potential risk for suicide, especially in patients who also have depression. While one can assume that giving the low self-esteem and high impulsive nature, suicidal behaviors should be directly linked with NPD (Campbell, Miller, & Widiger, 2010).

Social Impact

Ironically patients with NPD, also known as narcissists are reportedly happier than others in society. Being highly materialistic, self-enhancing, entitled and impulsive, they may not learn from mistakes, and have a tendency to get into even greater trouble, notably legal and disciplinary (Ronningstam & Weinberg, 2013). These maladaptive coping mechanisms can result in issues in the work place or in school, or unemployment.

Patients with NPD tend to be drawn to people of a high societal class, who think very highly of them (Campbell, Miller, & Widiger, 2010). The constant desire for admiration may cause romantic relationships to be short lived, as they constantly seek for something better, or when their lack of empathy becomes apparent to their partners (Ronningstam & Weinberg, 2013). So patients with NPD may exhibit an unforgiving nature and showcase anger and aggression in such close relationships (Ronningstam & Weinberg, 2013). This can also affect work relationships or any close group activities.

References

American Psychiatric Association. (2013). Personality disorders. In Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition ed.). Washington, DC: American Psychiatric Publishing Inc.

Campbell, W. K., Miller, J., & Widiger, T. (2010). Narcissistic Personality Disorder and the DSM–V. Journal of Abnormal Psychology, 119(4), 640 – 649. Retrieved March 7, 2014, from http://wkeithcampbell.com/wp-content/uploads/2013/08/MillerWidigerCampbell20101.pdf

Gildersleeve, M. (2012). Demystifying Paradoxical Characteristics of Narcissistic Personality Disorder. Indian Journal of Psychological Medicine, 34(4), 403-404. Retrieved March 7, 2014, from http://www.ijpm.info/article.asp?issn=0253-7176;year=2012;volume=34;issue=4;spage=403;epage=404;aulast=Gildersleeve

Matusiewicz, A., Hopwood, C., Banducci, A., & Lejuez, C. (2011, Sep 1). The Effectiveness of Cognitive Behavioral Therapy for Personality Disorders. Psychiatr Clin North Am, 33(3), 657–685. Retrieved March 7, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138327/

Narcissistic Personality Disorder. (2011, Aug 29). Narcissistic Personality Disorder. Retrieved March 7, 2014, from Cleveland Clinic: http://my.clevelandclinic.org/neurological_institute/center-for-behavorial-health/disease-conditions/hic-narcissistic-personality-disorder.aspx

Pies, R. (2011, Feb). How To Eliminate Narcissism Overnight. Innovations in Clinical Neuroscience, 8(2), 23–27. Retrieved March 7, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071092/

Ronningstam, E., & Weinberg, I. (2013, Spring). Narcissistic Personality Disorder: Progress in Recognition and Treatment. The Journal of Lifelong Learning in Psychiatry, XI(2), 167-177. Retrieved March 7, 2014, from http://focus.psychiatryonline.org/data/Journals/FOCUS/926935/167.pdf

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