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Narcissus , the mythical Greek youth, after whom narcissism is named, as depicted in John William Waterhouse 's "Echo and Narcissus," ca 1903 Narcissus might have been diagnosed as a classic, somatic narcissist
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(NPD), a term first used by
Heinz Kohut in 1971Kohut, Heinz, The Analysis of the Self, 1971, is a form of pathological
Narcissism acknowledged in the
Diagnostic And Statistical Manual Of Mental Disorders in 1980, in the edition known as DSM-III. Narcissistic personality disorder is characterized by extreme focus on oneself, and is a maladaptive, rigid, and persistent condition that may cause significant distress and functional impairment.
DSM-IV divides
Personality Disorder s into three clusters based on symptom similaritiesDSM IV-TR,
Diagnostic criteria for 301.81 Narcissistic Personality Disorder :
Narcissistic personality disorder is a "cluster B"
Personality Disorder .
The
ICD-10 (''International Classification of Mental and Behavioural Disorders'', published by the
World Health Organisation in Geneva
1992 ) regards narcissistic personality disorder (NPD) as "a personality disorder that fits none of the specific rubrics". It relegates it to the category known as "Other specific personality disorders", which also includes the eccentric, "haltlose", immature,
Passive-aggressive , and psychoneurotic personality disorders.
While the ICD-10 does not specifically define the characteristics of this personality disorder, it is classified in the category "Other Specific Personality Disorders".
ICD-10 states that Narcissistic Personality Disorder is "a personality disorder that fits none of the specific rubrics F60.0-F60.7". That is, this personality disorder does not meet the diagnostic criteria for any of the following:
- F60.0 Paranoid Personality Disorder
- F60.1 Schizoid Personality Disorder
- F60.2 Dissocial (Antisocial) Personality Disorder
- F60.3 Emotionally unstable (borderline) Personality Disorder
- F60.4 Histrionic Personality Disorder
- F60.5 Anankastic (Obsessive-Compulsive) Personality Disorder
- F60.6 Anxious (Avoidant) Personality Disorder
- F60.7 Dependent Personality Disorder
Narcissist Personality Disorder (NPD) is isolating, disenfranchising, painful, and formidable for those diagnosed with it and often those who are in a relationship with them. Distinctions need to be made among those who have NPD because not each and every person with NPD is the same. Even with similar core issues, the way in which one's individual narcissism manifests itself in his or her relationships varies.
Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.
50 to 75% of those with this diagnosis are men.
1
The etiology of this disorder is unknown.
2
Some sources suggest that narcissistic personality disorder may be an infantile, defensive personality structure in response to abuse and trauma, usually developing in early childhood or early adolescence. They suggest that narcissistic personality disorder may be a maladaptive defense of the abused child's or adolescent's emotional splitting, resultant cognitive distortions, and negative/hostile worldview.
Some think that caregiver deprivation at approximately 36 months of age is a major risk factor for the later development of this disorder. Conversely, some theories suggest that the disorder can manifest itself in people who have been over-indulged and doted on by their parents.
At least five of the following are necessary for a diagnosis (as with many DSM diagnoses, they must form a pervasive pattern; for example, a person who shows these criteria only in one or two relationships or situations would not properly be diagnosed with NPD):
#has a grandiose sense of self-importance
#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 other special people
#requires excessive admiration
#strong sense of
Entitlement
#
Takes Advantage of others to achieve his or her own ends
#lacks
Empathy
#is often
Envious or believes others are envious of him or her
#
Arrogant Affect .
::(see also
full list in DSM-IV-TR, p. 717 )
According to DSM IV, the prevalence of NPD is less than 1% of the general population, though it manifests itself in 2-16% of
Psychiatric outpatients. Studies have not conclusively demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to NPDAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 660. However, evidence for heritability greater than that of other personality disorders has been reportedLivesley, W.J., Jang, K.L., Jackson, D.N. and P.A. Vernon (1993). "Genetic and environmental contributions to dimensions of personality disorder". ''American Journal of Psychiatry'' 150, 1826-1831. Abstract online. Accessed June 18, 2006..
Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood they may intensify to the point where NPD is diagnosed. The disorder occurs 50 to 75 percent more frequently in men than in women. It has been suggested that NPD may be exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes.
Pathological narcissism occurs in a spectrum of severity . In its more extreme forms, it is narcissistic personality disorder. NPD is considered to result from a person's belief that he or she is flawed in a way that makes the person fundamentally unacceptable to others Golomb, Elan PhD (1992). ''Trapped in the Mirror''. New York: Morrow, pages 19-20. This belief is held below the person’s conscious awareness; such a person would typically deny thinking such a thing if questioned. In order to protect themselves against the intolerably painful rejection and isolation they imagine would follow if others recognized their supposedly defective nature, such people make strong attempts to control others’ view of them and behavior towards them.
Psychologists commonly believe that pathological narcissism results from an impairment in the quality of the person’s relationship with their primary caregivers, usually their parents, in that the parents were unable to form a healthy, empathic attachment to them. This results in the child conceiving of themselves as unimportant and unconnected to others. The child typically comes to believe that he or she has some defect of personality which makes them unvalued and unwanted Johnson, Stephen M PhD (1987). Humanizing the Narcissistic Style. New York: Norton, page 39.
To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others' needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen . They may also demand certain behavior from their children because they see the children as extensions of themselves, and need the children to represent them in the world in ways that meet the parents’ emotional needs Rappoport, Alan, Ph. D.[http://www.alanrappoport.com/Co-Narcissism%20Article.pdf Co-Narcissism: How We Adapt to Narcissistic Parents. The Therapist, in press]. (For example, a narcissistic father who was a lawyer demanded that his son, who had always been treated as the "favorite" in the family, enter the legal profession as well. When the son chose another career, the father rejected and disparaged him.)
These traits will lead overly narcissistic parents to be very intrusive in some ways, and entirely neglectful in others. The children are punished if they do not respond adequately to the parents’ needs. This punishment may take a variety of forms, including physical abuse, angry outbursts, blame, attempts to instill guilt, emotional withdrawal, and criticism. Whatever form it takes, the purpose of the punishment is to enforce compliance with the parents' narcissistic needs.
People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight, real or imagined American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 659. To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility.
There is a broad spectrum of pathologically narcissistic personalities, styles, and reactions -- from the very mild, reactive and transient, to the severe and inflexible narcissistic personality disorder.
Though individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements Golomb, Elan PhD (1992). ''Trapped in the Mirror''. New York: Morrow, pages 22. With narcissistic personality disorder, the person's perceived fantastic grandiosity, often coupled with a
Hypomanic mood, is typically not commensurate with his or her real accomplishments.
The exploitativeness, sense of entitlement, lack of empathy, disregard for others, and constant need for attention inherent in NPD, adversely affects interpersonal relationships. Individuals with NPD frequently select as mates, and engender in their children, "co-narcissism," which is a term coined to refer to a co-dependent personality style similar to co-alcoholism and co-dependency . Co-narcissists organize themselves around the needs of others. They feel responsible for others, accept blame readily, are eager to please, defer to others’ opinions, and fear being considered selfish if they act assertively.
Alexander Lowen describes pathological narcissism, and narcissistic personality disorder, as "the denial of the true self"Lowen, Alexander, M.D. (1997) ''Narcissism: Denial of the True Self'' Touchstone (New York), ISBN 0-7432-5543-7
Masterson describes the creation of a false self as:
when a young child fails to separate her own self-image from that of her mother. This happens roughly between the ages of two and three, often because of a parent’s own emotional problems. A mother’s encouragement of a child's self-assertion is vital. When the mother suffers from low self-esteem, she has difficulty encouraging her child’s emerging self. The child experiences this absence as a loss of self, creating feelings of abandonment that lead to depression. To deal with the depression, the child gives up efforts to support her emerging self. Instead, she relies on her mother’s approval to maintain the esteem of a "false self."
It has been suggested that Narcissistic personality disorder may be related to defenses against shame. Wurmser L, Shame, the veiled companion of narcissism, in The Many Faces of Shame, edited by Nathanson DL. New York, Guilford, 1987, pp 64–92
Gabbard suggested NPD could be broken down into two subtypesGabbard GO,
subtypes of narcissistic personality disorder. Bull Menninger Clin 1989; 53:527–532. He saw the "oblivious" subtype as being grandiose, arrogant and thick skinned and the "hypervigilant" subtype as easily hurt, oversensitive and ashamed.
He suggested that the oblivious subtype presents a large, powerful, grandiose self to be admired, envied and appreciated, which is the antithesis of the weakened and internalised self that hides in a generic state of shame, in order to fend off devaluation, whereas the hypervigilant subtype, far from fending off devaluation, is obsessed with it, neutralising devaluation by seeing others as unjust abusers.
Though there is controversy in the profession, most psychiatrists and psychologists regard NPD as a relatively stable condition when experienced as a primary disorder Rappoport, Alan, Ph. D.[http://www.alanrappoport.com/Co-Narcissism%20Article.pdf Co-Narcissism: How We Adapt to Narcissistic Parents. The Therapist, in press].
James F. Masterson 's
A Therapist's Guide to the Personality Disorders: The Masterson Approach outlines a prominent approach to healing NPD, while discusses a continuum of severity and the kinds of therapy most effective in different cases. Typically, as narcissism is an ingrained personality trait, rather than a chemical imbalance, medication and therapy are not very effective in treating the disorder.
It is unusual for people to seek therapy for NPD. Subconscious fears of exposure of inadequacy are often met with defensive disdain of therapeutic processes Golomb, Elan PhD (1992). ''Trapped in the Mirror''. New York: Morrow, page 23, Kohut, Heinz, (1971). The Analysis of the Self.
Pharmacotherapy is rarely used, though there is one unofficially documented observation of therapeutic response with the atypical
Anti-depressant Bupropion (
Wellbutrin ).
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Because NPD contributes to negative, stressful life experiences characterized by the mental health field as "clinically significant distress" or "impairment", co-existing conditions of depression and anxiety are typical, and can improve with pharmaceutical interventions. NPD sufferers are more likely to seek such treatment from primary care physicians for relief of immediate symptoms of distress / depression.
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