Narcissistic Personality Disorder

Although often symptom free and well functioning, the narcissistic personality is chronically unsatisfied due to a constant need for admiration and habitually unrealistic self-expectations.

The narcissist is impulsive and anxious, has ideas of grandiosity and “specialness,” becomes quickly dissatisfied with others, and maintains superficial, exploitative interpersonal relationships. Under stress and when needs are not met, the narcissist may become depressed, develop somatic symptoms, have brief psychotic episodes, or display extreme rage.

Clinical Presentation

The narcissistic personality is characterized by the following behavioral and interpersonal style, cognitive style, and affective style. Behaviorally, narcissistic individuals are seen as conceited, boastful, and snobbish.

They appear self-assured and self-centered, and they tend to dominate conversations, seek admiration, and act in a pompous and exhibitionistic fashion. They are also impatient, arrogant, and think skinned or hypersensitive. Interpersonally, they are exploitive and use others to indulge themselves and their desires. Their behavior is socially facile, pleasant, and endearing. However, they are unable to respond with true empathyOpens in new window to others. When stressed, they can be disdainful, exploitive, and generally irresponsible in their behavior.

Their thinking style is one of cognitive expansiveness and exaggeration. They tend to focus on images and themes rather than on facts and issues.

In fact, they take liberties with the facts, distorts them, and even engage in prevarication and self-deception to preserve their own illusions about themselves and the projects in which they are involved. Their cognitive style is also marked by inflexibility.

In addition, they have an exaggerated sense of self-importance and establish unrealistic goals of power, wealth, and ability. They justify all of this with their sense of entitlement and exaggerated sense of their own self-importance.

Their feeling or affective style is characterized by an aura of self-confidence and nonchalance, which is present in most situations except when their narcissistic confidence is shaken. Then, they are likely to respond with rage at criticism. Their feelings toward others shift and vacillate between overidealization and devaluation. Finally, their inability to show empathy is reflected in their superficial relationships with minimal emotional ties or commitments.

DSM-5 Characterization

Individuals with this personality disorder are characterized by an unremitting pattern of self-centeredness and grandiosity. More specifically, they have an exaggerated sense of their own abilities and achievements. They may have a constant need for attention, affirmation, and praise.

Typically, they believe they are unique or special and should only associatiate with others of the same status. They are likely to have persistent fantasies about attaining success and power.

These individuals can exploit others for personal gain. A sense of entitlement and the expectation of special treatment is common. They may come across as snobbish or arrogant. They appear to be incapable of showing empathy for others. In addition, they can be envious or think that others are envious of them (American Psychiatric Association, 2013).

Case Example: Mr. N.

Mr. N. is a 32-year-old male who presented for therapy after his wife of six years threatened to leave him and because his employer was pressuring him to resign his position as a sales executive for a condominium project.

Apparently, Mrs. N. had told her husband that he loved himself “a hundred times more than you love me.” Mr. N. dismissed this by saying he needed to buy $600 suits because his job demanded that he look his best at all times and that he was “tall, dark, handsome, and sexy, all any woman could want in a man.”

Mr. N. denied that he used scare tactics, exaggerated claims, or other pressure-selling techniques with customers. “Sure, I’m a bit aggressive, but you don’t get into the ‘Millionaire’s Club’ by being a wimp.” He added that his employer would “go belly up without me,” and that he was too important to be dismissed for such petty reasons.

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulation may be helpful in understanding how the Narcissistic Personality Disorder is likely to have developed.

Biologically narcissistic personalities tend to have hyper-responsive temperaments (Millon, 2011). As young children they were likely to be viewed by others as being special in terms of looks, talents, or “promise.” Often, as young children, they had early and exceptional speech development. In addition, they were likely keenly aware of interpersonal cues.

Psychologically, the narcissists’ view of themselves, others, the world, and life’s purpose can be articulated in terms of the following themes: “I’m special and unique, and I am entitled to extraordinary rights and privileges whether I have earned them or not.”

Their world-view is a variant of the theme: “Life is a banquet table to be sampled at will. People owe me admiration and privilege.” Their goal is: “Therefore, I’ll expect and demand this specialness.” Common defense mechanismsOpens in new window utilized by the narcissistic personality involve rationalization and projective identification.

Socially, predictable parental patterns and environmental factors can be noted for the narcissistic personality. Parental indulgence and overevaluation characterize the narcissistic personality.

The parental injunction was likely to be: “Grow up and be wonderful — for me.” Often they were only children, and, in addition, may have sustained early losses in childhood. From an early age they learned exploitive and manipulative behavior from their parents. The narcisstic pattern is confirmed, reinforced, and perpetuated by certain individual and systems factors. The illusion of specialness, disdain for others’ views, and a sense of entitlement lead to an underdeveloped sense of social interest and responsibility. This, in turn, leads to increased self-absorption and confirmation of narcissistic beliefs.

Treatment Considerations

In terms of treatment goals, a decision needs to be made as to whether the treatment is short term and crisis oriented, or long term and focused on personality restructuring.

Crisis-oriented psychotherapyOpens in new window usually focuses on alleviation of the symptoms, such as anxietyOpens in new window, depressionOpens in new window, or somatic symptomsOpens in new window associated with the narcissistic injury or wound. This injury occurs when others fail to respond to the narcissist’s sense of entitlement and specialness.

Empathic mirroring or reflection and soothing are the treatments of choice (Kohut, 1971). The goals of longer-term therapy involve the restructuring of personality. These goals include increasing empathy, decreasing rage and cognitive distortions, and increasing the individual’s ability to mourn losses.

Treatment methods and strategies include empathic mirroring (Kohut, 1971), anger management, cognitive restructuring, and empathy training, as well as interpretation. When marital issues are involved, couples therapy has been shown to be a useful treatment modality (Feldman, 1982).

Medication management is directed at treatable symptoms such as depression, anxiety, etc. (Reid, 1989). Clinicians have noted that the majority of narcissistic personalities who present for treatment are interested only in having the narcissistic wound soothed; then they leave treatment.