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Narcissistic Personality Disorder

Paroma Mitra; Dimy Fluyau.

Author Information

Authors

Paroma Mitra1; Dimy Fluyau2.

Affiliations
1 New York University School of Medicine
2 Emory University

Last Update: May 1, 2022.

Continuing Education Activity

Narcissistic personality disorder (NPD) is a complex personality disorder often detected with
other affective and personality disorders. This activity outlines the evaluation of narcissistic
personality disorder and discusses a multi-modal approach to treatment. This article also outlines
complications related to personality disorder and discusses interprofessional approaches to the
same.

Objectives:

Identify the etiology of narcissistic personality disorder.

Summarize the evaluation of narcissistic personality disorder.

Review management options available for narcissistic personality disorder.

Describe the complications of narcissistic personality disorder, including comorbid

diagnosis and relation to suicidal behavior.

Access free multiple choice questions on this topic.

Introduction
Narcissistic personality disorder (NPD) is a pattern of grandiosity, need for admiration, and lack
of empathy per the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). The
disorder is classified in the dimensional model of "Personality Disorders."NPD is highly
comorbid with other disorders in mental health. Persons with NPD can often present with
impairment in maintaining work and relationships.[1] NPD is highly prevalent in society;
however, there has been limited research on the same. Given the limited research on the same
and differences in the diagnosis of the disease, it was initially going to be discontinued from the
DSM.NPD is under the umbrella of Cluster B personality disorders, which include antisocial
personality disorder, histrionic personality disorder, and borderline personality disorder. Cluster
B typically presents with overtly emotional and unpredictable behavior.[2] 

NPD has been associated with the concept of " development." "Development" has been central to
studies that have been done to understand the psychopathology and etiology of NPD. Experts
such as Otto Kernberg and Eve Caligor have introduced more standardized evaluation tools to
understand the disorder. Due to NPD comorbidity with other mental disorders and its elevated
medical, social, and psychiatric complications, and a gap of knowledge about the disorder,
understanding NPD is warranted. This paper aims to cover the gap and incite more research on
NPD.

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Etiology
The etiology of narcissistic personality disorder is multifaceted. Some studies have suggested a
genetic predisposition toward the disorder.[3] Traits such as aggression, reduced tolerance to
distress, and dysfunctional affect regulation is prominent in persons with NPD.
[4] Developmental experiences, negative in nature, being rejected as a child, and a fragile ego
during early childhood may have contributed to the occurrence of NPD in adulthood.[5][6] In
contrast, excessive praise, including the belief that a child may have extraordinary abilities, may
also lead to NPD.

Epidemiology
Given the challenges of diagnosing narcissistic personality disorder, there have been varying
reports of prevalence in the United States of America( USA). Prevalence rates from community
samples have been from 0.5% to 5% of the US population.[7] However, in clinical settings, NPD
appears to be more prevalent. Prevalence rates can be from 1% to 15% of the United States
population. NPD may coexist with other mental disorders rendering its diagnosis challenging.
Substance use disorders are among the most comorbid conditions.[8] Other personality disorders
such as antisocial personality disorder, borderline personality disorder, histrionic personality
disorder, and schizotypal personality disorder are also common in people with NPD.[9] 

Comorbid antisocial personality disorder is said to have the most negative effect. There is much
contention around the diagnosis of NPD. There are two basic subtypes, including grandiose and
vulnerable narcissistic personality disorder. The grandiose subtype includes overt grandiosity,
presence of aggression, and boldness. The vulnerable subtype presents with hypersensitivity and
defensiveness and is often easy to miss.[10] There has been some research on the grandiose
subtype, which includes evidence of behavior such as overt aggression, lack of empathy, and
exploitation of the other.[11][12] Interviews of 34,653 adults who participated in the Wave 2
National Epidemiologic Survey on Alcohol and Related Conditions revealed a lifetime
prevalence of NPD of 6.2%: 7.7% greater in men and 4.8% in women. A high prevalence of
NPD was found among Black men and women and Hispanic women.[1] 

Pathophysiology
There has been limited work done on neuroimaging in persons diagnosed with narcissistic
personality disorder. A voxel-based morphometry (VBM) study done in Germany with a small
sample size showed gray matter abnormalities in the prefrontal and insular regions.[13] Another
voxel-based morphometry and diffuse tensor imaging study(DTI) done in Germany showed grey
matter abnormalities in the right prefrontal and anterior cingulate cortices. There were
abnormalities detected in the white matter of the frontal lobe as well.[14]

History and Physical

Obtaining an accurate history can be somewhat challenging for persons with narcissistic
personality disorder, given the variability of the presentation. In the outpatient setting,
individuals can be well related and high functioning, while in the inpatient setting, they can be
some of the most aggressive and challenging patients. Most of the time, NPD patients come into
contact with clinicians during emergencies were more often than not, they are noted to behave
aggressively.[15]

The aggression indicates the severity of the personality disorder, i.e., the more aggression
detected, the personality disorder is considered more severe. Otto Kernberg cited extensive cases
correlating aggression with the severity of personality disorders.[16]

Per the DSM, NPD includes:

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A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and with lack of
empathy, beginning by early adulthood, as indicated by at least five of the following:

Has a grandiose sense of self-importance (e.g., exaggerates achievements, expects to be

recognized as superior without actually completing the achievements)

Is preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.

Believes that they are "special" and can only be understood by or should only associate
with other special people (or institutions).

Requires excessive admiration.

Has a sense of entitlement, such as an unreasonable expectation of favorable treatment or

compliance with his or her expectations).

Is exploitative and takes advantage of others to achieve their own ends.

Lacks empathy and is unwilling to identify with the needs of others.

Is often envious of others or believes that others are envious of them.

Shows arrogant, haughty behaviors and attitudes

The diagnosis of NPD as other personality disorders requires evaluation of long-term patterns of
functioning. One needs to be cautious not to jump to hasty conclusions because NPD can trigger
countertransference. A careful evaluation of the different aspects of a person's life and an
understanding of the person's childhood development can assist in the evaluation and diagnosis
of NPD.

Evaluation
A standard psychiatric interview is often used to make a diagnosis of personality disorders. Otto
Kernberg's structured clinical interview, which was created in 1981, has continued to undergo
revisions and restructuring as a structured clinical interview for personality disorders. The
current version is a semi-structured diagnostic interview with questions focused on personality
organization, defenses, object relations, and coping skills. This interview focuses on
interpersonal relationships. The current version is copyrighted by the Personality Institute at The
Weill Cornell Institute. The interview is based on psychodynamic principles and is expected to
be used by persons who had have had previous training in psychoanalytical work.[17]

Other instruments may measure the severity of narcissistic personality disorder, such as the five-
factor narcissism inventory that looks at the five aspects of general personality. There are about
148 questions that are asked on the measure.[18] Another measure that may be useful is the
Narcissistic Personality Inventory.[19]

The instruments above are mostly used in research settings. In the clinical world, the clinical
interview is of most value. An excellent clinical interview focuses on interpersonal relationships
as persons with an NPD often present with conflicts with others in inpatient or outpatient
settings. In outpatient settings, referrals are often made at the behest of a loved one. In inpatient
or emergency room settings, symptoms often come into play when there is interaction with other
personnel, especially others in authority. Persons with NPD often describe themselves in relation
to others with themes of comparison.[10]

Often a clinician's countertransference may help with forming a diagnosis. Often, persons with
NPD create feelings of either feeling flattered or admired, or on the other extreme, having
feelings of inadequacy and low self-worth.[20][21] Glen Gabbard is another analyst who has
done extensive work in understanding these feelings described as "countertransference" in the

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therapist. As a clinician, it is always important to pay attention to the feelings evoked by a patient
in themselves as this is often diagnostic.

Treatment / Management
No standardized pharmacological or psychological treatment has been established for persons
with narcissistic personality disorder.[10] More often than not, NPD is present, along with other
mood disorders. Once a diagnosis is established, it is essential to discuss the diagnosis because of
several challenges that will mostly be present in the future. It is equally important to treat
ongoing symptoms of co-occurring affective disorders.[22]

Kohut and Kernberg have focused on long-term therapy and exploring the relationship between a
therapist and patient, which continues to be an established treatment for persons with a
narcissistic personality disorder.[23] Psychodynamic psychotherapy focuses on defenses present
during therapy sessions.[24] Many therapists have advocated for ongoing therapy for patients
with an established diagnosis of NPD. NPD may significantly reduce emergency department
visits and lower the incidence of self-harm. Of note, studies are more focused on borderline
personality disorder; however, borderline personality disorder's findings may be generalizable to
other disorders as well.

Transference-focused therapy is structured twice a week psychoanalytic therapy that focuses on

personal expression of emotions toward a therapist. Given that persons with NPD can often be
provoked by their perception of being treated by another, their own emotions towards other
people are essential.[25]

Schema-focused therapy is relatively new and focuses on alternate forms of cognitive-behavioral

therapy, including activating emotional senses.[26]

There are no FDA-approved medications for the treatment of NPD, but many patients may
benefit from the treatment of symptoms, including anxiety, depression, mood lability, transient
psychosis, and impulse control issues. Antidepressants, including selective serotonin reuptake
inhibitors and serotonin-norepinephrine reuptake inhibitors, have been used. Risperidone, an
antipsychotic, has shown benefit in some patients. Some patients are given mood stabilizers like
lamotrigine.

Differential Diagnosis
The differential diagnosis often includes prevailing mood or anxiety disorders. Often persons
with grandiose narcissism can present with heightened mood and more energy when excited by a
new idea, which may initially point to a hypomanic/manic presentation; however, the personality
aspect would be prominent in their interaction with others. On the other extreme, persons with
vulnerable narcissism may present with salient features of dysthymia, depression, and anhedonia.
However, the grandiosity and need for admiration would be prominent despite the affective
symptoms, which would differentiate it from a major depressive disorder.

The closest differentials continue to remain other cluster B personality disorders, including
antisocial personality disorder, histrionic personality disorder, and borderline personality
disorder. It bears mention that persons with NPD do not show overt signs of impulsivity and self-
destructiveness associated with borderline personality disorder. Similarly, apparent emotional
responses are associated with histrionic personality disorder. NPD is most similar to antisocial
personality disorder with a lack of empathy and superficial charm. However, persons with an
antisocial personality disorder would show a lack of morals compared to persons with NPD and
have a past diagnosis of conduct disorder.

Antisocial personality disorder

Borderline personality disorder

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Histrionic personality disorder

Major depressive disorder

Obsessive-compulsive disorder

Substance-induced mood disorder

Prognosis
The prognosis, as discussed above, depends on the presence of comorbid disorders and the level
of functioning of the patient. Aggression is often directly related to the severity of the disease;
rather, the more aggressive the patient appears, the more severe is the personality disorders.

Complications
The complications essentially involve the presence of comorbid conditions, including mood and
substance use disorders. The presence of other personality disorders is also common. However,
narcissistic personality disorder is associated with a higher risk of death by suicide compared to
other personality disorders.[27] In contrast, there is mixed evidence of suicide attempts and
persons with narcissistic personality disorder since NPD is associated with factors such as “self-
love” and “grandiosity” and comparatively less impulsivity.[28] Substance use disorder is also
related to NPD, and when there is an association of substance use disorder with NPD, there is
significantly more hostility, and aggression is also present. This makes treatment even more
challenging than usual. There are several theories related to both biology and trauma regarding
the same.[29][30]

Deterrence and Patient Education

As detailed above, it is necessary to discuss the diagnosis with the patient as soon as possible. It
is equally important to discuss the process of arriving at this conclusion, including clinical
information gathered and observed behaviors. Discussion of other comorbid disorders, including
mood and substance use disorders, if present, needs to be addressed. Often family members also
require education about personality disorders, their behaviors, and complications.

Pearls and Other Issues

1. Obtaining a detailed history is vital. A primary psychiatric interview focuses on symptoms;

however, longitudinal assessments focusing on interpersonal relations are helpful to point
toward a diagnosis of NPD.

2. Given that there are two subtypes established, it is essential to focus on identifying both
grandiose and vulnerable forms, given that the latter is missed in place of other diagnoses.

3. It is essential to be mindful of other comorbid diagnoses given the high levels of

comorbidity with affective and other cluster B personality disorders.

4. Literature has shown that most persons with narcissistic personality disorder are difficult to
engage; hence, being empathetic is necessary when beginning treatment.

5. Once a diagnosis is established, it is important to share the same with the patient. Lack of
sharing may lead to further complications during care.

6. It is equally important to treat comorbid mood and substance use disorders.

7. It is crucial for treating clinicians to be aware that there are high rates of drop-outs and
increased rates of therapeutic disruption with persons with a narcissistic personality
disorder.

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8. It is essential to recognize that most clinicians experience negative countertransference

when treating persons with NPD. Clinicians are advised to be aware of the same and
process emotions that arise in treatment.

Enhancing Healthcare Team Outcomes

Often collaborative work is required in the medical setting when patients with NPD work with
non-mental health professionals such as surgeons, medical nursing, nutritionists, etc. These
patients are often described as "difficult and demanding," and importantly, their medical needs
remain untreated. Often mental health professionals may be consulted for a mood disorder on the
inpatient floor for a patient with underlying NPD and have to liaison with the primary medical
team in charge of the patient. Other medical professionals must be educated about personality
disorder and their countertransference towards the patient so that it does not impact clinical care.
Mental health professionals in the consult-liaison service may provide support and education to
the first medical teams as well.

In the outpatient setting, patients are asked to discuss their diagnosis as they feel relevant to their
medical providers. A partnership among medical professionals and other ancillaries may ensure
optimal care. Pharmacists need to have input into the medication process, ensuring proper dosing
and the absence of interactions. Nurses function as the glue that holds the team together and are
often the primary point of patient contact. The education of both patients and their providers is
also helpful. All these disciplines functioning as an interprofessional team are vital to achieving
optimal patient outcomes. [Level 5]

Review Questions

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