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Narcissistic Personality Disorder

DSM-IV Diagnostic Criteria

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. The disorder begins by early adulthood and is indicated by at least five of the following:

An exaggerated sense of self-importance.

Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

Believes he is "special" and can only be understood by, or should associate with, other special or high-status people (or institutions).

Requires excessive admiration.

Has a sense of entitlement.

Takes advantage of others to achieve his own ends.

Lacks empathy.

The patient is often envious of others or believes that others are envious of him.

Shows arrogant, haughty behavior or attitudes.

Clinical Features of Narcissistic Personality Disorder

Patients with narcissistic personality disorder exaggerate their achievements and talents, and they are surprised when they do not receive the recognition they expect.

Their inflated sense of self results in a devaluation of others and their accomplishments.

Narcissistic patients only pursue relationships that will benefit them in some way.

These patients feel very entitled, expecting others to meet their needs immediately, and they can become quite indignant if this does not happen.

These patients are self-absorbed and unable to respond to the needs of others. Any perception of criticism is poorly tolerated, and these patients can react with rage.

These patients are very prone to envy anyone who possesses knowledge, skill or belongings that they do not possess. Much of narcissistic behavior serves as a defense against very poor self esteem.

Epidemiology of Narcissistic Personality Disorder

The prevalence of NPD is less than 1% in the general population and up to 16% in clinical populations.

The disorder is more common in men than women.

Studies have shown a steady increase in the incidence of narcissistic personality disorder.

Differential Diagnosis of Narcissistic Personality Disorder

Histrionic Personality Disorder. Histrionic patients are also attention seeking, but the attention they seek does not need to be admiring. They are more highly emotional and seductive compared to patients with NPD.

Borderline Personality Disorder. These patients also tend to idealize and devalue others, but narcissistic patients lack the unstable identity, self-destructive behavior, and abandonment fears that characterize borderline patients.

Antisocial Personality Disorder. Interpersonal exploitation, superficial charm, and lack of empathy can be seen in both antisocial personality disorder and narcissistic personality disorder. However, antisocial patients do not require constant admiration nor do they display the envy seen in narcissistic patients. A history of criminal behavior is not typical of narcissism.

Personality Change Due to a General Medical Condition and Substance-Related Disorder. All symptoms are temporally related to medication, drugs or a medical condition.

Treatment of Narcissistic Personality Disorder

Psychotherapy is the treatment of choice, but the therapeutic relationship can be difficult since envy often becomes an issue.

Coexisting substance abuse may complicate treatment.

Depression frequently coexists with NPD; therefore, antidepressants are useful for adjunctive therapy.