Narcissistic Personality Disorder

Basic Information

The narcissist personality turns inward for gratification and relies on the self only for self-esteem. Narcissists feel more important than others and strive to secure power, wealth, prestige and status to enhance their security, safety and well-being. This is a means of protecting themselves from the hostility and victimization they expect from others as a matter of course, i.e., the world at large cannot be trusted, only subjugated. They cannot stand to feel vulnerable to others and fear that if they lose their sense of power and potency they will surely be exploited. They intimidate others by projecting a superior attitude and use devaluation of others, overtly or covertly, to keep them in a place of inferiority. In reality their egos are fragile -- their self-esteem and even identities built on the illusion of a "grandiose self" which if deflated or criticized can illicit feelings of rage, humiliation, shame and worthlessness. Depending on the circumstances they can swing rapidly between the two extremes of grandiosity and worthlessness.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has classified the narcissistic disorder as one of the basic personality disorders. It is classified as a disorder because the narcissist personalities have learned to overvalue their self-worth and exploit others whom they assume will recognize their superiority, even if there is no evidence or reason to support this elevated position of self. They do not have to earn this "specialness" -- it is enough that they project this arrogant self-assurance and expect others to acknowledge and admire them. DSM-IV classifies this disorder as a mildly pathological pattern in contrast to the more moderate or severe levels of pathology (such as borderline, schizoid or paranoid personalities) because the narcissistic personalities are generally able to function well socially, utilize effective coping methods, are not particularly vulnerable to the ups and downs of everyday life and exhibit no confusion or unhappiness with their view of life and their elevated place in it. After all, they are perfect and who can argue with perfection? Thus the narcissist can go through life expecting special consideration and entitlement. They are above social conventions and feel exempt from the shared responsibilities of societal living. Their wishes supersede those of others so they are unable to feel empathy for others and cannot experience how others feel. Taking advantage of others to indulge the narcissist's whims and desires is a commonplace occurrence, thus making it impossible for healthy reciprocal relationships to occur. There is no equal give and take. The narcissist generally has an exhibitionistic need for admiration and attention and will devalue those in a relationship who do not provide this. But even if a romantic partner will accommodate this devaluation, the narcissist will never find satisfaction but will often substitute erotic fantasies with a driven quality, devoid of pleasure. What the narcissist cannot obtain in fantasy he will repress. In trusting therapy interactions, the narcissist will sometimes admit to the therapist or psychiatrist that he feels "dead inside".

The background of many narcissists include cold parental figures who project feelings of either indifference or spite towards the child. In the face of this the child will often develop a special talent or "genius" which can provide a refuge from the cold and rejecting parent. The child finds a way to feel worthwhile and will continue to seek this "narcissistic" recognition through adulthood. The double-edged sword is that the narcissist will emulate or look up to successful parental type figures in adulthood, but will find himself lacking in comparison and suffer low self-esteem, depression and fear and will revert to the "grandiose self" where he can devalue, humiliate and attack or degrade those around him. Narcissists can never be enough in comparison to those they admire and find their only relief is being superior to others and keeping them in subservient positions.

Symptoms

As discussed above the narcissistic personality exhibits:

• grandiosity
• entitlement
• self-importance
• lack of empathy
• exploitative behavior

In addition the narcissist is hypersensitive to criticism -- if he feels rejected and humiliated he will feel justified in retaliation -- punishing and undermining those he feels have unjustly attacked him.

What lies behind the grandiose, superior personality, however, is:

• low self-esteem
• fear of lack of potency and power
• fear of intimacy
• fear of humiliation
• fear of loss of admiration
• fear of vulnerability and exploitation

Diagnosis/Treatment

A health care provider in tandem with a therapist and/or psychiatrist may find it difficult to diagnose narcissistic personality disorder at first -- mistaking the self-assured, superior manner of the patient for genuine confidence. Narcissists are usually slow to seek therapy, doing so only when an event or events have undermined their own inflated self-image and a little voice inside begins to tell them they are phonies. They may begin to lose self-control or sense of proportion and their fantasies may begin to overwhelm them and take on deviant qualities. They may, through rebuffs that genuinely surprise them, feel social alienation and begin to ruminate and distort events. Inside they may feel their perceptions are faulty. But they are unlikely to lay their feelings out on the table.

Thus the health care provider is often able to make a diagnosis not only through family psychological history or presentation of the patient's affect, but by observing how the narcissistic patient behaves toward the health care provider.

The narcissist usually seeks to outwit or undermine the health care provider, using anger or intimidation to maintain superiority. This can be a key to help in appropriate diagnosis. Treatment and management of the patient with narcissistic personality disorder requires patience and non-personalization of the overt/covert attacks the health care provider is likely to experience. The health care provider usually sees the attack as coming from a wounded child who is having an explosive outburst. Acknowledging that the patient feels hurt is important. The key to treatment is for the patient to feel the health care provider is non-judgmental and caring and thus able to help the patient resolve problems. In a good health care provider/patient relationship, that is what happens. There is trust and open communication and the patient can feel free to discuss perceived insults or "attacks" to his self-esteem. If a patient over time continues to attack the health care provider resolution can occur in two ways:

• a) the health care provider can ask the patient why he is so angry when in the past he has praised the abilities of the health care provider, thus deflecting the fearful feelings and continuing to correct reality distortions with the patient; or
• b) offer a referral to another health care provider as an option, not an ultimatum.

Treatment goals include:

• strengthening the narcissist's ability to look at their own weaknesses and shortcomings;
• greater self-control
• accepting responsibilities of shared societal living
• increasing sensitivity
• increased awareness of reality

Pharmacological treatment appears to be of limited value. Changing attitudes towards the self, others and society seems to be more beneficial.

If you have questions or concerns about narcissistic personality disorder, please see your health care provider.