Narcissistic Personality Disorder (NPD)

Brief Overview of Diagnostic Category

There are numerous diagnoses in the DSM-5. To understand the diagnostic category of Personality Disorders, it is imperative to recognize the denotation of both “personality” and disorder. “Personality is seen today as a complex pattern of deeply embedded psychological characteristics that are largely unconscious, cannot be eradicated easily, and express themselves automatically in almost every facet of functioning. Intrinsic and pervasive, these traits emerge from a complicated matrix of biological dispositions and experiential learnings and now comprise the individual’s distinctive pattern of perceiving, feeling, thinking, and coping” (Derksen, 1995). Personality is the habitual predisposition a person holds for their perception of the world in their life. Nature can not exist without nurture. Personality is a multidimensional facet embedded with, “biological, psychological and genetic influences,” that fraternize with, “temperament, upbringing, and experience.” Personality would not exist without each of those. 

Disorder has been accepted as, “inflexible and maladjusted and lead to significant functional limitations or personal problems” (Derksen, 1995). When a person changes environments or cultures, they are expected to adapt accordingly. Everywhere has its own culture. People are expected to live into that culture when they are new. There is an implicit presupposition based on an arbitrary idea that there is a standard for how a person should act. That does not mean no one can change it. It only means that it is respectful to acknowledge the traditions and expectations from the people around you first. 

Mental health has commonly been accepted as, “the extent to which an individual behaves in accord with the needs of the system and does so without showing signs of stress” (Kaczynski, 1995). When someone does not conform to the norms of society, that does not dictate the existence of a disorder. Man is subjected to the society he resides in by his superiors. That person could be right about their perception and everyone else could be wrong. It is inevitable for a red wildebeest to be attacked by lions when they have differentiated themselves. Freud suggests classifying a disorder for a person is permitted, “only when their symptoms prevented working, loving, and playing” (Derksen, 1995). 

The DSM-5 defines a personality disorder as, “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” It states that 15% of U.S. adults are estimated to see the world through one of the lenses of the outlined personality disorders in its manual.

People with personality disorders tend to have a common fabrication including: temperament, childhood, and social context. It is important to note that personalities in this diagnostic category tend to get more easily upset than “healthy people” by something and become emotional as a response to that disturbance. There is a level of impulsiveness apparent. People with personality disorders, “hold on to regularity, habits and principles” (Derkson, 1995). During childhood there was a traumatic external event that occurred (i.e. “hospitalization of the mother during early childhood, an accident, a disaster in the form of a war, etc.”)(Derksen, 1995). Neglect, physical abuse, or sexual abuse is a common occurence that repeatedly is observed with people who live with a personality disorder. The relationship of caretaker and child is often marked with a weak sense of emotional and/or physical safety. It is hard to find a correlation between an event in adulthood that causes this behavior. It is not as indicative of events from their childhood (Derksen, 1995).

Personality disorders are divided into three clusters based on their commonalities. Narcissistic Personality Disorder (NPD) falls into the diagnostic sub-category of Cluster B. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders. Some common attributes of these personalities have been observed to be dramatic, emotional, or erratic. 

Description of the Specific Diagnosis: Emphasizing key features of the disorder

“...we describe a narcissist as a person who is preoccupied with him- or herself to the exclusion of everyone else” (Lowen, 2004). That person fabricates a reality in their mind and believes wholeheartedly that they are the center of their world. The experience of a narcissist is uniquely illustrated by, “various combinations of intense ambitiousness, grandiose fantasies, feelings of inferiority, and overdependence on external admiration and acclaim” (Lowen, 2004). It is fascinating to reconcile the idea of a person being deeply insecure about who they are while manifesting an appearance of beauty and perfection. They are infatuated with who they want to be, their idealized self, that they lose the sense of who they are. Their body influences their mind which manufactures a reality. Rather, it is an image that they want to live into. It is a ‘distortion’ of development (Lowen, 2004). Narcissists see their body as a slave to their mind. They can subject their bodies to do anything their mind wants them to. They are cerebral in nature and often deny feeling (Lowen, 2004). 

Relationally, they are not seeking the welfare of the people around them. In a romantic relationship: “Couples may join together to protect themselves and each other from inner conflict. A collusive contract maintains the consistency of each partner’s perceptions. In this way, neither must deal with overwhelming negative or dangerous emotions. Unfortunately, reciprocity of this type can do little more than provide a temporary illusion of comfort” (Marion, 1992). They are appeasing their own anxiety of their insecurities which only provides a mirage of comfort, intimacy, and safety within the relationship. They choose someone who will make them look better when they are seen together to feed into the image they want to display. A narcissistic person lacks empathy toward other people, acts entitled believing they deserve everything, has grandiose expectations, wants to only be affiliated with the elite people or places, is superficial, and is always concerned about their appearance. Nothing is ever their fault, it is always the people around them that are misbehaving. More often than not, they are manipulating everyone around them to achieve their personal jihad (MedCircle, 2018, 1).

Common comorbid disorders and relevant information for making differential diagnosis

NPD has many other disorders that are often found comorbid: other personality disorders, most commonly anxiety, and substance use disorders. According to the DSM-5, when criteria is met for multiple personality disorders, they can all be diagnosed. However, clinical psychologist from Cal State Los Angeles Dr. Ramani Durvasula, will not diagnose both NPD and BPD in the same person (MedCircle, 2018, 1). 

The DSM-5 defines anxiety as the, “anticipation of future threat. Karen Horney often referred to it as, “basic anxiety.” She defined it as, “the feeling of being helpless and alone in a world experienced as potentially hostile.” Someone with NPD is always trying to live up to their idealized expectations. When they don’t meet them, it creates a sense of shame. They are, “yearning for absolute uniqueness and sole importance to someone else, a ‘significant other’” (Morrison, 19097). They are constantly consumed with potential threats and not finding the person they are unequivocally important to, where they feel they don’t have to compete for their care. Having both anxiety and NPD only compounds the symptoms apparent.

Substance use disorders or rather substance abuse has a multitude of reasons for its partaking. Although there are a range of reasons for their use, there is a common theme that has been observed. Some of the most common reasons are: “change or lift your mood, increase your energy levels, change your perspective, aid sleep, help you relax, remove emotional or physical pain…”(Emmett, 2006). People generally will use substances to mask their problems, which only works temporarily. Sometimes the reason may be something as small as boredom or a weak self esteem. People with NPD have a weak self esteem; so, it is understandable why they would attempt to mask that feeling with a substance. 

NPD can commonly be misdiagnosed with other personality disorders in the same cluster. Cluster B is categorized by being dramatic, having extreme emotional experiences, and unpredictability. There is a significant amount of overlap between the same category. However, it is important to note different unique schemas are apparent that differentiate one diagnosis from the others. The magnitude of grandiosity seems to be the largest determinant when deciphering the different disorders. 

NPD is most commonly misidentified as Borderline Personality Disorder. They both are charming, charismatic, and seemingly confident. Someone with NPD will feel ashamed when they have done something wrong. Opposed to someone with BPD not having clear boundaries and over identifying with another person’s emotions. A good distinction to make is BPD being seductive in nature because they crave intimacy, but don’t know how to get it. BPD and NPD often attract each other because they know they make each other look better. The person with BPD will do everything they can to not lose someone. The person with NPD will leave someone before the other person gets a chance if they feel the relationship is coming to an end (MedCircle, 2018, 2).  NPD will interact in a cold manner, they are not overly emotionally expressive. NPD tends to be characterized by a fixed image of themself. They may have a precisely inaccurate depiction of their reality; however, it is consistent. The grandiosity and idealized image they project to the public is a way of them masking the insecurity about who they really are. Self destruction, impulsivity and the preoccupation with the fear of abandonment resonate more with BPD than NPD. Overidentifying with achievements and a lack of empathy discern NPD from histrionics. Narcissists need more attention and praise relative to the other disorders of the same cluster categorization. Much like antisocial, NPD shares characteristics of, “tough-minded, glib, superficial, exploitative, and unpathic” (DSM-5). They are not usually found to be aggressive. OCD and NPD exist in a notably similar range on the spectrum of perfectionism and believe other people can’t perform at the same level they can. People with NPD opposed to the other disorders of cluster B, “are more likely to believe that they have achieved perfection” (DSM-5). They are not withdrawn or overly concerned with social shyness. If they do become consumed by those thoughts, it is generally insecurity about their self image that keeps them from engaging. 

Gender and cultural considerations

There are approximately 6.2% of the American population with NPD. Men have been concluded to have it more than women, calculated at 7.7% of the population. Opposed to women, at 4.8%. Black men and women are the demographic that most commonly have NPD. The next most common demographic is hispanic women, then young adults. Seperated, divorced, widowed, and never married adults are demographics that commonly have been found to have a correlation to NPD. As people age, the percentage of people with NPD decreases. The most common age range is 20-29. The most common income bracket is under $20k annually. People who are never married or have less than a high school diploma are the most popular population for this personality disorder. People who live in urban environments opposed to rural environments have NPD more. Lastly, the most popular region for this diagnosis to occur is in the west (Stinson, 2008).

The data suggests that although there are some demographics that NPD is more popular among, the spreads are similar. They are not drastically different. Although when translated to exact population, the spread would appear larger and farther apart. It is important to note that the correlation does not go both directions. A person can have NPD and make less than $20k annually. If their salary is under $20k, that does constitute having NPD. 

Although the presentation may manifest itself differently across various cultures, the criteria remains constant according to the International Classification of Diseases (ICD-10). A culturally attuned therapist should be aware of the different expectations a person has in the environment they reside in. They should remain in a posture of curiosity with the client as the subject, which allows them to continually refine the understanding of the expectations they have for the client's “normal” (Schloesser, 2010).

Lifespan and family implications

Entitlement in NPD can appear as acts out of blaming, boasting, and intolerance of criticism. Blaming is a way of patronizing other people. This often results in the blamer feeling superior to the person they are blaming. Boasting occurs to manufacture a sense of praise and envy from the people around them. Ultimately, their accomplishments aren’t satisfying without the attention from other people. When they receive criticism, it is often met with, “how dare you say that about me!” They are always only focused on themselves. On top of that, they lack the ability to empathize. These characteristics can be difficult to manage within a family setting and don’t facilitate the environment a family needs to flourish (Brown, 1998).

NPD has a unique impact on the people around them. Everyone is affected, whether it is directly with a person or indirectly as a consequence of their actions. (Day, 2019). A family with a member that has NPD is more likely to have a higher level of both subjective and objective burden, grief, and lower overall mental health. Relative to other personality disorders, NPD tends to have the most extreme effects. With all of the symptoms from the person with NPD, no one around them is receiving reciprocal care. For spouses and children, it can feel like they are looking into a mirror with nothing looking back at them (Day, 2019).

Families often prompt the treatment of people with NPD. A narcissistic person rarely, if ever, instigates the admission of them having a problem. A person with NPD can make little changes to their personality. The probability they will become a person that most people find pleasant to keep around is extremely low. The best thing a person can do as a response to someone with NPD is manage their expectations and fortify their boundaries. A spouse that wants to stay in a marriage with someone who has NPD should not expect them to care about their emotions everyday. They should focus on cultivating relationships outside of the family where their needs are met in a healthy manner. The practice of maintaining healthy boundaries is essential to ensure self preservation. It is difficult to be in relation with someone who has NPD. There is no reason one person should be a martyr for the personal agenda of another family member (MedCircle, 2018, 2). 

Treatment recommendations

Looking at treatment through a psychodynamic lens, “the therapeutic alliance can be defined as a real object relationship which is conscious and in which both patient and therapist implicitly agree and understand that they are working together to help the patient mature through insight, progressive understanding and control” (Masterson, 2014). This step is monumental in the treatment of a person with NPD. Without creating a safe space for this to occur, nothing is going to change for the client. “...the therapist is utilized not as a real object but as a displaced object upon whom is projected unresolved infantile fantasies” (Masterson, 2014). The therapist must demonstrate a secure attachment within the room for the client. They are attempting to replicate the transference to interrupt and change how the client interacts with the world. The NPD, “...acts out in the transference either the defensive, grandiose, omnipotent self-object fused-unit or the underlying empty, aggressive fused-unit” (Masterson, 2014).  The therapist must be conscious of the scrutiny they are under when working with this client. The client will be extremely sensitive by reacting to the therapist’s perceived failures to demonstrate empathy. When they miss an opportunity, it is imperative for the therapist to acknowledge and apologize. 

During the testing phase, the client may act from a place of resistance and defense (Masterson, 2014). It is important to know that the client wants you to be in charge, even though they have wanted special treatment from everyone before. It is likely that if you give them exactly what they want, they will respect and trust the therapist less. It is important to treat them as a normal client with no exceptional treatment for the therapy to be successful. Some common issues that may arise are as follows: unnecessary changing of the time to suit the clients unreasonable demands simply for their convenience (i.e. they want to go to a baseball game), adding time at the end of the hour when the client showed up late, not holding the client accountable for canceled sessions, not properly and thoroughly assessing the client’s financial situation to fulfill financial obligations to the therapist, allowing phone calls at inappropriate times of the day, seeing a patient on drugs, not requiring client to pay bill on time, succumbing to irrelevant conversations at the end of the session, not starting or ending the session on time, and calling adult patients by their first names (Masterson, 2014). All of this structure, if properly in place, will only work to benefit the client in learning that they must abide by the rules and not everything is about them. 

During the working through phase, it can be described with anger and depression (Masterson, 2014). After some of the destructive aspects of the client’s behavior, a therapeutic alliance should be established. It is only through that confrontation the client will begin to trust the therapist. The cycle of this phase is transference acting out, confrontation, and working through. As more of these cycles occur and the client gains more insight into a more grounded sense of reality, their life is observed to experience less daily crises. Everything becomes more localized as they begin to see the world more accurately (Masterson, 2014). There will be the impulse that must be alleviated where you desire to seek revenge, talionic impulse. The talionic impulse must be managed to ensure that the client is receiving the best care possible (Masterson, 2014).

In a therapeutic relationship, the success of that relationship is determined by what happens after termination. It is important for the client to test the attenuation of their impulses and for them to prove their independence in taking personal responsibility for their lives (Masterson, 2014). When a therapist gives into the clients manipulations for taking care of them, it is virtually inevitable that they will terminate themselves earlier than clinically ept. There are no new techniques needed during this phase. The client has learned what they need to know. Usually, the client should suggest termination after reasonably progressing in their work. The expectation of availability of the therapist after termination should be assumed and not elaborated on (Masterson, 2014).

Hypothetical Scenario

George is a 35 year old black male. He was referred to by his doorman after his model wife and kids left him. He does not understand what the problem is. He thinks the world is out to get him and can’t make sense of anything around him. He presents as a well groomed and a well kept, articulate man. He works in finance on Wall Street for Goldman Sachs because he believes they are the most powerful in the industry. Everything he does is a competition. From his haircuts, to his business cards, to the car he drives, and the restaurants he eats at: everything has to be the best. He only spends time with people that are at his caliber of prestige. There is always something better and George is always chasing it. 

Everything George does needs praise. He wants to be the hero of everyone's story. He constantly needs to be reminded of how much he is appreciated for the difference his presence makes in his family or at work. Part of what got George his job and his wife is his confidence. At work he has a reputation for creating portfolios that outperform everyone else in the office and closes business deals that no one else can. He is relentless when it comes to his career. Nothing is off the table for George, when it comes to reaching his goal. Once he is on a mission, there is no stopping him. He doesn’t pay attention to the people around him. Anywhere he goes he immediately commands the room. Everyone serves him because he gets them excited about something bigger that they can be a part of. George has an affinity for getting mad at waiters when they mess up his order because he believes their job is not hard. 

George does not believe he has a problem. He believes his wife and kids are unappreciative for everything he does for them. He has two daughters that he claims have everything given to them. There is no reason they should not like him. George says it doesn't make sense why one of his co-workers has the perfect family. 

References

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MedCircle. (2018). These Are The Signs You’re Dating A Narcissist. In YouTube. https://www.youtube.com/watch?v=TLM94DnKkQo

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