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Day # 133: Narcissistic Personality Disorder

Today we will continue our current theme of cluster B personality disorders as we discuss narcissistic personality disorder.

Introduction 1

  • Individuals with narcissistic personality disorder (NPD) have a sense of superiority, grandiose feelings of uniqueness, desire for admiration, lack of empathy, and may exploit others for their own gain.

  • Despite their sense of grandiosity and superiority, their self-esteem is often fragile and vulnerable to minor criticism.

  • Common traits/symptoms may include being -> self-centered, grandiose, arrogant, selfish, manipulative, unsympathetic, exploitative, vain, and desperate for admiration or attention.

Diagnostic Criteria 2

  • The diagnosis of NPD requires a pervasive pattern of grandiosity, need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts.

  • ≥5 of the following must also be present: Mnemonic "GRANDIOSE"

  • Grandiose - Exaggerated sense of self-importance

  • Requires excessive admiration

  • Arrogant - or haughty

  • Needs to be special - Believes that he or she is “special” or unique and can associate only with other high-status individuals

  • Dreams - Preoccupied with fantasies of unlimited money, success, brilliance, etc.

  • Interpersonal explotations - Takes advantage of others for self-gain

  • Others - Lacks empathy for others

  • Sense of entitelement

  • Envious - Envious of others or believes others are envious of him/her

Epidemiology/Pathogenesis 3, 4, 5

  • Prevalence is estimated to be 1-9% of the general population and is more common in men. Some data suggests a higher prevalence in Black men and women and Hispanic women.

  • As with all personality disorders, the dominant theory suggest NPD develops from a combination of genetic vulnerability and environmental stressors.

  • Some studies suggest a genetic predisposition toward the disorder. Other risk factors include negative developmental experiences such as being rejected or having a fragile ego during childhood. In contrast, excessive praise, including the belief that a child may have extraordinary abilities, may also lead to NPD. Parents with NPD may impart an unrealistic sense of grandiosity/talent/beauty and thus increase the risk of their children developing the disorder.

  • Prognosis: Symptoms are chronic and difficult to treat. Patient may struggle to deal with blows to their ego/narcissism resulting from their own behavior or life experience. As these patients age there is a higher rate of depression and "midlife crises" since these patients put such a high value on youth, power, beauty, and strength. The risk of suicide in NPD is associated with high-lethality suicide attempts especially when suffering "narcissistic injury".

Clinical Pearls 4, 5, 6

  • History: Narcissistic PD begins by early adulthood. Individuals are self-centered, want their own way, and are frequently ambitious to achieve fame, power, or riches. They may have difficulty in their relationships due to their sense of entitlement, requirement of excessive admiration, and difficulty showing empathy, however they may be able to feign sympathy in order to achieve their own selfish ends. As mentioned above, some individuals are more susceptible to depression later in life due to their fragile self-esteem.

  • Subtypes: There are two basic subtypes of NPD: grandiose and vulnerable. The grandiose subtype includes overt grandiosity, boldness, presence of aggression, and lack of empathy and is more consistent with the DSM-5 criteria. Growing evidence suggest existence of a vulnerable subtype characterized by hypersensitivity and defensiveness and is often easy to miss as patients may appear shy and hypersensitive which masks a deeper hidden grandiosity and sense of entitlement.

  • Mental status exam: Individuals may appear arrogant or manipulative during an interview and their sense of entitlement is often striking. They may "fish for compliments" and become irritated or anxious when they are not treated as important or special. They tend to handle criticism poorly and become offended, hostile, or indifferent when someone criticizes them. Some experts describe their style of communicating as if they are "addressing a large audience".

  • Optional personality questionnaires: Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory (MMPI), Narcissistic Personality Inventory (NPI), Grandiose Narcissism Scale, Hypersensitive Narcissism Scale.

  • Differential diagnosis: Consider and rule out substance use disorders, mania/hypomania, and other personality disorders. Grandiosity may emerge as part of manic/hypomanic episodes or substance use, but the association with mood change or functional impairments helps distinguish these episodes from narcissistic personality disorder. Also consider other personality disorders in the differential diagnosis, particularly other cluster B disorders (antisocial, histrionic, borderline). Individuals with NPD and ASPD both may take advantage of others, however NPD patients desire status and recognition whereas ASPD patients want material gain or simply the control of others.

Treatment 7, 8, 9, 10

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: Clinical trials for psychotherapies for NPD are limited and expert clinicians typically modify treatment modalities for borderline personality disorder for use with patients with NPD such as dialectical behavioral therapy (DBT), mentailzation-based therapy, and transference-focused therapy. Transference-focused therapy focuses on personal expression of emotions toward a therapist. Psychiatrists such as Heinz Kohut and Otto Kernberg advocated the use of long-term therapy and psychodynamic approaches that focus on exploring the relationship between therapist and patient and the defenses present during sessions. Other authors advocate for group therapy, so their patients can learn how to share with, and potentially develop an empathic response, to others. More research is needed to validate the best treatment approaches in this population.

  • Pharmacotherapy: There are no FDA approved medications for NPD. No clinical trials demonstrate efficacy of any medication for NPD specific symptoms. Clinical practice is largely based on expert option and case studies. Mood stabilizers (specifically lamotrigine, lithium, and the antipsychotic risperidone) have been used with patients whose clinical picture includes severe mood swings, aggression, and impulse control issues. Many patients may benefit from the treatment of comorbid anxiety, depression, and mood lability which should be treated accordingly (see treatment of depression; treatment of anxiety). Caution should be used when selecting medications due to the high addictive potential of these patients. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment.


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