Narcissistic Personality Disorder

Narcissistic Personality Disorder


Narcissistic personality disorder is classified as cluster B personality disorder. It shows general symptoms of exaggeration of self importance, lack of empathy, and some cases show signs of depression (Butcher J.N. et al. 2010). People with Narcissistic personality disorder generally react unusually strong to criticism. The most prominent diagnostic factor used in DSM to diagnose Narcissistic personality disorder is the feeling of grandiosity (Butcher J.N. et al. 2010). It is suggested that this grandiosity is a cover for very low self-esteem for people with narcissistic traits (Butcher J.N. et al. 2010).


The general symptoms of NPD are indicated as exaggeration of self-importance, lack of empathy, and some cases show signs of depression. People with NPD generally react strongly to criticism. The most prominent diagnostic factor used in DSM to diagnose NPD is the feeling of grandiosity. It is suggested that this feeling of grandiosity is a cover for very low esteem. Because of the very low self-esteem, people with NPD have excessive need of admiration. They strongly believed in their ability, intelligence and success, and also, their beauty and attraction (Macdonald, P. 2011). They have unrealistic belief that they should be treated favorably by other people. They behave in an arrogant way and would be envious to other people, and believe that other people are also envious of him or her (Macdonald, P. 2011).
Case history of a NPD patient named Robin mentioned that, “narcissistic rage” is different from normal rage, that “narcissistic rage” is more frequent and inconsistent. Since people with narcissistic personality disorder have an idealized self as well as idealized others, once other people’s behaviours do not meet the standard they set, they would be extremely angry and would be always complaining. In the case of Robin, he kept believe that he should have a personal space belong to him in the hospital, so he was always enraged when his request was not carried out by others. (Macdonald, P. 2011)

Hypothesis of causal social factors

Causal factors of Narcissistic Personality disorder are mostly attributed to social factors and parental style is the most important factor that was discussed the most. Unfortunately, the two most influential theories about social causal factors of NPD are controversial. One group of people like Heinz Kohut, a famous psychodynamic theorist, suggested that neglectful parental style may cause narcissistic traits appear in children, since parents are devaluing and unempathetic, so children in this environment would develop very low esteem and would have strong need of admiration and appreciation from other people (Butcher J.N. et al. 2010). So their unusually strong need of appreciation from people surround them is from their lack of appreciation from their parents. While, a controversial group of people represented by Theodore Million suggested that narcissistic personality disorder may be caused by over-indulging parental style. They believed that children in an indulging environment would develop beliefs and perceptions of their grandiosity, since their parents would carry out whatever they requested and their parents confirmed that they are beautiful, attractive, intelligent, successful and other people would always admire them (Butcher J.N. et al. 2010). Their parents give them the sense that they are the center of the world, and this is where the feeling of grandiosity comes from; so their unusual strong need of admiration is because the belief that they deserve admiration from others.

DSM diagonsis of NPD and its weakness

DSM-IV-TR (retrieved from Butcher J.N. et al. 2010)
Criteria for Narcissistic personality disorder
1. Grandiose sense of self importance
2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty.
3. Belief that she/he is special and unique
4. Excessive need for admiration
5. Sense of entitlement
6. Tendency to be interpersonal exploitative
7. Lacks empathy
8. Is often envious of others or believes that others are envious of him or her
9. Shows arrogant, haughty behaviours or attitudes

A new proposed formulation of DSM V: (retrieved from Elsa, R. 2009)
1. Grandiosity
2. Vulnerable and fluctuating self-esteem
3. Strong reactions to perceived challenges or threats to self-esteem
4. Self-enhancing interpersonal behaviour
5. Self-serving interpersonal behaviour
6. Interpersonal aggression
7. Interpersonal control
8. Fluctuating or impaired empathetic ability
9. Exceptionally high or perfectionist personal ideals and standards

Grandiosity is always the most prominent feature to diagnose NPD, but in the new proposed DSM V, a new dimension is emphasized, which is vulnerable and fluctuating self-esteem (Elsa, R. 2009). This new criteria indicated changeability and difficulty to diagnose NPD, since vulnerability and fluctuating self-esteem indicated a contradictory side of grandiosity such as being shy, which is totally opposite to being arrogant and imempathetic. The criteria of strong reactions to perceived challenges or threats to self-esteem also became increasingly important, since emotional dysregulation, as one of the typical symptoms of NPD is included within this criteria. People with NPD are unusually sensitive and respond with extreme rage to any criticism that they perceived as threats to their self-esteem (Elsa, R. 2009).

Narcissistic personality disorder and other disorders

The reason that emotional dysregulation is emphasized in NPD because of the stress it carried out made NPD more likely to comorbid with other type of disorders such as depression, borderline personality disorder and eating disorder (Elsa, R. 2009).

Narcissistic personality disorder and borderline personality disorder

Both narcissistic personality disorder (NPD) and borderline personality disorder (BPD) patients show signs of hyper-reactivity and even aggression to particular emotional stimuli. Borderline personality disorder is characterized by suicidal and self-injury behaviour, and is more likely to comorbid with depression; people with BPD also shows signs of unstable interpersonal relationships and identity (Leichsenring,F. etal. 2011). In comparison, NPD is more correlated with stress, antisocial behaviours, aggression and emotional outbursts (Clemence, A.J. 2009). It seems like that NPD and BPD are totally different, but the point of similarity comes from “vulnerability” of NPD we have talked about, that people with NPD have vulnerable and fluctuating self-esteem. Clinicians represented by Russ subdivide NPD into three subtypes, which are the “grandiose/malignant” type, the “fragile” type and a “high functioning” type (Russ, e. 2008). People belong to the grandiose/malignant type may more likely to show signs of paranoid, aggressive and anti-social behaviours, while people belong to the vulnerability type would be similar to BPD, that they would more likely to show signs of depression and suicidal behaviours (Clemence, A.J. 2009). Another huge similarity of NPD and BPD is that both disorders show strong signs of resistance to treatment (Clemence, A.J. 2009).
Emotional dysregulation is involved in both NPD and BPD, and the emotional hyperactivity and vulnerability is highly correlated to hyper-activation of amygdala. A group of scientists use functional magnetic imaging to examine how people with BPD respond differentially from normal people to various facial expressions. The result was that people with BPD had greater activation of left amygdala in response to facial expressions (Donegan,2003). Scientists suggest that amygdala dysfunction is the key route that lead to psychopathology, since amygdala dysfunction is the major cause of emotional dysregulation that it made people un-empathetic and inresponsive to other people’s fear and sadness (Mack, T.D. 2011). Keep in mind that being un-empathetic is also a typical symptom of NPD, which suggests how amygdala hyperactivity involved in both NPD and BPD.
Amygdala is shown in Figure 1.
Figure 1: Depiction of amygdala in a coronal brain slice

__Neuroscientist. Author manuscript; available in PMC 2009 November 2.__
Published in final edited form as:
Neuroscientist.2009 October;15(5): 540���548.
Published online 2009 April 9. doi: 10.1177/1073858409333072

Depressed NPD and paranoid symptoms

People with paranoid personality disorder (PPD) are always being suspicious of that others would harm them, so they may be constantly anxious, resentful, or even aggressive. A great similarity of PPD to NPD is that PPD also show signs of hyper-vigilance and unusual strong reaction to any criticism (livesley, W.J. and Schroeder, M.L. 1990).
Interestingly, a group of researchers studied past empirical report and predicted that people with NPD, if depressed, would show signs of paranoid symptoms. Since being depressed is the vulnerable side of NPD, that people have fluctuating self-esteem. The unstable self-esteem make this group of NPD people vulnerable, suspicious, hyper-vigilance and gradually develop paranoid symptoms. Researchers also found that the correlation between depressed NPD and PPD is only an unidirectional relationship, which means that people with PPD, if depressed, may not necessarily develop narcissistic traits (Joiner, T.J. 2008).

NPD and eating disorders

Narcissistic personality disorder is often associated with eating disorders, such as anorexia nervosa, bulimia nervosa, and unhealthy cognitions associated with eating disorders (Campbell, M. and Waller, G. 2010). A study was conducted on how narcissistic level is correlated with different behaviours of eating disorders. Participants were 110 adult females, that some of them had anorexia nervosa, some had bulimia nervosa, while others had non-specified eating disorders. Their narcissistic level was measured by O’ Brien Multiphasic Narcissism Inventory (a questionnaire). The result was that, the higher the level of narcissistic level a person has, the more likely that the person shows signs of excessive exercise (Campbell, M. and Waller, G. 2010). This is very reasonable since excessive exercise may be an indication of fluctuating self-esteem and vulnerability, or on the other side, satisfying the sense of grandiosity.
There was also a study indicated that narcissistic traits made eating disorders particularly hard to treat, since people with narcissistic traits are extremely resistant to any assistance that they perceived as criticism or threats to their egotism. This made cognitive therapy hard to be carried out and hard to alter their distorted perceptions of themselves (Waller, J. etal. 2008).

Treatments of NPD

There are various treatments of NPD, such as psychoanalysis, cognitive therapy, cognitive-behavioural therapy, and specific symptom targeted therapy.

Cognitive therapy

Cognitive therapy is based on the idea that people’s attitudes would influence people’s behaviour. Cognitive therapy was developed during 1950s and 1960s by Albert Ellis and Aaron Beck (Gunderman, R.B. 2006). Psychologists believe that people could adjust their reactions to specific stimulus rationally, and this is also what cognitive therapists help people do during treatments (Gunderman, R.B. 2006). During cognitive therapy for treatments of NPD patients, their unhealthy cognition of self-esteem is what therapists target on.
Even though cognitive therapy is effective and popular to treat various psychopathology, in the case of NPD, applying cognitive treatment to NPD patients become very challenging. The first reason is that, the “treatment alliance” between therapists and patients is hard to form, since therapists have to face distrusts, constant dissatisfaction and resistance from patients with NPD (Elsa, R. 2011). Another important reason is that the type of NPD patients with vulnerable and fluctuating self-esteem usually make therapists ignore their underlying narcissistic traits; since this type of NPD patients show less grandiosity, and instead, they seem to show compliance and do cooperate with therapists. In other words, NPD patients with fluctuating self-esteem usually have their feeling of grandiosity and other narcissistic traits concealed. They are conflicted and anxious, which direct cognitive therapy that therapists conducted to other directions (Elsa, R. 2011).

Drug therapy: selective serontonin reuptake inhibitors

Selective serontonin reuptake inhibitors (SSRIs) include Prozac, Zoloft, and Paxil etc (Preston, P. 2007). Using selective serontonin reuptake inhibitors to treat NPD patients actually uses the way of targeting specific symptoms of NPD, which is depression. Since NPD patients with fluctuating and vulnerable self-esteem usually show signs of agitation and depression, therapists may use SSRIs to relieve depression and anxiety. SSRIs are very effective to treat depressive symptoms, especially suicidal impulses and anxiety, since serontonin dysregulation is a cause of suicidal impulsivity (Preston, P. 2007).
Effectiveness of SSRIs to relieve depression and anxiety was further proved when researchers depleted SSRIs treated depressive patients of serontonin, and the result was recurrence of depression in those patients (Nutt, D.J. etal. 1999).
Mechanism of SSRIs:
Serotonergic neurons are promnient in limbic system of human brain, which are important in emotional regulation. On the synapse level, SSRIs bind to 5-HT receptors on pre-synaptic membrane to prevent reuptake of serontonin, to increase serotonin level in synapse (Lattimore, K.A. etal. 2005). The mechanism is indicated as Figure 2.

Figure 2: mechanism of how serotonin reuptake inhibitors (SSRIs) act on 5-HT receptors to block reuptake of serotonin
Figure 2 is retrieved from: Lattimore, K.A., Donn, S.M., Kaciroti, N. etal. (2005) Selective serotonin reuptake inhibitors (SSRIs) use during pregnancy and effects on the fetus and new born: A meta-analysis. Journal of Perinatology, 25: 595-604.


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