What is a narcissistic personality disorder (NPD) and when to seek treatment for narcissism?
Although NPD has been excluded from the latest International Classification of Diseases 11th Revision (ICD-11), overexpressed narcissistic personality traits may be profoundly dysfunctional for many individuals and the people they have personal and professional relationships with. This article will discuss NPD and the treatment of narcissism.
Diagnostic criteria for NPD
In another diagnostic manual, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), NPD is still present. It features a persistent pattern of grandiosity (in fantasy or behaviour), a constant necessity for admiration and a lack of empathy, starting by early adulthood and existing in a variety of settings as indicated by the presence of at least five of the following nine criteria:
- a grandiose sense of self-value;
- a preoccupation with imagining limitless success, supremacy, smartness, attractiveness or ideal love;
- a belief in being unique and special;
- a need for extreme admiration;
- a sense of privilege;
- interpersonally repressive behaviour;
- an absence of empathy;
- envy of other people or a belief that other people are envious;
- an exhibition of arrogant attitudes or behaviours.
In a suggested alternative DSM-5 model, NPD is presented as moderate or greater impairment of personality, which is manifested by complications in two or more of the following four areas:
- empathy,
- self-direction,
- identity,
- intimacy.
Additional characteristics of NPD
Furthermore, the NPD diagnosis requires the presence of both attention seeking and grandiosity. NPD is not related to any specific physical features. However, physical consequences of substance misuse, frequently linked to NPD, may also be apparent on examination. A mental status check-up may disclose a depressed mood. Patients suffering from narcissistic grandiosity may demonstrate signs of mania and hypomania.
Patients with NPD seeking treatment for narcissism usually present to the healthcare specialist after hitting “rock bottom” in their personal lives or careers. In addition, people often seek help at the strong influence of a family member insisting that they get professional advice for their behaviour. Because NPD, by its nature, involves a pompous disregard for others and an insistence on one’s inborn superiority, narcissistic individuals are unlikely to acknowledge their need for therapy. Therefore, patients with a mere diagnosis of NPD constitute a very small part of the total patients seen by clinicians. Narcissistic personality disorder (NPD) is one of the least detected personality disorders. However, overexpressed narcissistic traits exist in many individuals presenting to a psychiatrist with complaints of depressed mood or other psychiatric symptoms.
Long-lasting patterns of maladaptive behaviour
To be diagnosed with NPD, an individual must exhibit a steady and long-lasting pattern of dysfunctional behaviour, starting in early adulthood and comprising five or more of the nine above-mentioned criteria specified in the DSM-5.
Although many people demonstrate these criteria to some degree, the NPD diagnosis applies only when the symptoms are persistent, incapacitating, socially and personally maladaptive. Furthermore, the symptoms markedly interfere with the daily functioning of an affected individual.
Individuals with NPD are extremely sensitive to criticism or refusal and may avoid circumstances where there is the likelihood of feeling “less than.” When criticised, such individuals may become enraged and withdraw into a shell of hatred. At their essence, these reactions are believed to be due to a sense of inferiority or innately low self-esteem.
Theories and origins
Most concepts of narcissism roughly belong to either phobia theories or trauma theories. The central focus of Kernberg and Rosenfeld’s phobia theories is anxiety within the personality, which is related to fear of annihilation and the death instinct. The subject copes with this anxiety by discharging it and placing it in external objects.
Trauma theorists such as Kohut and Mollon claim that narcissism is nearly always the consequence of some shock or change in conditions. Trauma can take the form of deprivation, abuse and loss. According to Kohut, extremely traumatising is the experience of interacting with emotionally unresponsive parents and the absence of emotional support from a mother or father.
Treatment for narcissism
Psychological therapy for narcissism
Whereas psychoanalysis is the method often chosen for the treatment of NPD, clinicians extensively debate optimal treatment techniques. The two main concepts in this regard are the object-relations approach of Kernberg and the self-psychology approach of Kohut. The theorists offer seemingly contradictory narcissism treatment stances.
According to Kernberg, the end goal of therapy is to eradicate or reduce the individual’s pathological grandiosity through the confrontation of narcissistic temper. Conversely, Kohut promoted a more empathic tactic. According to Kohut, psychotherapists should encourage the individual’s grandiose self. The end goal of treatment is to strengthen the patient’s innately flawed self-structure.
No research has strongly favoured one psychotherapeutic perspective over another. Currently, most therapists employ a method that combines elements of both. The preference is for a moderate technique that combines an empathic understanding of the individual’s need for narcissistic defences with an exhaustive exploration of those defences. Consequently, the clinician should acknowledge the self-preserving role of narcissism in the individual’s day-to-day life. Therefore, therapists should be careful about eradicating narcissistic defences too fast. At the same time, the psychotherapist should aim at helping the individual gain an accurate understanding of their behavioural shortages.
Cognitive Behaviour Therapy (CBT) also benefits narcissistic patients. A specific form of CBT, schema-focused therapy, focuses on fixing narcissistic schemas and dysfunctional coping strategies. This intensive therapy encourages narcissistic personalities to identify and challenge cognitive distortions (e.g. black-and-white thinking) and dysfunctional core beliefs.
Pharmacological therapy
No specific pharmacological treatment for narcissism or other personality disorders exists. However, psychiatrists may prescribe some psychiatric medications (e.g. antidepressants, mood stabilisers, antipsychotics), which may help alleviate symptoms related to the disorder (e.g. anxiety, poor impulse control, depression, transient psychosis).
Conclusion
The main characteristics of NPD are the need for admiration, grandiosity and lack of empathy. These distinctive patterns can affect an individual’s daily functioning and interpersonal relationships in an overwhelmingly adverse manner.
Treatment for narcissism usually involves individual psychoanalytic psychotherapy and schema-focused therapy. Psychiatric medications may also help improve some symptoms associated with NPD.