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Narcissistic Personality Disorder
Diagnostic Criteria
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
requires excessive admiration
4) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
5) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
6) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
7) is often envious of others or believes that others are envious of him or her
8) shows arrogant, haughty behaviors or attitudes
Psychosocial Treatment
Basic Principles:
Narcissistic patients try to sustain an image of perfection and personal invincibility for themselves and attempt to project that impression to others as well. Physical illness may shatter this illusion, and a patient may lose the feeling of safety inherent in a cohesive sense of self. This loss precipitates a panicky sensation that "my world is falling to pieces," and the patient feels a sense of personal fragmentation.
The histrionic patient's idealization of the physician stands in contrast to the narcissistic patient's frequent contemptuous disregard for the physician, who is denigrated in a defensive effort to maintain a sense of superiority and mastery over illness. Only the most senior physician in a prestigious institution is deemed worthy of respect as the frightened patient seeks an external reflection of his or her own fragile grandeur in the doctor. More junior members of the health care team may be the targets of derision as the patient seeks to establish hierarchical dominance in order to counter the shame and fear triggered by illness.
Health care professionals must convey a feeling of respect and acknowledge the patient's sense of self-importance so that the patient can reestablish a coherent sense of self, but they must at the same time avoid reinforcing either pathologic grandiosity (which may contribute to denial of illness) or weakness (which frightens the patient). An initial approach of support followed by step-by-step confrontation of the patient's vulnerabilities may enable the patient to deal with the implications of illness with feelings of greater subjective strength. The increased self-confidence may reduce the patient's need to attack the health care team in a misguided effort at psychologic self-preservation and eases the pressure to provide perfect care, since the patient's antagonistic feeling of entitlement (defined by DSM-III as an "expectation of special favors without assuming reciprocal responsibilities") is reduced.
Many of the treatment principles and approaches discussed for this disorder apply as well to Borderline Personality Disorder.
The individual with narcissistic and related personality disorders is likely to present with Axis I symptoms and disorders at various times in his or her life. These should be treated as described elsewhere. Caution should be observed, however, not to overdiagnose psychotic decompensation as Schizophrenia unless all DSM-III criteria are apparent. The same caveat applies to the pharmacologic treatment of depressive symptoms in the absence of clinical signs of Major Affective Disorder. When treating presenting symptoms and Axis I disorders in patients with Narcissistic Personality Disorder and other similar conditions, attention should be paid to the consequences of removing symptoms in a patient whose underlying character is primitive and or fragile.
Some clinicians, suggest that the grandiosity and tendency to idealize and devalue should be interpreted as defensive maneuvers when aspects of early conflictual relationships are played out in adult life. Other clinicians, posit that the emergence of the patient's grandiosity and tendency to idealize the therapist should initially be viewed supportively. To help the individual develop stronger self-esteem regulation, the therapist then gradually points out the realistic limitations of patient and therapist alike while also offering an empathic ambience to cushion patients in their efforts to accept and integrate these experiences. Unfortunately, much research will be required to validate the description and course of narcissistic personality disorder before further research can answer which techniques bring about a better response to treatment.
