Narcissistic Personality Disorder (NPD)

Narcissistic Personality Disorder (NPD)

Narcissistic Personality Disorder (NPD)

People with narcissistic PD (NPD) have a lifelong pattern of grandiosity (in behavior and in fantasy), a thirst for admiration, and an absence of empathy. These attitudes permeate most aspects of their lives. They regard themselves as unusually special; they are self-important individuals who commonly exaggerate their accomplishments. (From the outset, however, we need to note that these traits constitute a PD only in adults. Children and teenagers are naturally self-centered; in kids, narcissistic traits don’t necessarily imply ultimate PD.)

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Despite their grandiose attitudes, people with NPD have fragile self-esteem and often feel unworthy; even at times of great personal success, they may feel fraudulent or undeserving. They remain overly sensitive to what others think about them, and feel compelled to extract compliments. When criticized, they may cover their distress with a façade of icy indifference. As sensitive as they are about their own feelings, they have little apparent understanding of the feelings and needs of others and may feign empathy, just as they may lie to cover their own faults.

Patients with NPD often fantasize about wild success and envy those who have achieved it. They may choose friends they think can help them get what they want. Job performance can suffer (due to interpersonal problems), or it can be enhanced (due to their eternal drive for success). Because they tend to be concerned with grooming and value their youthful looks, they may become increasingly depressed as they age.

NPD has been seldom studied. It appears to occur in under 1% of the general population; reportedly, most patients are men. There is no information about family history, environmental antecedents, or other background material that might help us to understand these difficult personalities.

Essential Features of Narcissistic Personality Disorder

These people possess grandiosity, together with a craving for admiration. To get it, they typically exaggerate their own abilities and accomplishments. They tend to be preoccupied with fantasies of beauty, brilliance, perfect love, power, or limitless success, and believe that they are so unusual that they should only associate with people or institutions of rarefied status. Often arrogant or haughty, they may believe that others envy them (though the reverse may actually be true). Lack of empathy engages their feelings of privilege in justifying the exploitation of others to achieve their own goals.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, bipolar disorders, other personality disorders)

Berna Whitlow

“Dr. Whitlow, you’re my backup for emergency clinic this afternoon. I’ve got to have some help from you!” Eleanor Bondurak, a social worker at the mental health clinic, was red-faced with anger and frustration. It wasn’t the first time she had had difficulty working with this clinician.

At the age of 50, Berna Whitlow had worked at nearly every mental health clinic in the metropolitan area. She was well trained and highly intelligent, and she read voraciously in her specialty. Those were the qualities that had landed her job after job over the years. The qualities that kept her moving from one job to another were known better to those who worked with her than to those who hired her. She was famous among her colleagues for being pompous and self-centered.

“She said she wasn’t going to take orders from me. And her attitude said for her, ‘You’re nothing but a social worker.’ ” Eleanor was now reliving the moment in a heated discussion with the clinical director. “She said she’d talk to my boss or to you. I pointed out that neither of you was in the building at the time, and that the patient had brought in a gun in his briefcase. So then she said I should ‘write it up and submit it,’ and she would ‘decide what action to take.’ That’s when I had you paged.”

With the crisis over (the gun had been unloaded, the patient not dangerous), the clinical director had dropped in to chat with Dr. Whitlow. “Look, Berna, it’s true that ordinarily the social worker sees the patient and does a write-up before you step in. But this wasn’t exactly an ordinary case! Especially in emergencies, the whole team has to act together.”

Berna Whitlow was tall, with a straight nose and jutting chin that seemed to radiate authority. Her long hair was thick and blond. She raised her chin a bit higher. “You hardly need to lecture me on the team approach. I’ve been a leader in nearly every clinic in town. I’m a superb team leader. You can ask anyone.” As she spoke, she rubbed the gold rings that encircled nearly every finger.

“But being a team leader involves more than just giving orders. It’s also about gathering information, building consensus, caring about the feelings of oth—”

“Listen,” she interrupted, “it’s her job to work on my team. It’s my job to provide the leadership and make the decisions.”

Evaluation of Berna Whitlow

From the material we have (which does not include a clinical interview, so our conclusions must be tentative), Dr. Whitlow’s personality traits would seem to have caused difficulties for many years. They affected her life broadly, interfering with work (many jobs) and interpersonal relationships. Of course, a full assessment would inquire about her personality as it affected her home and social life.

Symptoms suggestive of NPD included her haughty attitude (NPD criterion A9), exaggerating her own accomplishments (“I’m a superb team leader”—A1), insisting that she receive orders or requests only from persons of high rank (A3), expecting obedience (from a sense of entitlement—A5), and lacking empathy with fellow workers (A7). Five criteria are needed; affective, cognitive, and interpersonal features were present (see the Essential Features for a general PD earlier in this chapter).

Several other PDs can either accompany or be confused with NPD. Patients with histrionic PD are also extremely self-centered, but Dr. Whitlow was not as theatrical (although she did wear a lot of rings). As is the case in borderline PD (and most other PDs), patients with NPD have a great deal of trouble relating to other people. But they (including Dr. Whitlow) are not especially prone to unstable moods, suicidal behavior, or brief psychoses under stress. Although there is a hint of the deceitful in narcissistic exaggerations, these people lack the pervasive criminality and disregard for the rights of others that are typical of antisocial PD.

Although dysthymia and major depressive disorder frequently accompany NPD, there is no evidence in the vignette to support either of those diagnoses. Dr. Whitlow’s tentative diagnosis (GAF score of 61) would be as follows: