Pathological narcissism is a life-long pattern of traits and behaviours which signify infatuation and obsession with one’s self to the exclusion of all others and the egotistic and ruthless pursuit of one’s gratification, dominance and ambition.
As distinct from healthy narcissism which we all possess, pathological narcissism is maladaptive, rigid, persisting, and causes significant distress, and functional impairment.
Pathological narcissism was first described in detail by Freud in his essay “On Narcissism” (1915). Other major contributors to the study of narcissism are: Melanie Klein, Karen Horney, Franz Kohut, Otto Kernberg, Theodore Millon, Elsa Roningstam, Gunderson, and Robert Hare.
What is Narcissistic Personality Disorder (NPD)?
The Narcissistic Personality Disorder (NPD) (formerly known as megalomania or, colloquially, as egotism) is a form of pathological narcissism. It is a Cluster B (dramatic, emotional, or erratic) personality disorder. Other Cluster B personality disorders are the Borderline Personality Disorder (BPD), the Antisocial Personality Disorder (APD), and the Histrionic Personality Disorder (HPD). The Narcissistic Personality Disorder (NPD) first appeared as a mental health diagnosis in the DSM III-TR (Diagnostic and Statistical Manual) in 1980.
The ICD-10, the International Classification of Diseases, published by the World Health Organisation in Geneva  regards the Narcissistic Personality Disorder (NPD) as “a personality disorder that fits none of the specific rubrics”. It relegates it to the category “Other Specific Personality Disorders” together with the eccentric, “haltlose”, immature, passive-aggressive, and psychoneurotic personality disorders and types.
The American Psychiatric Association, based in Washington D.C., USA, publishes the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR)  where it provides the diagnostic criteria for the Narcissistic Personality Disorder (301.81, p. 717).
The DSM-IV-TR defines Narcissistic Personality Disorder (NPD) as “an all-pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration or adulation and lack of empathy, usually beginning by early adulthood and present in various contexts”, such as family life and work.
The DSM specifies nine diagnostic criteria. Five (or more) of these criteria must be met for a diagnosis of Narcissistic Personality Disorder (NPD) to be rendered.
[In the text below, I have proposed modifications to the language of these criteria to incorporate current knowledge about this disorder. My modifications appear in bold italics.]
[My amendments do not constitute a part of the text of the DSM-IV-TR, nor is the American Psychiatric Association (APA) associated with them in any way.]
[Click here to download a bibliography of the studies and research regarding the Narcissistic Personality Disorder (NPD) on which I based my proposed revisions.]
Proposed Amended Criteria for the Narcissistic Personality Disorder
- Feels grandiose and self-important (e.g., exaggerates accomplishments, talents, skills, contacts, and personality traits to the point of lying, demands to be recognised as superior without commensurate achievements);
- Is obsessed with fantasies of unlimited success, fame, fearsome power or omnipotence, unequalled brilliance (the cerebral narcissist), bodily beauty or sexual performance (the somatic narcissist), or ideal, everlasting, all-conquering love or passion;
- Firmly convinced that he or she is unique and, being special, can only be understood by, should only be treated by, or associate with, other special or unique, or high-status people (or institutions);
- Requires excessive admiration, adulation, attention and affirmation – or, failing that, wishes to be feared and to be notorious (Narcissistic Supply);
- Feels entitled. Demands automatic and full compliance with his or her unreasonable expectations for special and favourable priority treatment;
- Is “interpersonally exploitative”, i.e., uses others to achieve his or her own ends;
- Devoid of empathy. Is unable or unwilling to identify with, acknowledge, or acceptthefeelings, needs, preferences, priorities, and choices of others;
- Constantly envious of others and seeks to hurt or destroy the objects of his or her frustration. Suffers from persecutory (paranoid) delusions as he or she believes that they feel the same about him or her and are likely to act similarly;
- Behaves arrogantly and haughtily. Feels superior, omnipotent, omniscient, invincible, immune, “above the law”, and omnipresent (magical thinking). Rages when frustrated, contradicted, or confronted by people he or she considers inferior to him or her and unworthy.
Prevalence and Age and Gender Features
According to the DSM IV-TR, between 2% and 16% of the population in clinical settings (between 0.5-1% of the general population) are diagnosed with Narcissistic Personality Disorder (NPD). Most narcissists (50-75%, according to the DSM-IV-TR) are men.
We must carefully distinguish between the narcissistic traits of adolescents – narcissism is an integral part of their healthy personal development – and the full-fledge disorder. Adolescence is about self-definition, differentiation, separation from one’s parents, and individuation. These inevitably involve narcissistic assertiveness which is not to be conflated or confused with Narcissistic Personality Disorder (NPD).
“The lifetime prevalence rate of NPD is approximately 0.5-1 percent; however, the estimated prevalence in clinical settings is approximately 2-16 percent. Almost 75 percent of individuals diagnosed with NPD are male (APA, DSM IV-TR 2000).”
From the Abstract of Psychotherapeutic Assessment and Treatment of Narcissistic Personality Disorder By Robert C. Schwartz,Ph.D., DAPA and Shannon D. Smith, Ph.D., DAPA (American Psychotherapy Association, Article #3004 Annals July/August 2002)
Narcissistic Personality Disorder (NPD) is exacerbated by the onset of aging and the physical, mental, and occupational restrictions it imposes.
In certain situations, such as under constant public scrutiny and exposure, a transient and reactive form of the Narcissistic Personality Disorder (NPD) has been observed by Robert Milman and labelled “Acquired Situational Narcissism”.
There is only scant research regarding the Narcissistic Personality Disorder (NPD), but studies have not demonstrated any ethnic, social, cultural, economic, genetic, or professional predilection to it.
Comorbidity and Differential Diagnoses
Narcissistic Personality Disorder (NPD) is often diagnosed with other mental health disorders (“co-morbidity”), such as mood disorders, eating disorders, and substance-related disorders. Patients with Narcissistic Personality Disorder (NPD) are frequently abusive and prone to impulsive and reckless behaviours (“dual diagnosis”).
The personal style of those suffering from the Narcissistic Personality Disorder (NPD) should be distinguished from the personal styles of patients with other Cluster B Personality Disorders. The narcissist is grandiose, the histrionic coquettish, the antisocial (psychopath) callous, and the borderline needy.
As opposed to patients with the Borderline Personality Disorder, the self-image of the narcissist is stable, he or she are less impulsive and less self-defeating or self-destructive and less concerned with abandonment issues (not as clinging).
Contrary to the histrionic patient, the narcissist is achievements-orientated and proud of his or her possessions and accomplishments. Narcissists also rarely display their emotions as histrionics do and they hold the sensitivities and needs of others in contempt.
According to the DSM-IV-TR, both narcissists and psychopaths are “tough-minded, glib, superficial, exploitative, and unempathic”. But narcissists are less impulsive, less aggressive, and less deceitful. Psychopaths rarely seek narcissistic supply. As opposed to psychopaths, few narcissists are criminals.
Patients suffering from the range of obsessive-compulsive disorders are committed to perfection and believe that only they are capable of attaining it. But, as opposed to narcissists, they are self-critical and far more aware of their own deficiencies, flaws, and shortcomings.
Clinical Features of the Narcissistic Personality Disorder
The onset of pathological narcissism is in infancy, childhood and early adolescence. It is commonly attributed to childhood abuse and trauma inflicted by parents, authority figures, or even peers. Pathological narcissism is a defense mechanism intended to deflect hurt and trauma from the victim’s “True Self” into a “False Self” which is omnipotent, invulnerable, and omniscient. The narcissist uses the False Self to regulate his or her labile sense of self-worth by extracting from his environment narcissistic supply (any form of attention, both positive and negative).
There is a whole range of narcissistic reactions, styles, and personalities – from the mild, reactive and transient to the permanent personality disorder.
Patients with Narcissistic Personality Disorder (NPD) feel injured, humiliated and empty when criticized. They often react with disdain (devaluation), rage, and defiance to any slight, real or imagined. To avoid such situations, some patients with Narcissistic Personality Disorder (NPD) socially withdraw and feign false modesty and humility to mask their underlying grandiosity. Dysthymic and depressive disorders are common reactions to isolation and feelings of shame and inadequacy.
The interpersonal relationships of patients with Narcissistic Personality Disorder (NPD) are typically impaired due to their lack of empathy, disregard for others, exploitativeness, sense of entitlement, and constant need for attention (narcissistic supply).
Though often ambitious and capable, inability to tolerate setbacks, disagreement, and criticism make it difficult for patients with Narcissistic Personality Disorder (NPD) to work in a team or to maintain long-term professional achievements. The narcissist’s fantastic grandiosity, frequently coupled with a hypomanic mood, is typically incommensurate with his or her real accomplishments (the “grandiosity gap”).
Patients with Narcissistic Personality Disorder (NPD) are either “cerebral” (derive their Narcissistic Supply from their intelligence or academic achievements) or “somatic” (derive their Narcissistic Supply from their physique, exercise, physical or sexual prowess and romantic or physical “conquests”).
Patients with Narcissistic Personality Disorder (NPD) are either “classic” (meet five of the nine diagnostic criteria included in the DSM), or they are “compensatory” (their narcissism compensates for deep-set feelings of inferiority and lack of self-worth).
Some narcissists are covert, or inverted narcissists. As codependents, they derive their narcissistic supply from their relationships with classic narcissists.
Based on a survey of 1201 therapists and psychologists in clinical practice, Prof. Drew Westen of Emory University postulated the existence of three subtypes of narcissists:
- High functioning or Exhibitionist: “(H)as an exaggerated sense of self-importance, but is also articulate, energetic, outgoing, and achievement oriented.” (The equivalent of the Cerebral narcissist).
- Fragile: “(W)ants to feel important and privileged to ward off painful feelings of inadequacy and loneliness” (The equivalent of the Compensatory narcissist).
- Grandiose or Malignant: “(H)as an exaggerated sense of self-importance, feels privileged, exploits others, and lusts after power.” (The equivalent of the Classic narcissist).
Treatment and Prognosis
The common treatment for patients with Narcissistic Personality Disorder (NPD) is talk therapy (mainly psychodynamic psychotherapy or cognitive-behavioural treatment modalities). Talk therapy is used to modify the narcissist’s antisocial, interpersonally exploitative, and dysfunctional behaviors, often with some success. Medication is prescribed to control and ameliorate attendant conditions such as mood disorders or obsessive-compulsive disorders.
The prognosis for an adult suffering from the Narcissistic Personality Disorder (NPD) is poor, though his adaptation to life and to others can improve with treatment.
- Goldman, Howard H., Review of General Psychiatry, fourth edition, 1995. Prentice-Hall International, London.
- Gelder, Michael, Gath, Dennis, Mayou, Richard, Cowen, Philip (eds.), Oxford Textbook of Psychiatry, third edition, 1996, reprinted 2000. Oxford University Press, Oxford.
- Vaknin, Sam, Malignant Self Love – Narcissism Revisited, eighth revised impression, 1999-2006. Narcissus Publications, Prague and Skopje.
- Westen, Drew et al. Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes (Posted at http://ajp.psychiatryonline.org/ )
The Narcissist – A Case Study
Who is a Narcissist?
Narcissistic Personality Disorder – Diagnostic Criteria
Narcissistic Personality Disorder – Prevalence and Comorbidity
Narcissistic Personality Disorder – Clinical Features
Narcissist vs. Psychopath
The Inverted Narcissist