Narcissistic personality disorder

Narcissistic personality disorder (NPD) is a characterized by a long-term pattern of, an excessive need for , and a lack of  toward other people. People with NPD often spend much time thinking about achieving and success, or on their. Typically, they also take advantage of the. Such narcissistic behavior typically begins by early adulthood, and occurs across a broad range of situations.

The causes of narcissistic personality disorder are unknown. The condition of NPD is included in the in the  (DSM). A diagnosis of NPD is made by a healthcare professional interviewing the person in question. The condition of NPD should be differentiated from and.

Treatments for narcissistic personality disorder have not been well studied. is difficult, because people with narcissistic personality disorder usually do not consider themselves to have a. About one percent of people are believed to be affected with NPD at some point in their lives. It occurs more often in men than women, and typically affects younger as opposed to older people. The was first described by the psychoanalyst, in 1925; and the term narcissistic personality disorder (NPD) was coined by , in 1968.

Signs and symptoms
People with narcissistic personality disorder (NPD) are characterized by the personality traits of persistent, an excessive need for , and a personal disdain and lack of for other people. As such, the person with NPD usually displays arrogance and a distorted sense of personal superiority, and seeks to establish over others. (a strong sense of self) is a personality trait different from the traits of narcissistic personality disorder; thus, people with NPD typically value themselves over others, to the extent of openly disregarding the wishes and feelings of anyone else, and expect to be treated as superior, regardless of their actual status or achievements. Socially, the person with narcissistic personality disorder usually exhibits a fragile ego, intolerance of criticism, and a tendency to belittle other people, in order to validate his or her own superiority.

The  (DSM-5, 2013) indicates that a person with NPD usually displays some or all of the following symptoms, typically without possessing the commensurate personal qualities or accomplishments for which they demand respect and status:


 * Grandiosity with expectations of superior treatment from other people
 * Continually criticizing, bullying and belittling others
 * Exploiting others to achieve personal gain
 * Explosive temper, especially if handling criticism. Can get very angry if their directions are not followed by others.
 * Lack of empathy for the negative impact they have on the feelings, wishes, and needs of other people
 * Fixation on fantasies of power, success, intelligence, attractiveness, etc.
 * Self-perception of being unique, superior, and associated with high-status people and institutions
 * Need for continual admiration from others
 * Sense of to special treatment and to obedience from others
 * Intense envy of others, and the belief that others are equally envious of them

Narcissistic personality disorder usually develops either in adolescence or in early adulthood; and it is common for children and adolescents to display personality traits that resemble NPD, but such occurrences are usually transient, and register below the clinical criteria for a formal diagnosis of NPD. True symptoms of NPD are pervasive, apparent in varied social situations, and are rigidly consistent over time. Severe symptoms of NPD can significantly impair the person's mental capabilities to develop meaningful human relationships, such as friendship, kinship, and marriage. Generally, the symptoms of NPD also impair the person's psychological abilities to function as a social animal, either at work, or at school, or within important societal settings. The DSM-5 indicates that, in order to qualify as symptoms of NPD, the person's manifested personality traits must substantially differ from the cultural norms of society.

Associated features
People with NPD exaggerate their skills and accomplishments, and their degree of intimacy with people they consider high-status. Such a sense of personal superiority may cause them to monopolize conversations, or to become impatient and disdainful when other persons talk about themselves. When wounded in the ego, either by a real or a perceived criticism, the narcissist's displays of anger can be disproportionate to the nature of the criticism suffered; but typically, the actions and responses of the NPD person are deliberate and calculated. Despite occasional flare-ups of personal insecurity, the inflated self-concept of the NPD person is primarily stable.

To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed who passes blame and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of his or her behaviors, whilst insisting that people see him or her as an ideal person. To protect their fragile self-concept, narcissists use psycho-social strategies, such as the tendency to devalue and derogate and to insult and blame other people, usually with anger and hostility towards people's responses to the narcissist's anti-social conduct. Because their fragile egos are hypersensitive to perceived criticism or defeat, people with NPD are prone to feelings of, humiliation, and worthlessness over minor incidents of daily life and imagined, personal slights, and usually mask such feelings from people, either by way of feigned humility, or by socially isolating themselves, or by responding with outbursts of rage and defiance, or by seeking revenge. The merging of the inflated self-concept and the actual self is evident in the grandiosity component of narcissistic personality disorder; also inherent to that psychological process are the defense mechanisms of and of.

The DSM-5 indicates that: "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting, and cause significant functional impairment or subjective distress, do they constitute narcissistic personality disorder." Given the high-function sociability associated with, some people with NPD might not view such a diagnosis as a functional impairment to their lives. Although overconfidence tends to make people with NPD very ambitious, such a mindset does not necessarily lead to professional high achievement and success, because they might be unwilling to compete, or refuse to take risks, in order to avoid failure or the appearance of failure. Moreover, the psychological inability to tolerate disagreement, contradiction, and criticism, and their apathy towards other people, make it difficult for persons with NPD to work cooperatively or to maintain long-term, professional relationships with superiors and colleagues.

Causes
The causes of narcissistic personality disorder are unknown. Researchers apply a of causation, whereby the occurrence and the expression of NPD — a pathological amplification of the traits of the  — are consequent to a combination of nature and nurture, of environmental and social, genetic and neurobiological factors.

Genetic
Narcissistic personality disorder is an inheritable psychological condition; research evidence indicates that a person is more likely to develop NPD if said personality disorder occurs in the medical history of his or her family. The results reported in A Twin Study of Personality Disorders (2000) indicate that the rate of occurrence of personality disorders in twins determined that there is a moderate-to-high likelihood of the of NPD; and the research of The Genetic Epidemiology of Personality Disorders (2010) indicates that specific  and genetic interactions  contribute to the formation of NPD, and to the development of a, yet how genetics influence the developmental and the physiologic processes underlying NPD remains undetermined.

Environment
Environmental and social factors also exert significant influence upon the onset of NPD in a person. In some people, pathological narcissism may develop from an impaired to the primary caregivers, usually the parents. That lack of psychological and emotional attachment to a parental figure can result in the child's perception of himself or herself as unimportant and unconnected to other people, usually family, community, and society. Typically, the child comes to believe that they have a personality defect that makes him or her an unvalued and unwanted person; in that vein, either overindulgent and permissive parenting or insensitive and over-controlling parenting are contributing factors towards the development of NPD in a child.

In Gabbard's Treatments of Psychiatric Disorders (2014), the following factors are identified as promoting the development of narcissistic personality disorder:


 * An oversensitive (individual differences of behavior) at birth.
 * Excessive admiration that is never balanced with realistic criticism of the child.
 * Excessive praise for good behaviors, or excessive criticism for bad behaviors in childhood.
 * Overindulgence and overvaluation by parents, family, and peers.
 * Being praised by adults for perceived exceptional physical appearance or abilities.
 * Severe in childhood.
 * Unpredictable or unreliable care-giving by the parents.
 * Learning the behaviors of from parents or peers.

Moreover, the research reported in "Modernity and Narcissistic Personality Disorders" (2014) indicates that cultural elements also influence the prevalence of NPD, because narcissistic personality traits more commonly occur in societies than in  societies.

Pathophysiology
Studies of the occurrence of narcissistic personality disorder (NPD), such as Gray Matter Abnormalities in Patients with Narcissistic Personality Disorder (2013) and Narcissists' Lack of Empathy Tied to Less Gray Matter (2016) identified structural abnormalities in the brains of people afflicted with NPD, specifically, a lesser volume of in the left, anterior. The results of the study Brain Structure in Narcissistic Personality Disorder: A VBM and DTI Pilot Study (2015) associated the condition of NPD with a reduced volume of gray matter in the. The regions of the brain identified and studied — the insular cortex and the prefrontal cortex — are associated with the human emotions of and, and with the mental functions of  and. The neurologic findings of the studies indicate that narcissistic personality disorder is related to a compromised (damaged) capacity for emotional empathy and emotional regulation.

DSM-5
The American Psychiatric Association's (APA) formulation, description, and definition of narcissistic personality disorder, as published in the  (DSM-IV-TR, 2000), was criticised by clinicians as inadequately describing the range and complexity of the personality disorder that is NPD. That the APA's formulation, description, and definition is excessively focused upon "the narcissistic individual's external, symptomatic, or social interpersonal patterns — at the expense of . . . internal complexity and individual suffering", which reduced the clinical utility of the NPD definition in the DSM-IV-TR.

In revising the diagnostic criteria for personality disorders, the work group for the list of "Personality and Personality Disorders" proposed the elimination of narcissistic personality disorder (NPD) as a distinct entry in the  (DSM-5, 2013), and thus replaced a categorical approach to NPD with a dimensional approach, which is based upon the severity of the dysfunctional-personality-trait domains. Clinicians critical of the DSM-5 revision characterized the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist", which is of limited usefulness in clinical practice. Despite the reintroduction of the NPD entry, the APA's re-formulation, re-description, and re-definition of NPD, towards a dimensional view based upon personality traits, remains in the list of personality disorders of the DSM-5.

ICD-10
The (ICD-10), of the World Health Organization (WHO), lists narcissistic personality disorder (NPD) under the category of "Other specific personality disorders". The ICD-10 requires that any personality-disorder diagnosis also meet and satisfy the used for determining that a person has a diagnosable personality disorder.

Subtypes of NPD
Although the DSM-5 indicates narcissistic personality disorder as a homogeneous syndrome, there is evidence of overt and covert subtypes in the expression of NPD. The study Narcissistic Personality Disorder: Diagnostic and Clinical Challenges (2015) indicates the existence of two subtypes of narcissism: (i) Grandiose narcissism, characterized by the personality traits of grandiosity, arrogance, and boldness; and (ii) Vulnerable narcissism, characterized by the personality traits of defensiveness and hypersensitivity. The research indicates that people with grandiose narcissism express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."

In an inventory of the types of NPD, the psychiatrist described the "oblivious" subtype of narcissist as being a grandiose, arrogant, and thick-skinned person; and described the "narcissistic vulnerability" of the subtype of person who consciously exhibits the personality traits of helplessness and emotional emptiness, and of low self-esteem and shame, which usually are expressed as socially avoidant behavior in situations where the narcissist's self-presentation is impossible; therefore, they withdraw from situations wherein the needed or expected social approval is not given. Gabbard also described the "" subtype of narcissist whose feelings are easily hurt, gas an oversensitive, and ashamed; and described the "high-functioning" subtype of narcissist as a person less functionally impaired in the areas of life where narcissists with a severe expression of NPD usually have difficulties in functioning as a normally-socialized person.

In the study Disorders of Personality: DSM-IV-TM and Beyond (1996), suggested five subtypes of narcissist; however, there are few, pure subtypes of narcissist. Morever, Millon's five subtypes of narcissist are not recognized in either the Diagnostic and Statistical Manual of Mental Disorders or in the International Statistical Classification of Diseases and Related Health Problems.

Comorbidity
The occurrence of narcissistic personality disorder presents a high rate of with other mental disorders. People with NPD are prone to bouts of psychological depression, often to the degree that meets the clinical criteria for a co-occurring. Moreover, the occurrence of NPD is further associated with the occurrence of, of , and of , especially. In that vein, NPD also might be comorbid with the occurrence of other mental disorders, such as, , , or.

Treatment
Narcissistic personality disorder is rarely the primary reason for which people seek mental health treatment. When people with NPD enter treatment (psychologic or psychiatric), they usually are prompted by difficulties in their lives, or are seeking relief from some other disorder of their mental health, such as a, a (drug addiction), a  (manic depression), or an  (anorexia nervosa, rumination disorder, bulimia nervosa). The reason for such an indirect path to psychotherapeutic treatment is partly because narcissists generally possess poor, and are unaware that their actions produced their mentally unhealthy circumstance, and so that their perceptions and behaviors are socially inappropriate and problematic, because of their very positive  (inflated self-concept).

In general, is the basis for treating narcissistic personality disorder. In the 1960s, and  challenged the conventional wisdom of the time with clinical strategies that applied psychoanalytic therapy to NPD clients, which, they claimed, effectively treated that personality disorder. Contemporary psychotherapy treatments include therapy;  therapy; and, to treat the client's particular subtype of NPD. Improvements to the mental health of patients with NPD are possible with psychopharmaceutical treatment of the symptoms of the comorbid disorders; despite such drug therapy, the psychologist Elsa Ronningstam said that "alliance-building and engaging the patient's sense of agency and reflective ability are essential for [achieving] change in pathological narcissism." s usually are not indicated for treating NPD, but can be used to treat the co-occurring symptoms of psychological depression, anxiety, and impulsiveness, when present in the NPD client. In the field of mental health therapy is most beneficial when both partners participate in the treatments.

Prognosis
The effectiveness of and  interventions in the treatment of narcissistic personality disorder has yet to be systematically and empirically investigated. Clinical practice guidelines for the disorder have not yet been created, and current treatment recommendations are largely based on theoretical models of NPD and the experiences of clinicians with afflicted individuals in clinical settings.

The presence of NPD in patients undergoing psychotherapy for the treatment of other mental disorders is associated with slower treatment progress and higher dropout rates.

Epidemiology
The lifetime rates of narcissistic personality disorder are estimated at 1% in the general population; and between 2% to 16% in the clinical population. A 2010 review found rates of NPD between 0% to 6% in community samples, and that the yearly number of new cases of NPD in men is slightly greater than in women. A 2015 review found that the rates of NPD have been relatively stable for men and women throughout the thirty-year period in which data were collected.

History
The narcissism, to describe a person's excessive vanity and self-centeredness, predates the modern medical classification of NPD (narcissistic personality disorder). The mental condition of narcissism is named after the Greek, mythological character, a beautiful boy, born of a nymph, who became infatuated with his own reflection in a pool of water. At first, Narcissus did not understand that the image he saw in the pool of water was a reflection of himself; when he did understand that fact, he pined for the unattainable image and died of grief, for having fallen in love with someone who did not exist outside of himself.

Further conceptual developments and refinements of the mental condition of Narcissim produced the term narcissistic personality structure, which was introduced by, in 1967; and the term narcissistic personality disorder, which was proposed by , in 1968.

Early Freudianism
Regarding the sense of omnipotence, Sigmund Freud said that "this belief is a frank acknowledgement of a relic of the old megalomania of infancy"; and concluded that: "we can detect an element of megalomania in most other forms of . We are justified in assuming that this megalomania is essentially of an infantile nature, and that, as development proceeds, it is sacrificed to social considerations."

In The Psychology of Gambling (1957), considered megalomania to be a normal occurrence in the psychology of a child, a condition later reactivated in adult life, when they takes up the  of. In The Psychoanalytic Theory of Neurosis (1946), said that for people who, in their later lives, respond with  to their own, usually undergo a similar  to the megalomania of childhood.

Object relations
In the second half of the 20th century, in contrast to Freud's perspective that megalomania is an obstacle to, in the U.S. and in Britain, Kleinian psychologists used the to re-evaluate megalomania as a , a circumstance that offered the psychotherapist access to the patient for treatment. Such a therapeutic approach built upon 's view of narcissistic megalomania as an aspect of normal mental development, by contrast with 's consideration of such grandiosity as a pathological distortion of normal psychologic development.

Society and culture
In popular culture, narcissistic personality disorder (NPD) is also known as.

Literature
In the article The Narcissism of Rosamond Vincy (2016), G. Peter Winnington said that in the novel ' (1871–1872), by George Eliot, the character Rosamond Vincy is a narcissist, as defined in the ' (DSM-5, 2013).

Cinema
In the film  (1995), the Suzanne Stone (Nicole Kidman) character wants to appear on television, at all costs, even if satisfying that desire involves having her husband murdered. A psychiatric assessment indicated that the Stone character "was seen as a prototypical narcissistic person, by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder . . . had [Suzanne Stone] been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder".

Television
The character Adam Demamp (Adam DeVine) in  is portrayed with a severe expression of narcissistic personality disorder.

Criticism
The Norwegian study, Validity Aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Narcissistic Personality Disorder Construct (2011) concluded that narcissism should be conceived as personality dimensions pertinent to the entire range of personality disorders, rather than as a distinct diagnostic category. In the study Debates on the Narcissism Conundrum: Trait, Domain, Dimension, Type, or Disorder? (2012) examining the past literature about NPD, the researchers Renato Alarcón and Silvana Sarabia concluded that narcissistic personality disorder "shows inconsistency, and that its consideration as a trait domain needed further research would be strongly beneficial to the field."