Narcissistic personality disorder

Narcissistic personality disorder (NPS) is characterized by a lack of empathy, overestimation of one's own abilities, and an increased desire for approval. Typically, affected individuals are overly preoccupied with impressing others and courting admiration for themselves, but have little interpersonal empathy themselves and return little emotional warmth to others.

Narcissistic personalities exhibit marked problems in adjusting to their circumstances and living environment and in the autonomous regulation of self-esteem. Such adjustment difficulties can manifest themselves in a variety of ways and can appear in different manifestations of NPS. The excessive drive for self-esteem can either be confidently enacted or shyly concealed. Accordingly, affected individuals may appear arrogant or act modest.

Pathological narcissism can manifest itself through bragging and grandstanding as well as insatiable demands and expectations. People with NPS tend to emotionally abuse those in their immediate environment (especially sexual partners and children) in order to increase their own self-worth (their "ego") at the expense of others. Other forms of narcissistic personality disorder are characterized by an unstable, rapidly changing sense of self-worth, which may swing in the extreme between grandiosity and shameful contrition. There may also be a chronically smoldering anger within, which can explode at the slightest provocation (especially in the case of criticism or a subjectively perceived slight).

"[T]he [NPS] is the most egocentric of all personality disorders" (Sachse, 2019, p. 127). Individuals have the impression that everything revolves around them. They subjectively see themselves as the "center of the universe" (ibid.).

Personalities with NPS consider themselves to be special. They also derive from this the right to be able to determine how other people have to deal with them and what behaviour of others they may expect. That is, they set rules for others. Because of these rules, which are usually not communicated at all, conflicts with third parties often arise for them, because they do not let themselves be offered such rules without further ado. (Sachse, 2019, p. 126ff, p. 131)

In the classification system of the World Health Organization (the ICD-10), narcissistic personality disorder is listed only in a residual category (F60.8. Other specific personality disorders). In the DSM-5 of the American Psychiatric Association, on the other hand, it is included as an independent disorder, where it belongs to cluster B, which includes the "moody, dramatic, emotional" personality disorders. In any case, it must be distinguished from normal narcissism as an actual or ascribed character trait.

Term History

The term "doxomania", which early Christian theologians used to describe the sin of pride and glory-seeking, belongs to the prehistory of the term.

In 1894 Sigmund Freud coined the term narcissistic neuroses (meaning: psychoses), which he distinguished from the actual neuroses - treatable with the psychoanalytic technique. In modern psychiatry this term is no longer used. Freud, like many of his contemporaries, referred to the symptom picture of narcissistic personality disorder as "delusions of grandeur" - a term that also no longer appears in current psychiatric category systems.

Normal vs. pathological narcissism

One of the first authors to explicitly distinguish between "normal" and pathological narcissism was the psychoanalyst Isidor Sadger in the early 20th century. That narcissism is part of normal human development was elaborated a little later by Otto Rank. In 1914, Sigmund Freud admitted that narcissism could indicate pathology, but like Rank, he conceived of it as a process of normal development rather than a clinical picture. His student Karl Abraham, on the other hand, saw narcissism as a pathology as soon as envy came into play.

In Great Britain, the psychoanalyst Ernest Jones had already written in 1913 of a "God complex," a pathology characterized by aloofness, self-admiration, exhibitionism, and fantasies of omnipotence and omniscience. Like Otto Rank before him, Jones assumed that this behavior could be explained as an attempt by an individual who felt threatened to protect himself. Annie Reich later went even further, considering narcissism to be a pathological form of self-esteem regulation in which self-aggrandizement and aggression are used to protect the concept one has made of the self.

Narcissistic character

The concept of a narcissistic personality or character was first described by the psychoanalyst Robert Waelder in 1925. Freud followed him in 1931 and now also described a "narcissistic character type" with a dynamic connection between narcissism and aggressiveness in reaction to criticism, offending or lack of attention. Wilhelm Reich took up this suggestion and in 1933 described for his part a "phallic-narcissistic character" which he had observed primarily in men and with a whole range of conspicuous features; in addition, he described in detail the dynamics of narcissism and aggressiveness which Freud had only mentioned in general terms.

In 1939, Karen Horney distinguished three subtypes of narcissistic characters (aggressive-expansive, perfectionistic, arrogant-revengeful) and made a precise distinction between healthy self-consciousness and pathological narcissism, with narcissists loving, admiring, and valuing themselves especially where nothing at all was lovable. Unlike Freud, Horney considered narcissists incapable of love, including love of the actual self; more consistently than Freud, she assumed that narcissistic grandiosity was based on defensiveness rather than authentic self-love. Donald Winnicott followed her in 1965, characterizing narcissists as individuals who protectively identify with a grandiose false self. As early as 1960, Annie Reich had determined the cause of this reaction to be the narcissist's inability to autonomously regulate his sense of self-worth due to repeated traumatic experiences that had created in him a persistent underlying sense of weakness and powerlessness. Reich's contribution to the narcissistic character is also important because she was the first to describe the constant fluctuations to which narcissistic self-esteem is subject; narcissists find it difficult to tolerate ambivalence, mediocrity and failure, and therefore see themselves either as perfect or as complete failures.

Mental disorder

The first author to see narcissism not only as a personality trait, but explicitly as a mental disorder and thus a disease, was the US psychiatrist John C. Nemiah, who was influenced by Freud. In his Foundations of Psychopathology (1961) he spoke of a "narcissistic character disorder". In 1964 Erich Fromm proposed the concept of malignant narcissism, whose symptom picture combines narcissistic, antisocial and sadistic traits; contemporary psychiatry has often referred to this, but this concept has not become established in diagnostics.

Nemiah's suggestion of a "narcissistic character disorder" was followed by the Vienna-born American psychoanalyst Otto F. Kernberg, who proposed the term "narcissistic personality structure" in 1967 and provided a comprehensive description of the symptoms in various publications. The American psychoanalyst Heinz Kohut, also from Vienna, finally introduced the term "narcissistic personality disorder" in 1968, which also forms the basis of this article.

Kohut's and Kernberg's conceptions do not differ from each other in the description (diagnosis), but in the explanation of the causes (etiology):

Kernberg understood pathological narcissism as the consequence of an upbringing by empathy-less, emotionally self-serving parents who meet the child with rejection and coldness and only give it their attention when this meets their own needs. Compensatorily, the child develops a grandiose self-concept. This serves him as the retreat where he can at least imagine in his imagination the admiration that is not given to him by the parents. Alongside this, however, there remains the negative self-image that the rejected child has of himself; this is split off and leaves behind, on the one hand, a feeling of shame and emptiness and, on the other, an insatiable hunger for admiration and excitement.

In contrast to Kernberg, Kohut conceived of narcissistic personality disorder as a failed turn within a normal development. While narcissism in the normal case is a kind of motor for allowing a realistic ambition to develop on the basis of realistic goals via early childhood identification with the idealized parents, this process remains unfinished in the pathological case, since here the child does not sufficiently idealize the rejecting parents and as a result does not acquire certain abilities of self-regulation; instead, he remains dependent on enlisting the services of other persons who are devoted to him and pay empathic attention to him for the day-to-day maintenance of his self-confidence.

Kernberg and Kohut published their work at a time when there was a growing interest in pathological narcissism, and it received considerable international attention. Although they held divergent views regarding etiology and therapy, they agreed on diagnosis. Together, they created the basis for a conception of narcissistic personality disorder that was widely disseminated beyond psychoanalysis and entered the influential American Psychiatric Association classification system (DSM-III) in 1980.

Differentiation into subtypes

The characterization of narcissistic personality disorder in DSM-III and DSM-IV soon aroused criticism from researchers who pointed out that the descriptions there only took into account the most conspicuous form of this disorder: a grandiose, unflinching, self-willed, exhibitionistic, thick-skinned and phallic narcissism. Another, second form of pathological narcissism - characterized by vulnerability, hypersensitivity, closed-mindedness and thin-skinnedness - could not be diagnosed with the given instruments and therefore fell through the cracks.

Common to both types, whose occurrence has also been empirically proven, is an extraordinarily high self-centeredness and unrealistically grandiose demands on one's own person.

In the most recent version of its classification system (DSM-5, 2013), the American Psychiatric Association reformulated its definition of narcissistic personality disorder so that it can now be used to diagnose covert narcissistic personality disorder.

Diagnosis

ICD-10

Narcissistic personality disorder is listed in ICD-10 only under the heading Other specific personality disorders (F 60.8). It is not further characterized there, although it is frequently used as a personality diagnosis in practice.

Preliminary research criteria are included in Appendix 1 in the green volume of the ICD-10, but they correspond almost verbatim to the corresponding official criteria text of the DSM-5 (see below). The ICD-10 particularly emphasizes that the general criteria for a personality disorder (F60) must be met.

DSM-5

In the current classification system of the American Psychiatric Association (DSM-5), the disorder is listed under the code 301.81. According to this, Narcissistic Personality Disorder is a profound pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. The onset is in early adulthood and the disorder manifests in a variety of situations.

At least five of the following criteria must be met:

1. Has a grandiose sense of one's own importance (e.g., exaggerates one's accomplishments and talents; expects to be recognized as superior without corresponding accomplishments).
2. Is strongly taken in by fantasies of boundless success, power, glamour, beauty or ideal love.
3. Believes oneself to be "special" and unique and to be understood by or to associate only with other special or distinguished persons (or institutions).
4. Demands excessive admiration.
5. Exhibits a sense of entitlement (i.e., exaggerated expectations of special favored treatment or automatic deference to one's expectations).
6. Is exploitative in interpersonal relationships (i.e. takes advantage of others to achieve own goals).
7. Demonstrates a lack of empathy: Is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes others are envious of him/her.
9. Exhibits arrogant, overbearing behaviors or attitudes.

Alternative model

In the alternative model of the DSM- 5, NPS is characterized by difficulties in identity, self-direction, empathy, and closeness, along with specific maladaptive personality traits in the domain of antagonism. Conditions A and B must be met.

A. Moderate or more severe impairment in the level of functioning of the personality manifested by typical difficulties in at least two of the following areas:

1. Identity: excessive comparison with others for self-definition and self-esteem regulation; exaggerated self-overestimation or underestimation, or fluctuating between extremes; emotion regulation depends heavily on fluctuations in self-esteem.
2. Self-direction: Personal goals are oriented towards gaining recognition from others; personal standards are inappropriately high in order to be able to experience oneself as exceptional, or too low due to an exaggerated attitude of entitlement; the person is often not aware of his/her own motivations.
3. Empathy: Limited ability to recognize or identify with the feelings and needs of others; excessive focus on the reactions of others, but only when they are considered important to oneself.
4. Closeness: Interpersonal relationships are largely superficial and serve self-esteem regulation; reciprocity is limited by little genuine interest in the experiences of others and by the predominant need for personal gain.

B. Presence of the following two problematic personality traits:

1. Grandiosity (a facet of the domain Antagonism): attitude of entitlement, either overt or covert; self-centeredness; strong adherence to the belief that one is better than others; condescending attitude toward others.
2. Seeking attention (a facet of the domain Antagonism): Excessive desire to stand out and be the center of attention of others; desire for admiration.

Criticism

Rainer Sachse raised the objection that the diagnostic criteria in the DSM mostly refer only to successful narcissists, therefore one cannot orientate oneself on its criteria. Sachse differentiates those affected into successful, failed and unsuccessful narcissists. However, he sees these types as specific to Western culture, as it is essentially based on differences with performance behavior strongly intertwined with it. (Sachse, 2019, pp. 122-123)