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  • Narcissistic Personality Disorder & Pathological Narcissism

    Brief History of Narcissistic Personality Disorder

    Narcissistic personality disorder entered DSM in 1980, despite of the pathology being observed in clinical & theoretical psychiatry for at least 100 years before then.  The name of the term originated from a Greek myth with a handsome young man named Narcissus, who rejected nymph Echo’s desperate love for him. The gods punished him by making him fall in love with his own reflection in the pool. Narcissus pined away & became the flower which bears his name. In 1887 Alfred Binet drew a comparison to this story, referring to a man who’s admiration extended only to his own physical self & at no time he showed any interest in a woman. Binet described it as perverted self-love & he’s the first known figure to use the term in psychiatry. In 1898 Havelock Ellis in his essay “Masturbation” used “Narcissus-like tendency” to describe a phenomenon of a person with abnormally increased level of self-admiration. The term “Narcissism” was finally coined by Sigmund Freud in his work “On Narcissism: An Introduction (1914)”. Freud moved the term from commonly being used as a sexual perversion to self-love & differentiated normal & pathological narcissism. He defined narcissism as a part of every born baby & as the baby grew & had to sacrifice his/her own needs because of the society around, he/she would move away from narcissism little by little. He believed that pathological narcissism was a consequence of an abnormal separation during this period. Freud also went into explaining what drives a person to choose a particular love object, it’s a wonderful work worth a read. Long story short, Freud founded the direction of modern understanding of pathological narcissism.

    Normal Narcissism, Pathological Narcissism & Narcissistic Personality Disorder

    Narcissism, pathological narcissism & narcissistic personality disorder became a very popular & interesting subject for many clinicians & theorists. Most believe that some level of narcissism is healthy for a person, in order to be able to function in society & be able to face challenges, have drive for success & creativity. As to where the healthy narcissism ends & pathological begins is not exactly clear. Moreover, some believe that pathological narcissism IS narcissistic personality disorder, while others think that narcissistic personality disorder is a whole new level compared to pathological narcissism. As with any mental disorder diagnosis will vary from case to case, from society to society. Mental disorder is a dynamic concept & it never stays stale. So really the line of pathological narcissism is very blurry, unless one equals it to narcissistic personality disorder. As to when narcissism evolves into pathological personality disorder, one needs to understand what personality disorder is. Personality traits that are inflexible and maladaptive and cause significant functional impairment or subjective distress constitute personality disorder.  Simply put personality traits are the way you perceive life, relate to others & environment, your thinking pattern. In other words, it all relates to individuals functioning in given society with given individuals personality traits & if those traits cause significant functional impairment or subjective distress, you’ve got yourself a personality disorder. As you can see, a fully functional human being with sound mental health in one society can become a persona with personality disorder in another society. Given this, now we can recap that:

    Definition of Narcissistic Personality Disorder

    Narcissistic traits that cause significant functional impairment or subjective distress constitute narcissistic personality disorder.

    DSM IV Definition of Narcissistic Personality Disorder

    DSM IV – 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.

    Narcissistic Personality Disorder – Statistics

    Less than 1% of general population is believed to have narcissistic personality disorder (2%-16% of clinical population) of which 50-75% are male.

    Characterizing Symptoms & Traits of Narcissistic Personality Disorder

    Characterizing symptoms of narcissistic personality disorder:

    • has a grandiose feeling of self-importance in one or more areas in life
    • has unusually high confidence in one or more fields, bordering with arrogant or arrogant
    • fears of being “normal” or like everybody else, will get frustrated or/and argue to death to prove that he/she is special & different if challenged
    • belittles other people’s problems & concerns, feels like their worries are unimportant & stupid
    • loves being admired, admiration is like fuel for a narcissist
    • has a pattern of troubled or/and unstable interpersonal relationships, low ability to attain intimacy
    • unable to trust or/and relate to others
    • fantasizes of big achievements, unwilling to settle for less, often will consider suicide over settling for less
    • compares himself/herself to people with huge success or achievements, likely to have them as role models
    • believes that he/she deserves better than most
    • has antisocial tendencies, disagrees with and/or disregards many social norms, although usually has no history of conduct disorder
    • has a very strong belief & commitment to a certain ideology
    • pays close attention & utmost importance to self-image (how others view him/her)
    • seems emotionally void or/and cruel, yet there is emotional hellfire burning deep inside, that he/she is convinced nobody can understand

    The characterizing symptoms of narcissistic personality disorder according to DSM-IV are:

    • has a grandiose feeling of self-importance (e.g., exaggerates achievements, talents, overestimates abilities, expects to be treated as special & recognized as superior)
    • is preoccupied with fantasies of huge success, power, beauty, ideal love, see themselves as a genius and often compare themselves to geniuses or famous people, depending on what they feel is important in life
    • believes that he or she is “special”, different & unique and can not be understood by “regular” people. See themselves as a part of special or high status people or institutions & believe that’s the only place where they can be understood & accepted
    • requires excessive admiration & reassurance of their achievements & superiority from others, constantly fishes for complements due to fragile self-esteem
    • has a sense of entitlement, unreasonable expectations, expects other to comply with his/her expectations & becomes furious & puzzled if it doesn’t happen, always expects special treatment
    • is interpersonally exploitative, expects others to bend their backs to help him/her achieve their goals; manipulates & takes advantage, is very likely to enter relationships for the sole purpose of achieving his/her goals or fulfilling their personal selfish needs
    • lacks empathy, unable to relate to others & put himself/herself in other people’s shoes: needs of others are often viewed as weaknesses and an opportunity to manipulate using the vulnerability, often speak lengthy of themselves & impatient with others who want to speak about their problems
    • is often envious of others and their achievements, believes that he/she deserved it more, harshly criticizes & tries to devaluate others’ achievements; also has a delusional belief that others are envious of him/her
    • shows arrogant, patronizing attitudes, overconfident & everknowing behaviors

    DSM-V proposition includes narcissism only as a trait under domain Antagonism:

    The characterizing traits of narcissism include:

    • vanity
    • boastfulness
    • self-centeredness
    • exaggeration of one’s achievements and abilities
    • preoccupation with having unlimited success, power, brilliance, and/or beauty
    • feeling and acting entitled
    • believing that one deserves only the best

    It’s common for adolescents to have narcissistic traits,  however this does not mean the individual will develop narcissistic personality disorder.

    Hotchkiss’ Seven Deadly Sins of Narcissism

    • Shamelessness
    • Magical thinking
    • Arrogance
    • Envy
    • Entitlement
    • Exploitation
    • Bad Boundaries – bad boundaries for narcissists, as per Freud, is viewing others as extension of themselves, as a new born child would. They do not recognize other people as separate individuals who have their own needs, instead they see them as extensions, subjects that operate to fulfill the needs of the narcissist.

    Causes of Narcissistic Personality Disorder, Pathological Narcissism as a Defense Mechanism

    The causes of narcissistic personality disorder are still being debated. The general consensus is that dysfunctional families create children with narcissistic pathology. Inability to trust family members, fear of not being accepted, understood or being judged, overcriticism, too much, unearned or ingenuine praise, being ignored by family members, all of these can root pathological narcissism. As a result of above mentioned reasons when being under stress, the child has nowhere to turn or learn how to deal with stress correctly, emotions keep bottling up & create mentally unbearable condition, therefore the child is likely to mentally create a parent figure that will lead the child’s existing, in child’s mind “faulty”, self that is haunted by low self-esteem. It’s probably worthy to mention that the child is not hallucinating, he/she is completely aware that the new “advisor” is his/her own thought that is disconnected from his/her emotions; in fact, that’s exactly what he/she intended to create, an emotionally disconnected, logically proof defense mechanism, that will prevent him/her from getting hurt & lead to success.

    BPO, Narcissistic & Borderline Personality Disorder – Similarities/Differences; Suicide & Suicidal Ideation

    Many clinicians believe that narcissistic personality disorder belongs to BPO (Borderline Personality Organization) branch & the root causes of the disorder are the same as of those with borderline personality disorder. Both are consequences of handling the crisis, only they handle it differently. An eye worthy mention is that a borderline person under stress is likely to develop paranoid thinking, while a narcissistic person is likely to have an abnormal level of logical & critical thinking & control. There are opinions that borderline & narcissistic couples are prevalent; the way narcissists handle stress is an admirable quality for a borderline, narcissists admire being admired, and borderline is unlikely to leave the unemphatic narcissist because of their paranoid  fear of abandonment & being alone. I don’t think there is any evidence to back these claims, but they are interesting, nonetheless. Grandiosity is a defining trait for a narcissistic person, while Needy is what common for a borderline; narcissists usually have stabile self-image & image of others, while borderlines have night & day shifts of their opinion of themselves & people surrounding them, narcissists are not prone to self-cutting, self-harming behavior, while borderlines are very likely to do so. Both personality types are likely to attempt suicides, with those suffering from narcissistic personality disorder with higher success rate. Unlike borderlines or many other depressive types, narcissists are not driven to suicide because of feelings of guilt. Narcissists are likely to view suicide as a method of control & reality escape, where they escape the reality with suicide in order to escape unwanted consequences of life or refusal to accept the unwanted reality; likely suicidal ideation for them can serve as an apparatus for courage in their drive to success, as they may view it as a control tool over a possible failure.

    Narcissistic Delusion, the Pathology of Self-Lying & Pathological Narcissistic Depression

    The pathology of lying is generally associated with low self-esteem. Narcissistic delusion is lying to self of being somebody you are not, self-lying grows to a point that it becomes delusional, the person is convinced of being somebody he/she isn’t, which is compensating for low self-esteem. It’s a protective action to escape the hurt & pain of the true self that the narcissist hates. Self-lying can have “positive” as well as “negative” effects. Positive effect is keeping the person from falling into depressive inactivity & despair, while keeping high performance ability for achievements which would otherwise be impossible for a depressed person. Future achievements play a key role in further development of “positive” or “negative” delusions. Unfortunately, the expected goals are usually unrealistically high & case of failure is likely to shift “positive” delusions into “negative” delusions of fantasy & inactivity, while being in denial of depressive state. An example would be alienation, withdrawal from society & magical thinking that he or she is too exclusive, elite, super-person, that doesn’t need society’s approval and things that are of a value for society are worthless & therefore there is no point in doing anything. This state of pathological narcissistic depression is dangerous, due to the fact that the person is in denial of being depressed, not likely to submit to treatment & the continuous feeling of emptiness & pointlessness of life. In this state the person is likely to commit suicide or other harmful irreversible actions to self or others without thinking about consequences.

    Treatment of Narcissistic Personality Disorder, Narcissist in Defensive Mode, Fear of Retraumatization

    Despite of what you may read in some places, narcissistic personality disorder is not treatable. There is no known medication that can cure this disorder. It is common for a psychiatrist to prescribe antidepressants, but these are prescribed to tame co-occurring depression, anxiety or other co-occurring conditions, usually caused by narcissistic trauma. Pathological narcissism is not curable per se. That said, there are ways to ease the impact of this disorder on them & people affected by them by psychodynamic talk therapy, more so educational psychotherapy with some twists. Cognitive-behavioral therapy is likely to be used for treating co-occurring conditions.

    People with narcissistic personality disorder are unlikely to turn themselves for treatment. This usually happens only when they are either dragged to a mental health professional by a family member, partner… well you get the picture …or they turn for a treatment for a co-occurring condition ex. sexual problems or other neurotic symptoms. Usually the goal of considerably “successful” therapy is involving the patient more in social interactions, if possible increasing interactions with family & increasing family ties as well as interpersonal intimate relationships, at the same time training to pay more attention to surroundings & feelings of others.

    Generally therapy will consist of short-term & long-term goals.

    Short-term goals will address critical situations evolved due to narcissistic trauma, like suicidal ideation, anxiety, depression, somatic symptoms etc. Medication is likely to be prescribed in this stage.

    Long-term goal is restructuring of personality, which includes increasing empathy, individual’s ability to mourn losses, decreasing rage & cognitive distortions.

    Given their inability to trust & skepticism to treatment, both confronting or agreeing-sympathizing with the patient are likely to result in no advancement or even worsening of the situation, by boosting sources of narcissistic supply and excessive individualism. It’s important to understand that narcissistic patients come to therapy in defensive mode, and are very likely to think that they are smarter than the therapist; in some cases, they will take the therapy as a challenge to outsmart the therapist & may enjoy the “process” of doing it. Building some level of trust is possible with some patients, however it’s important to constantly reassure who is in the control of the situation, since the narcissistic patients are likely to try to gain control & even try to convert the therapist to their ideology. They will constantly seek for a weakness &, once found, they will exploit it.

    The defense faced during treatment is largely patient’s effort to avoid retraumatization. The fear of entering the traumatic phase that was overwritten by this new narcissistic personality is of a great magnitude. Some therapists think it’s crucial getting the person back to the traumatic state in order to treat the disorder, in other words the treatment the patient should have received before he/she developed narcissistic defense mechanism should be applied now to the original self. A major obstacle for such approach is that patient’s personality has since evolved & changed, given that usually any kind of treatment, if ever occurs, happens years after the transition, so it’s difficult to exactly treat the disorder. On contrary, for the most cases treatment goal is handling the disorder & not really curing it, so it’s important for the patient to acknowledge that he/she has a problem that needs to be addressed, therefore patient’s understanding of the traumatic state & development of the disorder can be a key step for forward advancement in treatment.

    Narcissists & Relationships

    Narcissists generally avoid intimacy. They are unlikely to avoid sexual contacts or “business” relationships, but they tend to avoid entering a real relationship, mostly without even realizing this themselves. Much of this is caused by many of their personality traits, like inability to trust other people, inability to relate to others, inability to like others because of their sense of superiority & grandiosity. Finding & being in intimate relationships is a difficult task for people with NPD, however being in such relationships greatly reduces their dependence on reinforcing their self-esteem on sexual attractiveness, mental superiority or power. Relationships & attachments, need for achievements at work are probably some of the best recipes to tame down their excessive individualism. Narcissists generally have fantasies of ideal unconditional love. Given a reason to doubt the unconditionality of it, they’ll run away faster than you can imagine. Many people who are in relationships with narcissists make the mistake thinking that that the narcissist is likely to change. Unfortunately, these people are blinded by their own delusions & are setting themselves up for disappointment, because changes are unlikely to happen.

    Types of Pathological Narcissism

    When taking a deeper look into narcissistic types, it becomes clear that narcissism is a personality trait, and not a defining personality element. Therefore there can be unlimited narcissistic personality types.  Narcissism is a type of functioning, a definite way of handling the problem and a way of finding a solution, which most may find inappropriate, immature or unhealthy. Therefore every clinician and theorist comes up with a set of different narcissistic types, most popular of which are listed below.

    Unprincipled Narcissist;  fraudulent, exploitative, deceptive and unscrupulous

    Amorous Narcissist; Somatic, Exhibitionist: Histrionic, Erotic, Sexual, Exhibitionistic Traits

    Compensatory Narcissist; Negativistic, Passive-Aggressive, Avoidant Traits

    Elitist Narcissist; Phallic:

    Fanatic Narcissist

    Somatic Narcissist

    Nobel-Prize Narcissist

    Situational Narcissism

    Closet Narcissist; Depressive, Borderline, Needy, Clinging, Demanding Traits

    Corporate Narcissism; Profit Oriented:

    Cross-Cultural Narcissist;

    Narcissistic Antisocial Personalities; Manipulatory, Psychopathic, Sociopathic, Malignant, Aggressive, Cunning, Callous

    Malignant Narcissism; Paranoid, Psychopathic & Antisocial Traits

    Narcissistic Psychopath; Psychopathic, Antisocial Traits

    Narcissistic Sociopath; Sociopathic, Antisocial Traits