Narcissistic Personality Disorder

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Narcissistic Personality Disorder

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Definition Symptoms Causes Treatment Sources

Definition

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Personality disorders are rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal distress. Personality disorders are enduring and persistent styles of behavior and thought, not atypical episodes. An individual with narcissistic personality disorder exhibits extreme self-importance, need for admiration, inability to empathize with others and heightened sensitivity to criticism. Self-involvement and lack of empathy characterize this personality disorder.

People with narcissistic personality disorder are frequently perfectionists and need to be the center of attention, receiving affection and admiration, and controlling the situation. To get the attention he craves, he may try to create crises that return the focus to him. Like patients with antisocial personality disorder, this person places entitlement issues at the forefront of their thoughts. He feels that the world owes him, regardless of whether he makes a contribution.

Alcohol and other drugs (AOD) can induce states that mimic a personality disorder, but if an AOD-using person with a personality disorder abstains, only the symptoms of the personality disorder will still be evident. AOD use may trigger or aggravate a personality disorder. The course and severity of personality disorders can also be made worse if other psychiatric problems, such as mood, anxiety and psychotic disorders are present.

A person with a personality disorder frequently uses AODs to relieve her symptoms: to raise self-esteem, decrease feelings of guilt and amplify feelings of diminished individuality.

Narcissistic personality disorder often leads to use of drugs, particularly stimulants. As a disinhibitor, alcohol may help lower anxiety and alleviate depression. Socially awkward or withdrawn people with narcissistic personality disorder may depend on marijuana to relieve their social anxiety. While others with narcissistic personality disorder use steroids to boost confidence in physical perfection. Without AODs, a person with narcissistic personality disorder may believe that others are overly critical or do not adequately appreciate their work, talents and generosity. In a crisis, they may become severely depressed.

Symptoms

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Reacts to criticism with anger, shame or humiliation
Takes advantage of others to reach his or her own goals
Exaggerates own importance
Exaggerates achievements and talents
Entertains unrealistic fantasies about success, power, beauty, intelligence or romance
Has unreasonable expectation of favorable treatment
Requires constant attention and positive reinforcement from others
Is easily jealous
Disregards the feelings of others, lacks empathy
Has obsessive self-interest
Pursues mainly selfish goals

Causes

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The exact cause is not known. Although onset of the disorder is usually early adulthood, it is likely to be in response to childhood experiences. A psychological evaluation may be performed.

Treatment

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Psychotherapy may be useful in getting the individual with narcissistic personality disorder to relate to others in a less maladaptive manner. The following guidelines may help therapists working with these patients, especially those who are also AOD-dependant.

Engagement

Therapists can actually use the narcissistic features of their patients to engage and assess them. To avoid angering the patient, it's important to work with, rather than belittle, the narcissistic ego. A therapist should, for example, address a patient's heightened self-importance and desire for control by saying such things as "Because you are obviously such an intelligent and sensitive person, I'm sure that, working together, we can get you past your current difficulties."

Narcissistic personality traits can also be used to provide motivation for therapy. The patient may be induced to change negative behaviors: a better appearance, improved career prospects, or romantic and sexual conquests can been viewed as a reward for recovery.

Therapists will need to address thinking errors—which may reflect inflated self-esteem ("I'm the star of the office") or hypersensitivity ("My coworkers are trying to get me fired")—that interfere with the patient's ability to work.

While empathizing with the patient, the therapist should offer reality testing. If a patient complains that, "things are really going wrong" or "everyone is against me," the therapist might sympathize, but tactfully point out the reality of the situation and how it could be improved by behavior changes the patient could make.

To manage narcissistic rage and depression, therapists may contract for patient safety as well as for the safety of others. The therapist may offer the patient a combination of empathy and reality testing. For example, when patients say, "Everything is messed up," or "Everybody is causing me trouble," therapists may empathize with patients, while also indicating the reality of the situation and the need for behavior change.

Crisis stabilization

In a crisis situation, the therapist should assess the patient's defenses, and to put them to therapeutic use. For example, when a patient blames the police for "setting me up," the therapist can mention that the best way to avoid being set up again is to not drink and drive.

Patients with narcissistic personality disorder are often perfectionists. For them, the best way to approach their problems is from a "no-fault" disease perspective. This removes blame from the patient and allows her to perceive her illness as a biochemical disorder, reducing the sense of failure that can make treatment more difficult.

A patient with narcissistic personality disorder tends to become depressed when his feelings are badly hurt, when his defenses have let him down and when he believes his world is collapsing. When wounded, he is at the greatest risk of acting out, either against himself or others. A patient experiencing a narcissistic rage may become homicidal, particularly if he has a need to seek revenge. Because of the intensity of the narcissist's emotions, the counselor needs to deal very carefully with this rage and avoid a power struggle.

Patients believed to be suicidal should be asked to sign a safety contract. To stabilize the patient, a brief, goal-oriented hospitalization may be necessary.

Because HIV-positive patients with narcissistic personality disorder are likely to view themselves as expert lovers, therapists should establish contracts with them to practice safe sex. Otherwise, the wide-ranging sexual encounters that often accompany the narcissistic ego, puts them at high risk for sexually transmitted diseases.

Longer-Term Care Individual Counseling

Ongoing therapy is needed to manage not only the self-aggrandizement, hypersensitivity, and need for control, admiration and attention found in narcissistic patients, but also their anger and depression. Individual and group treatments for patients with antisocial personality disorder, including 12-step programs, are often helpful for patients with narcissistic personality disorder. In fact, therapists may want to approach an individual with narcissistic personality disorder as a hypersensitive patient with antisocial personality disorder.

Group Therapy

Group therapy may be helpful for patients with narcissistic personality disorder, but the therapist should, tactfully but firmly, place limits on their speaking time so that they cannot control the discussion or focus all the attention on themselves. Explaining that members of the group need to share the time, therapists may want to make a contract with patients with narcissistic personality disorder before each session to encourage pro-social behaviors. Some of these behaviors include:

Limiting speaking time in group sessions
Not interrupting other speakers
Respecting other group members' feelings and time
Responding to other group members
Listening objectively to responses and feedback from others

It is important not to smash the narcissistic ego or to attack the narcissistic patient within the group. It is more useful to comfort and confront the narcissist simultaneously: "I understand that the part of you that is sensitive is wounded to hear that the group does not believe everything you are saying." Continue to work with the narcissist's defenses, not against them.

Continuum of Care

For patients with narcissistic personality disorder, the least restrictive treatment environment is preferable. It permits patients to feel that they are in control. These patients are normally moved quickly from inpatient to outpatient levels of care. If they do not like the treatment, they will stop participating. Thus, it is critical not to over-pathologize the patient's disorder with constant criticism. However, acute hospitalization for psychiatric emergencies (such as homicidal or suicidal plans) may be necessary.

Narcissistic patients generally enjoy the attention they receive through involvement in outpatient treatment. Long-term outpatient involvement is critical to maintain a narcissistic patient's pro-social behavior and sobriety. Therapists who strive to build narcissistic patients' strengths and who pay close attention to them in therapy will find them active participants in the recovery process. In addition to their personality disorder and AOD use disorder, some patients may engage in compulsive sexual or spending behaviors that should be addressed therapeutically.

Sources

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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised.
Center for Substance Abuse Treatment. Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series, No.9.
National Institutes of Health - National Library of Medicine

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