Personality › Personality Disorder

Narcissistic Personality Disorder

A person with narcissistic personality disorder holds a grandiose sense of their own importance, often preoccupied with fantasies of success, power, or brilliance, and believes they are entitled to special treatment. This self-esteem, however, is fragile rather than robust, and is propped up by an exhibitionistic need for constant attention and admiration from others; envy is readily directed toward anyone perceived as more successful. Relationships tend to be entered into only where they are expected to be personally advantageous, with a corresponding lack of empathy and a willingness to exploit others, including, in romantic relationships, treating a partner as little more than a means of bolstering one's own self-esteem.

This has traditionally been noted as absent from one major classification system and not proposed for inclusion in its forthcoming revision, since the diagnosis is rarely made outside a small number of countries; its continued inclusion in another major system has been linked to the lasting influence of a particular psychoanalytic tradition, and possibly to wider media interest in the concept.

Recognition features

• A grandiose sense of self-importance and preoccupation with fantasies of success, power, or brilliance
• A belief in one's own entitlement to special treatment
• Underlying fragility of self-esteem, masked by an exhibitionistic need for constant attention and admiration
• Envy directed at those perceived as more successful
• Interpersonal exploitativeness and a lack of empathy, entering relationships chiefly where they are expected to be personally advantageous
• In romantic relationships, a tendency to treat the partner as a means of bolstering one's own self-esteem rather than as an end in themselves
• An outwardly arrogant manner

Eliciting it at interview

• Ask about the person's own account of their achievements and abilities, listening for grandiosity alongside evidence of how the person actually responds when this self-image is challenged
• Explore how the person describes their close relationships, including what they feel they gain from them and how they respond to a partner's own needs
• Since a degree of egocentricity occurs across several other personality disorders, assess it in combination with the other features here, such as grandiosity, entitlement, and fragile self-esteem, rather than treating egocentricity alone as diagnostic
• Consider how the person responds to setbacks or criticism, since fragility beneath an outwardly confident presentation is a recognised feature

Distinguishing features

• Differs from dissocial personality disorder in the quality of the person's regard for others: the narcissistic person tends to be well-disposed and believes others genuinely admire them, whereas a more malevolent feeling toward others is more characteristic of dissocial personality disorder
• Differs from borderline personality disorder in being less impulsive and less emotionally volatile
• Differs from histrionic personality disorder in being less overtly dramatic
• Differs from dependent personality disorder in generally being more cohesive and outwardly successful
• A degree of egocentricity is common across several personality disorders and is therefore not, on its own, diagnostic of this one; any of the disorders it is distinguished from above may, in practice, coexist with it

Common misconceptions

• That narcissistic personality disorder simply describes ordinary confidence or ambition; the diagnosis requires genuine grandiosity, entitlement, exploitativeness, and fragile self-esteem, together causing real difficulty
• That the person's confidence is robust rather than fragile; the grandiosity is understood as covering an underlying fragility, often revealed by an intense need for admiration and vulnerability to perceived slights

Related phenomena

Borderline Personality Disorder · Histrionic Personality Disorder · Dependent Personality Disorder · Dissocial Personality Disorder

Practice this

A 45-year-old executive describes his recent promotion as "the company finally recognising what everyone already knew," becomes coldly dismissive toward a colleague after a project's success is credited to the whole team rather than to him alone, and redirects a conversation about his partner's difficult week back to his own achievements within moments. What is this presentation most consistent with? · A 38-year-old man describes feeling "completely humiliated" and becoming furious for days after a minor, constructive piece of feedback from his manager, despite an otherwise strong performance review. He says he deserves to be running the department himself and describes colleagues who disagree with him as "just jealous." Before revealing the answer: which features here point toward narcissistic personality disorder specifically, rather than just an unusually thin skin? · Two patients each seem to crave a great deal of attention from others. Before revealing the answer, decide what would help you tell narcissistic personality disorder apart from histrionic personality disorder. · You want to assess a patient for features of narcissistic personality disorder during an interview, without simply labelling them as arrogant. Before revealing the answer, decide what you would actually explore. · Explain why egocentricity alone is not considered sufficient to diagnose narcissistic personality disorder.

Illustration

A 45-year-old executive describes his recent promotion as 'the company finally recognising what everyone already knew,' becomes coldly dismissive toward a colleague after a project's modest success is credited to the whole team rather than to him alone, and, when his partner mentions her own difficult week, redirects the conversation within moments back to his own recent achievements.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 10, 'Personality Disorders'.