Narcissistic Personality Disorder

Narcissistic Personality Disorder is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • A personality disorder (PD) is defined as an enduring pattern of inner experience and behavior that causes dysfunction, is inflexible, persists across multiple situations, and leads to clinically significant distress or impairment in functioning. Narcissistic personality disorder (NPD) is a cluster B PD, a group which includes antisocial PD, histrionic PD, and borderline PD. Patients with cluster B PDs commonly exhibit problems with impulse control and emotional regulation.
  • Patients with NPD exhibit a pattern of grandiosity, need for admiration/validation, and lack of empathy. These behaviors typically present by early adulthood and persist in multiple environments (1)[C].
  • Diagnostic criteria according to section II of the DSM-5 (must meet five or more of the following):
    • Grandiose sense of self-importance
    • Obsessed with fantasies of unlimited achievement or success, beauty, love
    • Believes they are “special” and should only associate with other high-status people or institutions
    • Requires excessive admiration
    • Has a sense of entitlement or has unreasonable expectations for favorable treatment
    • Is interpersonally exploitative, often takes advantage of others to achieve personal success
    • Lacks empathy toward others
    • Is often envious of others or believes others are envious of him or her
    • Shows arrogant, haughty behaviors or attitudes
  • Alternative DSM-5 model for PDs (section III) defines PD by specific criteria of impairments of personality functioning and pathologic personality traits. Specific PDs may then be diagnosed based on traits.
    • Typical features of NPD in this model include vulnerable and variable self-esteem and attempts to regulate self-esteem, thought approval, attention seeking, and grandiosity (may be externalized or internalized).
  • Controversy over diagnostic criteria and possible subtypes of NPD continue to exist.

Epidemiology

  • Onset usually in early adulthood (1)
  • More common in males than females (2)
  • Can still exist at older ages, although less common

Prevalence
  • Point prevalence in adult population 0.0–6.2%; mean prevalence 1.1% (3)
  • Most prevalence statistics are obtained via self-reported inventories, which may underestimate true prevalence (4)[B].

Etiology and Pathophysiology

  • Current DSM-5 definition supports pathologic central grandiosity, with core dysfunction rooted in managing needs for validation and admiration (1)[C].
  • Multiple twin studies show a relatively high heritability rate among PDs of 25–71% (2).

Commonly Associated Conditions

  • Mood and/or anxiety disorders
  • Substance use (especially cocaine use)
  • Anorexia nervosa
  • Bipolar disorder or hypomania
  • Depression/dysthymia
  • Obsessive-compulsive disorder
  • Self-harm behaviors
  • Other PDs, including histrionic, borderline, antisocial, and paranoid PDs

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