Understanding Narcissistic Personality Disorder

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Narcissistic personality disorder (NPD) is a widely discussed and popular “armchair diagnosis” that people give to everyone from troubled siblings to frustrating bosses and political figures. While some informally diagnosed colleagues may indeed have NPD, they often do not. Having narcissistic personality disorder is more than simply being self-interested, attention-seeking, or grandiose. It is a pattern of personality that reflects a deep and usually hidden confusion and sense of emptiness at the core of the self.

What Is Narcissistic Personality Disorder?

Personality disorders are a class of mental health conditions that are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a set of pervasive traits core to a person’s sense of identity. They are caused by a combination of biological and environmental factors and are established by late adolescence or early adulthood.

Narcissistic personality disorder is one of the “Cluster B” personality disorders, along with antisocial personality disorder, histrionic personality disorder, and borderline personality disorder. These disorders manifest differently but are linked by impulsivity, disinhibition, and emotional instability.

To be diagnosed with NPD, a person must exhibit five or more of the following traits:

  • Arrogant or haughty behaviors or attitudes
  • Demands for excessive admiration and praise
  • Grandiosity, or an exaggerated sense of self-importance and superiority
  • Preoccupation with fantasies of great power, success, beauty, glory, or love
  • A pattern of exploiting others or taking advantage of them for personal ends
  • Frequently becoming envious of others or believing others are envious of them
  • Lack of empathy, or being unwilling or unable to recognize others’ feelings and needs
  • Sense of entitlement, or unreasonable expectations of special treatment or compliance
  • Beliefs that their special qualities can only be understood by other special people

The current understanding of narcissism reflects the theories of Heinz Kohut, a psychoanalyst who published work on the topic in the 1970s. According to Kohut, every person is narcissistic. “Healthy narcissism” is actually an essential component of childhood development. Children are naturally grandiose, with an inflated sense of their ability to influence the world around them. In most children, experiences of disappointment in their parents or themselves temper this grandiosity. Over time, it transforms into a healthy and realistic sense of self-esteem.

However, in people with narcissistic personality disorder, this developmental process is disrupted. The key to transitioning from childhood grandiosity to adult confidence is empathy. Healthy people become more empathetic over the course of childhood and adolescence, while people with NPD never develop the capacity to fully empathize with others. One reason is that they frequently grew up with parents who were not supportive or were lacking in empathy. In some cases, they might have been praised excessively as children, but often in a cold way that emphasized achievements over inner qualities of the self.

What distinguishes someone with NPD from someone who is simply arrogant or grandiose is a disturbance at the core of the self. People with narcissistic personality disorder ultimately feel empty inside. Unlike people with borderline personality disorder, who respond to feelings of emptiness with self-harming behavior, frequent changes in personal interests, and intense pursuit of romantic love, people with NPD seek to fill their emptiness by gaining power or admiration. At the core of NPD is a vulnerable self that must never be exposed to the world.

Treatment for Narcissistic Personality Disorder

Medications are typically not used to treat NPD unless a person with NPD has a co-occurring disorder that responds to medication, such as depression or anxiety. A person with NPD may not even be aware of the distress driving their behavior, as traits of the disorder often function as an elaborate psychological defense against shame and depression. People with NPD often only pursue treatment secondary to external motivations like legal or relational problems.

The primary treatment for narcissistic personality disorder is therapy. Cognitive behavioral therapy (CBT) is one of the most well-established and researched forms of therapy and has been shown to be widely effective in treating a range of mental health conditions. In theory, CBT could help someone with NPD identify distorted thoughts, specifically those related to grandiosity. However, little research has been done on the efficacy of CBT in treating NPD.

Psychodynamic psychotherapy is a traditional form of therapy that has been proven to be as effective as CBT in treating some disorders and that may be especially effective for narcissistic personality disorder. A psychodynamic therapist helps clients gain insight into the causes of their psychological distress and become aware of previously unconscious beliefs and emotions. Because so much of NPD remains under the surface, this approach may yield a more immediate impact than CBT, which primarily helps with symptoms at the level of cognitive awareness.

Heinz Kohut developed a special kind of psychodynamic therapy for people with NPD based on his system of self psychology. His self psychological approach focuses on helping clients develop empathy and self-esteem through forming a strong relationship with a therapist who is able to express empathy to them and mirror them. It is not commonly practiced but some therapists still use it successfully.

For people with NPD who do not believe they have a problem, and are only in treatment to address external pressures, a motivational approach may be best. Motivational interviewing is an evidence-based approach primarily used to help people with substance use disorders find internal motivations for changing their behavior. It can be used in an array of clinical scenarios, including helping clients with NPD identify personal treatment goals and start working on them.

Narcissistic Personality Disorder and Addiction

Though it is harder to see, narcissistic personality disorder is just as driven by deep feelings of shame as borderline personality disorder. People with NPD may or may not be aware of these feelings. They may consciously avoid them or may have established a psychological defense in which they act in ways to prevent feeling shame without knowing that is what they are doing.

People with NPD are often unable to win the responses from others they seek. When they cannot experience external validation, they try to find other ways to feel powerful or good about themselves, or ways to simply avoid feeling shame. This dynamic often drives them to use substances and to become addicted to them. A little more than 40 percent of people with NPD have a substance use disorder at some point in their lifetimes.

People with NPD use alcohol more frequently than any other substance. They may choose alcohol for its ability to induce euphoria and reduce feelings of self-consciousness or shame. They are also often drawn to stimulants, especially cocaine, for the way they bolster grandiosity and induce feelings of power and presence.

People with NPD often receive behavioral health treatment for the first time when they seek treatment for a substance use disorder. If they are able to connect with strong motivations to maintain abstinence from substance use and embrace a recovery-based lifestyle, they might also start to identify and address their personality disorder. The deep work of later stages of recovery can help them unearth their hidden fears and sense of shame and start to address them in healthier ways.

Conclusion

About six percent of people in the United States have narcissistic personality disorder. Not all of them are as visible as popular psychology would suggest. Many suffer quietly and try to keep their sense of grandiosity as hidden as their shame. More than anything, they try to hide it from themselves. This can make it hard for them to recognize their disorder and seek treatment for it. However, when they do, they can start to heal the pain at their core and move forward to establish new ways of living.

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