Narcissistic personality disorder

Definition

Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they're superior to others and have little regard for other people's feelings. But behind this mask of ultra-confidence lies a fragile self-esteem, vulnerable to the slightest criticism.

Narcissistic personality disorder is one of several types of personality disorders. Personality disorders are conditions in which people have traits that cause them to feel and behave in socially distressing ways, limiting their ability to function in relationships and in other areas of their life, such as work or school.

Narcissistic personality disorder treatment is centered around psychotherapy.

Symptoms

Narcissistic personality disorder is characterized by dramatic, emotional behavior, in the same category as antisocial and borderline personality disorders.

Narcissistic personality disorder symptoms may include:

• Believing that you're better than others
• Fantasizing about power, success and attractiveness
• Exaggerating your achievements or talents
• Expecting constant praise and admiration
• Believing that you're special and acting accordingly
• Failing to recognize other people's emotions and feelings
• Expecting others to go along with your ideas and plans
• Taking advantage of others
• Expressing disdain for those you feel are inferior
• Being jealous of others
• Believing that others are jealous of you
• Trouble keeping healthy relationships
• Setting unrealistic goals
• Being easily hurt and rejected
• Having a fragile self-esteem
• Appearing as tough-minded or unemotional

Although some features of narcissistic personality disorder may seem like having confidence or strong self-esteem, it's not the same. Narcissistic personality disorder crosses the border of healthy confidence and self-esteem into thinking so highly of yourself that you put yourself on a pedestal. In contrast, people who have healthy confidence and self-esteem don't value themselves more than they value others.

When you have narcissistic personality disorder, you may come across as conceited, boastful or pretentious. You often monopolize conversations. You may belittle or look down on people you perceive as inferior. You may have a sense of entitlement. And when you don't receive the special treatment to which you feel entitled, you may become very impatient or angry. You may insist on having "the best" of everything — the best car, athletic club, medical care or social circles, for instance.

But underneath all this behavior often lies a fragile self-esteem. You have trouble handling anything that may be perceived as criticism. You may have a sense of secret shame and humiliation. And in order to make yourself feel better, you may react with rage or contempt and efforts to belittle the other person to make yourself appear better.

When to see a doctor
When you have narcissistic personality disorder, you may not want to think that anything could be wrong — doing so wouldn't fit with your self-image of power and perfection. But by definition, narcissistic personality disorder causes problems in many areas of your life, such as relationships, work, school or your financial affairs. You may be generally unhappy and confused by a mix of seemingly contradictory emotions. Others may not enjoy being around you, and you may find your relationships unfulfilling.

If you notice any of these problems in your life, consider reaching out to a trusted health care provider or mental health provider. Getting the right treatment can help make your life more rewarding and enjoyable.

Causes

It's not known what causes narcissistic personality disorder. As with other mental disorders, the cause is likely complex. Some evidence links the cause to a dysfunctional childhood, such as excessive pampering, extremely high expectations, abuse or neglect. Other evidence points to genetics or psychobiology — the connection between the brain and behavior and thinking.

Risk factors

Narcissistic personality disorder is rare. It affects more men than women. Narcissistic personality disorder often begins in early adulthood. Although some adolescents may seem to have traits of narcissism, this may simply be typical of the age and doesn't mean they'll go on to develop narcissistic personality disorder.

Although the cause of narcissistic personality disorder isn't known, researchers continue to learn more about the factors that may increase the risk of developing the condition. In the past, experts believed excessive praise, admiration and indulgence from parents may lead to a pathologically inflated sense of self. Today, however, psychiatrists believe parental neglect is more likely responsible.

Risk factors for narcissistic personality disorder may include:

• Parental disdain for fears and needs expressed during childhood
• Lack of affection and praise during childhood
• Neglect and emotional abuse in childhood
• Unpredictable or unreliable caregiving from parents
• Learning manipulative behaviors from parents

Children who learn from their parents that vulnerability is unacceptable may lose their ability to empathize with others' needs. They may also mask their emotional needs with grandiose, egotistical behavior that's calculated to make them seem emotionally "bulletproof."

Complications

Complications of narcissistic personality disorder, if left untreated, can include:

• Substance abuse
• Alcohol abuse
• Depression
• Suicidal thoughts or behavior
• Eating disorders, particularly anorexia nervosa
• Relationship difficulties
• Problems at work or school

Preparing for your appointment

People with narcissistic personality disorder are most likely to seek treatment when they develop symptoms of depression — often because of perceived criticisms or rejections. If you recognize that aspects of your personality are common to narcissistic personality disorder or you're feeling overwhelmed by sadness, talk with your doctor. Whatever your diagnosis, your symptoms signal a need for medical care.

When you call to make an appointment, your doctor may immediately refer you to a mental health provider, such as a psychiatrist.

Use the information below to prepare for your first appointment and learn what to expect from the mental health provider.

What you can do:

• Write down any symptoms you're experiencing, and for how long. It will help the mental health provider to know what kinds of events are likely to make you feel angry or defeated.
• Write down key personal information, including traumatic events in your past and any current, major stressors.
• Make a list of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications or supplements you're taking.
• Take a family member or friend along, if possible. Someone who has known you for a long time may be able to ask questions or share information with the mental health provider that you don't remember to bring up.
• Write down questions to ask your mental health provider in advance so that you can make the most of your appointment.

For narcissistic personality disorder, some basic questions to ask your mental health provider include:

• Do I have narcissistic personality disorder?
• Do I have any other mental health conditions?
• What is the goal of treatment in my case?
• What treatments are most likely to be effective for me?
• How much do you expect my quality of life may improve with treatment?
• How frequently will I need therapy sessions, and for how long?
• Would family or group therapy be helpful in my case?
• Are there medications that can help?
• I have these other health conditions. How can I best manage them together?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your mental health provider, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your mental health provider
The mental health provider is likely to ask you a number of questions to gain an understanding of your symptoms and how they're affecting your life. The mental health provider may ask:

• What are your symptoms?
• When do these symptoms occur, and how long do they last?
• How do you feel — and act — when others seem to criticize or reject you?
• Do you have any close personal relationships? If not, how do you explain that lack?
• What are your accomplishments?
• What do you plan to accomplish in the future?
• How do you feel when someone needs your help?
• How do you feel when someone expresses difficult feelings, such as fear or sadness, to you?
• How would you describe your childhood, including your relationship with your parents?
• How would you say your symptoms are affecting your life, including school, work and personal relationships?
• Have any of your close relatives been diagnosed with a mental health problem, including a personality disorder?
• Have you been treated for any other mental health problems? If yes, what treatments were most effective?
• Do you use alcohol or illicit drugs? How often?
• Are you currently being treated for any other medical conditions?

Tests and diagnosis

Narcissistic personality disorder is diagnosed based on signs and symptoms, as well as a thorough psychological evaluation that may include filling out questionnaires.

Although there's no laboratory test to diagnose narcissistic personality disorder, you may also have a physical exam to make sure you don't have a physical problem causing your symptoms.

Some features of narcissistic personality disorder are similar to those of other personality disorders. It's possible to be diagnosed with more than one personality disorder at the same time.

To be diagnosed with narcissistic personality disorder, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for narcissistic personality disorder to be diagnosed include:

• Having an exaggerated sense of self-importance
• Being preoccupied with fantasies about success, power or beauty
• Believing that you are special and can associate only with equally special people
• Requiring constant admiration
• Having a sense of entitlement
• Taking advantage of others
• Having an inability to recognize needs and feelings of others
• Being envious of others
• Behaving in an arrogant or haughty manner

Treatments and drugs

Narcissistic personality disorder treatment is centered around psychotherapy. There are no medications specifically used to treat narcissistic personality disorder. However, if you have symptoms of depression, anxiety or other conditions, medications such as antidepressants or anti-anxiety medications may be helpful.

Types of therapy that may be helpful for narcissistic personality disorder include:

• Cognitive behavioral therapy. In general, cognitive behavioral therapy helps you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones.
• Family therapy. Family therapy typically brings the whole family together in therapy sessions. You and your family explore conflicts, communication and problem solving to help cope with relationship problems.
• Group therapy. Group therapy, in which you meet with a group of people with similar conditions, may be helpful by teaching you to relate better with others. This may be a good way to learn about truly listening to others, learning about their feelings and offering support.

Because personality traits can be difficult to change, therapy may take several years. The short-term goal of psychotherapy for narcissistic personality disorder is to address such issues as substance abuse, depression, low self-esteem or shame. The long-term goal is to reshape your personality, at least to some degree, so that you can change patterns of thinking that distort your self-image and create a realistic self-image.

Psychotherapy can also help you learn to relate better with others so that your relationships are more intimate, enjoyable and rewarding. It can help you understand the causes of your emotions and what drives you to compete, to distrust others and perhaps to despise yourself and others.

Lifestyle and home remedies

Whether you decide to seek treatment on your own or are encouraged by loved ones or a concerned employer, you may feel defensive about treatment or think it's unnecessary. The nature of narcissistic personality disorder can also leave you feeling that therapy or the therapist is not worth your time and attention, and you may be tempted to quit. Try to keep an open mind, though, and to focus on the rewards of treatment.

Also, be sure to:

• Stick to your treatment plan. Attend scheduled therapy sessions and take any medications as directed. Remember that it can be hard work and that you may have occasional setbacks.
• Learn about it. Educate yourself about narcissistic personality disorder so that you can better understand symptoms, risk factors and treatments.
• Get treatment for substance abuse or other mental health problems. Your addictions, depression, anxiety and stress can feed off each other, leading to a cycle of emotional pain and unhealthy behavior.
• Learn relaxation and stress management. Try such stress-reduction techniques as meditation, yoga or tai chi. These can be soothing and calming.
• Stay focused on your goal. Recovery from narcissistic personality disorder can take time. Keep motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and become happier with your life.

Prevention

There's no known way to prevent narcissistic personality disorder with any certainty. Getting treatment as soon as possible for childhood mental health problems may help. Family therapy may help families learn healthy ways to communicate or to cope with conflicts or emotional distress. Parents with personality disorders may benefit from parenting classes and guidance from therapists or social workers.