Narcissistic Personality Disorder

Narcissus was a mythical character from ancient Greek times who was the son of the river god Cephissus and nymph Liriope. He was physically beautiful, but disdained those who loved him. The goddess Nemesis learned of him and drew him to a pool of water, where Narcissus saw his own reflection, fell in love with his own image and starved to death rather than leave the picture of perfection.

This myth gave rise to the term Narcissism – an exaggerated opinion of self and self worth, which lead to Narcissistic Personality Disorder (NPD), previously called megalomania. NPD should only be diagnosed by specialists, and while it is easy to see someone acting egotistical and self centred and label them as NPD, the odds are you are just dealing with a selfish person.

People often mix up the meanings of NPD and psychopathy (sometimes referred to as sociopathy). While they are both personality disorders, they are polar opposites. Both can be devastatingly harmful to others. Psychopaths don’t get empathetic feedback from others and so don’t really care what you think, just don’t get in their way too much. Narcissists need you to have positive feelings for them. There is far more to psychopathy, but that isn’t the scope of this entry.

Narcissists fear being exposed as frauds, being seen as weak, incapable or vulnerable. This fear requires them to create an image of perfection for everyone to admire. Narcissists need admiration of others. This fear of exposure makes it very hard for them to get help as they first have to admit to someone else that they need help and expose their vulnerabilities to a therapist to work on the core fear of exposure.

It is thought that roughly 1 in 100 people have NPD to some pathological level, although it is hard to truly gauge as people who could be given an NPD diagnosis don’t tend to come forward to be assessed. While the prevalence could be as low as 50% male vs 50% female, it is thought to be as high as 75% male vs 25% female. Mostly it is considered to be more likely a male trait, but certainly not exclusive.

The American Diagnostics and Statistics Manual version 5 (DSM V) states the following:

[TLDR – To have NPD, the condition must hinder the individual and others in specific ways and be characterised by some antagonism, grandiosity (feelings of entitlement) and attention seeking, but not be a recent or brief thing or explained by some other condition or circumstance.]

“The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:

Significant impairments in personality functioning manifest by:

  1. Impairments in self functioning (a or b):
  2. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
  3. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

AND

Impairments in interpersonal functioning (a or b):

  1. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
  2. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality  constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain

Pathological personality traits in the following domain:

  1. Antagonism, characterized by:
  2. Grandiosity: Feelings of entitlement, either overt or covert;  self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
  3. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
  4. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
  5. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
  6. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).”

While the exact mechanism for why the disorder occurs is unclear (could be a genetic component, environmental component, developmental delay etc), the traits often begin in adolescence and get stronger. Many teens show some of the traits – being self centred and reactive is often what it means to be a teen, the traits in most teens are not overrepresented and will diminish in time. When the traits get stronger and don’t resolve the NPD diagnosis may become relevant.

It is easy to over pathologise being confident and assertive as NPD. Being sure of yourself and your capabilities is not a hallmark of NPD. What is a better tell is what happens if you are told you are wrong. If you check to see if you are, or take on board suggestions from others, then you do not have NPD. If you feel threatened and retaliate to reclaim your feeling of comfort, then perhaps you should speak to a professional therapist.

The core of the disorder appears to be the fear of the self being weak, and the need to prove that isn’t true. That very need to prove capability and brilliance proves the weakness. A person who knows they have ability just goes quietly along and does what they need to do. They don’t need others to congratulate them, admire them or reassure them. They just do it. The occasional thanks is nice, but not required.

It is tempting to pathologise the human need to be recognised as worthwhile, and have your actions validated. The difference between this human need and NPD is in two parts: the first is that when most people are validated, it assures them they are on track – it is a confirmation rather than a requirement; the second is how the person seeks that validation and what they do if the person is told they are doing the thing wrong – NPD people will attack if they are not validated and will seek the validation using negative manipulation or cajoling, while other people will check to see if they need to change what they are doing to better match reasonable societal expectations.

If you have read this and think … oh dear, perhaps I have NPD, then by all means go and talk to a therapist and get yourself checked out. In Australia, go to your doctor, express your concerns and get a referral to a suitable therapist. You can learn to decrease your fear and empathically connect better to others.

If you have read this and think … oh dear, my family member / close friend / boss may have NPD, then there are a few things that are a good idea to do. First of all, assess the damage that person is doing to others (including yourself). If there is no significant emotional harm, social harm or financial harm, then they probably don’t have NPD. NPD requires both the person to have a fragile ego and be causing problems with other people because of it. By all means, go see a therapist to discuss your concerns and get some specific help in working out if this person who is affecting you fits the profile – going through all the possibilities is beyond the scope of this article.

If your conclusion is that this person does fit the NPD profile, then you need to ensure you protect yourself first. These people are often incredibly charismatic and have a reality distortion field. If you see through these, they feel exposed and threatened by you and will act against you.

The charisma is the narcissists learned ability to manipulate the affection and awe of those around them to validate their need to be loved and respected despite their fear that they are inadequate. Unfortunately most people are prone to fall for these as the manipulation methods rely on hijacking normal social interactions and tuning them for their own exaggerated benefit. The reality distortion field (named after the Steve Jobs effect) is where reality seems to be different around these people. They can convince people that black is white, giraffes are short and that things that you thought happened didn’t, oh and by the way, you are responsible for that thing that went bad. This can leave you very confused about what is right and proper, wondering if you are really the one who needs help because there is clearly something wrong with you.

When a person with NPD fails to charm you, or you fail to admire them, or you seem immune to their reality distortion field, they will feel threatened by you. The fear they have is that you can see through to their true self, whom they feel is pathetic and worthless. While it is tempting to try to convince them that you can see their true self and want to nurture it, to help them grow to not be what they fear, the majority of people diagnosed with NPD will see you as a threat and will take steps to protect themselves from the perceived threat. This will take the form of crass social manipulation, threats, erratic mood swings, childish tantrums and possibly direct attack. In effect, they will try to bully you into submission, demonise you, and try to convince others that you are some kind of evil. The charismatic nature of the condition means that people will begin to believe the person with NPD, or keep giving them the benefit of the doubt. In short, you can’t nurture them back to a healthy balance.

Sometimes it is best to walk away. Only if the person with NPD recognises themselves for what they are and seek help on their own (by all means encourage, but don’t push), will they have a chance to work through the diagnosis and recover their sense of inherent self worth rather than fabricating a facade of competence.