Contemporary concepts

Kohut, in The Analysis of the Sell,8) described narcissistic personality disorder as presenting a failure to internalize healthy self-esteem; it is a derivative of normal infantile grandiosity, causing a poor self-image against which narcissism develops as a defensive reaction. Kernberg (41) divided narcissism into normal infantile, normal adult, and pathological. This idea is in tune with the continuum of psychopathology ( Table.. ...10), in which fixation or regression to infantile narcissistic goals is an important feature of all personality disorders that include narcissistic traits or narcissism as a defensive reaction. Narcissism, in its normal sublimated form, is necessary for the self-esteem essential for a healthy life and a capacity for deep object relations.

Table 10 Types of narcissism

A narcissistic personality has a pathological grandiose self which hides a diffuse and aimless inner identity. Kernberg argues that self-hatred, rather than self-love, lies at the root of pathological narcissism, and distinguishes between narcissism in the broad sense and the specific pathological structures of the narcissistic personality. According to Kernberg, narcissistic patients function on a borderline level. Malignant narcissism, (31) which develops when primitive aggression infiltrates the pathological grandiose self, lies at the extreme end of a continuum. It is a combination of narcissistic personality disorder, antisocial behaviour, egosyntonic aggression or sadism directed against others, and a strong paranoid orientation.

Narcissistic personality disorder was officially accepted in DSM-III. Somewhat refined criteria were adopted in DSM-IV ( T§bl.§...H), because some studies showed a substantial lack of diagnostic reliability when the DSM-III criteria were used. Narcissistic personality disorder is not included in ICD-10, being mentioned only in the category 'Other specific personality disorders'.

Table 11 DSM-IV diagnostic criteria for narcissistic personality disorder

Epidemiology

The prevalence of narcissistic personality disorder in the community has been found to be 0.4 per cent. (49) Its prevalence in clinical populations is estimated to range from 1 to 3 per cent, and is greater among males. It is not yet clear whether this is due to diagnostic bias, more frequent seeking of treatment by males, or the difference in psychosexual development between males and females.

Aetiology

There has been very little empirical investigation of the aetiology of narcissistic personality disorder. It is probably multidimensional, as in other personality disorders, with biological, developmental, and social factors. In the absence of other information, psychoanalytical theory remains the most important of the aetiological explanations.

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