Interpersonal relationships

Interpersonal relationships are frequently parasitic, manipulative, and exploitative. They idealize people whom they expect to feed their narcissism, but deprecate and treat with contempt others (often former idols) from whom they do not expect to receive anything. They lack empathy and concern for others, who are welcome only as an applauding crowd and as mirrors of success.

Typical defence mechanisms (omnipotence, omniscience, intellectualization, rationalization, idealization, and devaluation) are derived from splitting. The Narcissistic Personality Inventory(91> and the semistructured Diagnostic Interview for Narcissism (92> assess characteristics imputed to pathological narcissism.

Comorbidity and differential diagnosis

Narcissistic personality disorder is often comorbid with major depression, dysthymic disorder, substance abuse, and anorexia nervosa. Patients meeting criteria for narcissistic disorder have a high overlap with histrionic, borderline, and antisocial personality disorders, and also with schizotypal, paranoid, and passive-aggressive personality disorders.

Narcissistic personality disorder may display some features of bipolar disorder (manic and hypomanic episodes). However, the mood swings are of limited duration and change rapidly, while insight is maintained and the general integrity of the personality is preserved.

Narcissistic personality disorder is strikingly similar to borderline personality disorder. Phenomenologically, grandiosity is the best discriminator between the two disorders/9:3 In narcissistic personality disorder, there is also better impulse control, greater social adjustment and anxiety tolerance, less frequent suicide attempts, and less danger of regressive fragmentation and psychotic episodes.

Narcissistic individuals, especially those manifesting malignant narcissism, may demonstrate antisocial behaviour. However, antisocial individuals are more impulsive and less capable of concentrating on work and career, and they are devoid of guilt feelings. Similarities with histrionic and obsessive-compulsive personalities are superficial, since people with these disorders have a capacity for empathy and a concern and love for others.

Course and prognosis

Patients often become depressed or defensively hypomanic during middle age, when their internal life gradually deteriorates owing to a vicious circle of frustrations and disappointments and diminishing narcissistic supplies. They may cynically withdraw into 'splendid isolation', away from the 'empty' external world. Hypochondriasis and anxiety disorders are frequent complications.

Treatment

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