Narcissistic Personality Disorder

Clinical Description

The narcissistic personality is characterized by an exaggerated or grandiose sense of self-importance and an illusion of being unique or "special" that lead to feelings of entitlement. Such persons overestimate their abilities, popularity, and power, frequently coming across as self-centered, conceited, and boastful. They are typically preoccupied with themselves and their self-affirming fantasies of unlimited success, fame, intellectual sophistication, power, and beauty. Sadly, their excessive self-regard is equaled only by their cavernous misperception—they think and expect that others should recognize their superiority, special talents, and uniqueness. Underneath, it is presumed that the narcissist feels inadequate and dependent, with fragile self-esteem (Kernberg, 1975). The narcissistic type often responds to negative feedback with intense rage and attempts to degrade those who were critical, presumably in an attempt to bolster fragile self-esteem.

Another feature is that the narcissistic type has a strong need to be admired by others and frequently fishes for compliments. They also lack sensitivity and compassion for others and have difficulty understanding the needs, feelings, and perspectives of others. Interpersonally, they are exploitative, chronically seeing others as unimportant and unworthy. As such, they are prone to take advantage of others because they see their own needs as primary. They choose to associate only with the "best" doctors and the most gifted professionals and peers. When they find themselves in situations where they are not surrounded by people they perceive as being as special, high status, and privileged as themselves, they respond with demeaning, arrogant, and haughty behaviors. Their entitlement is often expressed as expecting especially favorable treatment (without earning it) and having others comply with their requests, no matter how unreasonable. They expect that the world and others "owe them" without assuming reciprocal responsibilities. As such, their near-total preoccupation with themselves massively disturbs interpersonal relationships and their occupational opportunities. The DVM-IV-TR diagnostic criteria for Narcissistic Personality Disorder are shown in Table 3.4.

Table 3.4 DSM-IV-TR Diagnostic Criteria for Narcissistic Personality Disorder (Code: 301.81)

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associated with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.

Potential Age-Bias of Criteria

Most of the criteria for Narcissistic Personality Disorder seem to apply reasonably well in the later-life context although some minor issues are worth noting. Criterion 6 (is interpersonally exploitative, that is, takes advantage of others to achieve his or her own ends) may be somewhat problematic because of the actual reductions in power and influence experienced by many in later life, especially those who had high-powered occupations from which they are removed. With real reductions in control and power come reduced opportunities to exploit others, especially in work settings.

Criterion 8 (is often envious of others or believes that others are envious of him or her) may also be somewhat concerning, especially when the aging individual experiences serious financial and health problems. In this context, common to later life, being somewhat envious of others who are healthier and financially secure would not be unreasonable. Conversely, older adults still meet this criterion if they habitually think that others are envious of them, especially if this belief lacks merit. Sadly, there is little reason to think that the core features of the disorder (exaggerated sense of self-importance, arrogance, need for admiration, and limited capacity for empathy) will improve simply as a result of aging.

Theorized Pattern in Later Life and Possible Impact of Aging The narcissist type has a particularly poor prognosis with advancing age. In fact, a host of aging issues impinge negatively on the individual with Narcissistic Personality Disorder. They sometimes come to later life alone, isolated, and bitter about their lack of success. One of our patients lamented, "Life never gave me the special treats I deserved." In other cases, they come into old age with great histories of accomplishment, although they often can no longer maintain that success. Alienation of family members is common due to a lifetime of perceived callous disregard for and purposeful manipulation of others in their family. Relationships with spouses and friends are usually impaired due to the narcissistic individual's lifelong patterns of being demanding, insensitive, and self-centered.

With advancing age, people with Narcissistic Personality Disorder frequently suffer narcissistic injuries when they lose power and prestige and receive messages from society that devalue older persons. Aging narcissists typically cannot handle usual, age-related changes in their appearance (e.g., hair loss, wrinkles, shrinking muscle mass) because they perceive signs of age as detracting from their superiority over others. Similarly, physical illness and bodily deterioration impact the narcissist's view of the self as better than others and not subject to the kinds of problems that many others experience. One of our older narcissistic patients bemoaned in therapy that he "thought he could beat aging" and became despondent when he showed physical signs of aging and also developed a limp due to severe arthritis.

Another problem is that the continuous streams of praise required by the narcissist usually diminish with advancing age, frequently leading to severe depression. This pattern is especially noteworthy in cases where the narcissistic person did manage to achieve some measure of prestige and success in the occupational sphere. At an earlier stage in life, the person may have been bolstered by the ability to wield power over subordinates and also to reap praise from them. With retirement, the aging narcissist often begins to feel powerless and deflated, and in reaction, responds with even greater demands for admiration which often go unheeded. Imagine the loss of prestige and power likely to be experienced by Donald Trump, who in later life, will no longer be able to espouse his business acumen; fire people on his television show, The Apprentice; and direct his massive conglomeration.

Increased dependency on others also results in problems for the narcissistic type. Throughout life, individuals with Narcissistic Personality Disorder see themselves as a "cut above the masses" and do not see the need for help or even collaboration from others. Instead, others are seen as objects to be taken advantage of. When narcissists find they need care and support from others (clearly indicating having lower social status), rageful reactions are common that result in increased negative feedback and further reductions in the sense of self.

In the clinical setting, it can be expected that therapy with the older narcissistic patient will be challenging. Perhaps the greatest issue is the patient's perception that the problem resides in other people who do not seem to recognize the patient's talents. A lifetime of relying on others' admiration, respect, and awe can be challenging to address. Another problem is that, stylistically, such patients devalue therapy and the therapist, so development of an alliance is often thwarted. Narcissistic patients often demand special consideration (e.g., seeing the therapist at their convenience, reduced fees) and move from therapist to therapist, trying to find one who is exceptionally well qualified and unique to treat them, but forever being disappointed.

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Responses

  • liya fikru
    How do people with narcassitic personality disorder react to feedback?
    27 days ago

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