Do you know someone who is highly competitive, charming, ingratiating, entitled, superior, grandiose or self-absorbed?
The chances are, you probably do and you’ve possibly considered them a ‘narcissist’ and the chances are that you’d be wrong. These are all behavioural characteristics that could describe any of us at different points in time. However, there is a big difference between someone being a bit over-confident and self-absorbed at times and someone diagnosed as having narcissistic personality disorder (NPD). They are not the same thing. Far from it.
We all have personality quirks that make us who we are. Our personalities are shaped by a range of factors such as our genetics, biochemical compositions, and the people and environment around us. Personalities develop right through childhood and into early adulthood, often not fully forming until our late teens or early twenties.
In conditions such as borderline, histrionic, antisocial, and narcissistic personality disorders, the personality development process gets interrupted before the personality fully forms – causing behaviour patterns to become rigid and inflexible, extreme, and pervasive. These conditions often arise from relational environments that are less than nurturing and cause much distress.
About narcissistic personality disorder
According to Stinson et al (2008)1, the prevalence of lifetime NPD was 6.2%, with rates greater for men (7.7%) than for women (4.8%), yet it has been one of the least studied personality disorders. Therefore, diagnosis is still very difficult and subject to a lot of confusion.
To complicate matters further, NPD often co-exists with other mental and physical health conditions, such as bipolar disorder, other personality disorders, and substance abuse. It is often these other conditions that first bring someone with NPD to clinical attention as they don’t generally perceive themselves as having a problem in this regard.
Challenges of diagnosing NPD
The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) states that individuals must display some or all of the core characteristics which include:
- Having a pervasive pattern of grandiosity (in fantasy or behaviour)
- Lacking in empathy for others
- Believing he or she is special, unique or superior
- Having a constant need for admiration
- Having a strong sense of entitlement
- Taking advantage of others for their own ends.
Yet, NPD has a much broader scope than this list implies. The journal article, ‘Narcissistic Personality Disorder: Diagnostic and Clinical Challenges’, published by the American Journal of Psychiatry2, outlines some of the many challenges relating to the diagnosis of NPD. The article authors point out that:
“(While the core characteristics of NPD listed in the DSM-5 do) capture important aspects of narcissistic pathology, they provide inadequate coverage of the broad population of individuals who receive the diagnosis in clinical practice … and they fail to cover core psychological features of the disorder, including vulnerable self-esteem; feelings of inferiority, emptiness, and boredom; and affective reactivity and distress.”
The study authors also state that there is mounting evidence to suggest a range of sub-types of NPD. The two most recognised sub-types are the grandiose, thick-skinned, overt subtype and the vulnerable, ‘fragile’ or thin-skinned, covert subtype. The overt sub-type includes those that show many of the characteristics listed above, while the covert subtype is often shy. They are also:
“Inhibited, manifestly distressed, hypersensitive to the evaluations of others while chronically envious and evaluating themselves in relation to others … slights, while harbouring secret grandiosity. Both types are extraordinarily self-absorbed”.
To complicate matters further, these sub-types also present on a spectrum from the low-level characteristics we can all display on occasion through to a severely dysfunctional and disabling condition. The most severe cases come under the banner of ‘malignant narcissism’. They display very antisocial and paranoid behaviour while often being quite sadistic, controlling, and dishonest toward others, including the clinician trying to treat them.
One tactic clinicians can use to help diagnose NPD is to ask the person to describe the significant people around them. These descriptions tend to be quite dismissive and derogatory, but they can also be overly inflated or even glorifying. Either way, the descriptions are generally quite vague and mainly stated in terms of how that person compares to themselves. On the other hand, the person’s description of themselves is generally more complete, even if it is coloured by their disorder.
Can NPD be treated? If so, how?
While narcissistic personality disorder is certainly complex and challenging, it is not impossible to treat. A lot depends on the severity of the disorder and the accuracy of the diagnosis. It is vital that other mental health conditions are ruled out through a process of elimination, especially other personality disorders, although it is possible that other conditions may co-exist.
A clinician trained in this area can follow current guidelines to assess the level of severity of NPD and use their own judgement as to how to proceed. People with NPD generally have difficulty engaging in a ‘normal’ manner with others and may resist any form of therapy. Clinicians in this field need to have a high degree of resilience as the person’s behaviour toward them will likely be quite negative at times.
If the person is prepared to accept that their behaviour is having a profound and negative effect on their life and relationships, then it is possible they might agree to begin long-term treatment. For this to happen, it is also vital that the clinician and the person with NPD develop a collaborative and constructive relationship themselves.
Treatments may include:
- Psychodynamic therapy
- Cognitive behavioural therapy
- Mentalisation-based therapy
- Transference-focused psychotherapy and
- Schema-focused psychotherapy.
What should you do if you or someone you know has NPD?
Relationships between someone with NPD and those around them are often abusive and traumatic. However, if you are close to the person, your love for them may be strong enough for you to be willing to maintain a relationship with them and to support them through treatment.
While there will, no doubt, be many times when you feel helpless and disempowered, there are things you can do that may help. These include:
- Learning as much about the condition as you can
- Allowing them to talk about their experiences with you if they want to
- Helping them look after themselves through things like diet, exercise, and relaxation time
- Encouraging them to plan regular enjoyable activities, and above all
- Taking care of your own needs, including maintenance of firm boundaries and your own mental health needs.
You may benefit from relationship or family counselling as well as support groups and resources for people in your position. You can find out more about how to care for someone with a mental health condition on the Australian Government Department of Health – Head to Health website.3
Over to you
Whether you are a person with a personality disorder or someone who cares for a person with such difficulties, there is help available. At Mindful Synergi, we use the most appropriate treatments and interventions for your situation with the ultimate aim of helping you or your loved one develop a more stable sense of self and an increased ability to manage and cope in daily life.
To make an enquiry or book an appointment, please contact us by phone 0411 313 726 or email firstname.lastname@example.org
References and resources
1 Stinson. F et al, 2008, ‘Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions’, NCBI Journal of Clinical Psychiatry, Jul; 69(7):1033-45. https://www.ncbi.nlm.nih.gov/pubmed/18557663
2 Caligor. E et al, 2015, ‘Narcissistic Personality Disorder: Diagnostic and Clinical Challenges’, American Journal of Psychiatry, Volume 172, Issue 5, April 2015, Pages 415-422 https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14060723
3 Australian Government Department of Health – Head to Health website: Supporting Yourself – Carers https://headtohealth.gov.au/supporting-yourself/support-for/carers