Narcissistic Personality Disorder: Challenge of Understanding and Diagnosis

This is the first of a two-part series.

The topic of psychotherapy in psychiatry easily leads to consideration of the personality disorders. Among APA’s treatment guidelines, those for borderline personality disorder uniquely recommend psychotherapy as the primary modality of treatment. While guidelines have not been developed for other personality disorders, the complex nature of these disorders calls for a comprehensive biopsychosocial approach including general psychiatric management, judicious use of psychopharmacology, and a central role for psychotherapy. We focus in this column on narcissistic personality disorder (NPD).

NPD has an estimated prevalence of 1 percent to 6 percent and can be associated with significant functional impairment and psychosocial disability. Review of a series of our clinical cases of NPD reveals, first, a high level of initial misdiagnosis and long periods of inappropriate treatments, typically targeting refractory depression. This phenomenon can lead to lost years in patients’ lives and the risk of suicide. Diagnostic confusion reflects at least in part the wide variety of clinical presentations, spanning a wide range of severity, that can characterize NPD. This is further complicated by a high level of co-occurence between NPD and other psychiatric disorders, notably affective disorders, especially bipolar disorder, substance misuse, and other personality disorders. Thus, the first requirement in adequately treating NPD is careful assessment and consideration of differential diagnosis.

Both the diagnosis and treatment of NPD require a coherent conceptualization of the disorder that can unify a wide range of clinical presentations. The DSM system has in the past focused on a descriptive characterization that emphasizes grandiosity (in fantasy or behavior), the need for admiration, entitlement, and a lack of empathy. However, these criteria do not cover core psychological features of the disorder, including difficulty with self-esteem, feelings of inferiority, emptiness and boredom, and affective reactivity and distress and do not describe the depressive and masochistic types of the disorder. The publication of DSM-5 and, in particular, of the Alternative Model for Personality Disorders included in Section III, begins to address psychological processes or structures in its understanding of personality disorders, emphasizing the centrality of Self and Interpersonal functioning. This approach is compatible with a longstanding tradition within psychodynamic psychiatry that understands and characterizes personality disorders in terms of the psychological processes underlying and organizing personality functioning and pathology, focusing on identity formation. This model can account for shared features that unify the various presentations of NPD.

One clinically useful psychodynamic perspective on NPD emerges from object relations theory. This model emphasizes the role of a particular form of identity formation as responsible for the faulty self and interpersonal functioning that characterizes NPD across different presentations and levels of severity. Object relations theory understands identity as reflecting the internalization of affectively charged experiences of self and other throughout the course of early development. Grossly speaking, those experiences sort out into two groups of experiences: those based on gratification and associated with loving feelings and those based on pain and frustration and associated with hateful feelings. In the course of successful psychological development, these polarized experiences of self and other become integrated into a complex and deep experience of self and of significant others, corresponding with normal identity formation. However, some individuals continue through life with extreme, highly positive or highly negative, caricatured views of self and other that are activated by external events, organizing inaccurate perceptions of interactions with others and consequent maladaptive behaviors. This polarized experience of self and others, described in terms of identity formation that is overtly unintegrated or “split,” is characteristic of borderline personality disorder (BPD).

In contrast to BPD, NPD can be seen as characterized by a superficially unified identity, created as an attempt to escape from the distress of internal fragmentation. However, this Self-structure does not provide the integrated experience of self and others provided by normal identity formation. Rather, the sense of self in NPD is based on the individual’s attribution to the self of all characteristics and affect states that are desirable and good, while relegating to others all that is devalued. This pathogenic Self-structure, referred to as the “grandiose self,” protects the individual from the distress of internal fragmentation but at the expense of a superficial and fragile self-concept based on needing to be exceptional and associated with difficulty establishing mutual relations with others. Whenever the individual experiences something that could become a building block of the self—an interest, an idea—aggressive and critical elements in the person’s mind attack it as not good enough, interfering with the individual capacity to take in anything of value. Thus the grandiose self provides some degree of stability but at the expense of stasis and internal emptiness. It is as though the individual has developed a personal narrative that absorbs all that is good but does not correspond to human emotional complexity or to the reality of life.

The therapist encountering the NPD patient can keep this view of the patient’s psychological structure in mind, as a way to empathize with the patient and to think about how to organize clinical intervention. These treatment considerations will be the subject of the next Psychotherapy in Psychiatry column. ■