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Narcissistic Personality Disorder

Practice Essentials

Narcissistic personality disorder (NPD) is a cluster B personality disorder defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy.

Signs and symptoms

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
NPD is defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of the following 9 criteria:

A grandiose sense of self-importance

A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

A belief that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions

A need for excessive admiration

A sense of entitlement

Interpersonally exploitive behavior

A lack of empathy

Envy of others or a belief that others are envious of him or her

A demonstration of arrogant and haughty behaviors or attitudes

In a proposed alternative model cited in DSM-5, NPD is characterized by moderate or greater impairment in personality functioning, manifested by characteristic difficulties in 2 or more of the following 4 areas
:

Identity

Self-direction

Empathy

Intimacy

In addition, NPD is characterized by the presence of both grandiosity and attention seeking.

NPD is not associated with any specific defining physical characteristics; however, physical consequences of substance abuse, with which NPD is often associated, may also be apparent on examination. Mental status examination may reveal depressed mood. Patients in the throes of narcissistic grandiosity may display signs of hypomania or mania.

See Presentation for more detail.

Diagnosis

NPD must be distinguished from the other 3 cluster B personality disorders, which are as follows:

Antisocial personality disorder (ASPD)

Borderline personality disorder (BPD)

Histrionic personality disorder (HPD)

Patients with NPD may also meet criteria for separate axis I diagnoses. Alternatively, patients with only NPD may at times have symptoms that mimic those of axis I disorders.

No specific laboratory studies are employed to diagnose NPD; however, it is wise to obtain a toxicology screen to rule out drugs and alcohol as possible causes of the pathology.

Although there is some debate regarding their usefulness and reliability, personality tests such as the following may be administered to help elucidate character pathology and facilitate the diagnosis of NPD:

Personality Diagnostic Questionnaire–4 (PDQ-4)

Millon Clinical Multiaxial Inventory III (MCMI-III)

International Personality Disorder Examination (IPDE)

See Workup for more detail.

Management

Long-term, consistent outpatient care is the treatment approach of choice, usually involving a combination of psychotherapy and medication management.

Options for psychotherapy include the following:

Individual psychotherapy (specifically, psychoanalytic psychotherapy) – Mainstay of treatment; schools of thought include Kernberg’s object-relations approach and Kohut’s self-psychology approach, as well as various combinations of the 2 approaches

Group therapy

Family therapy

Couples therapy

Cognitive-behavioral therapy (CBT; in particular, schema-focused therapy)

Short-term objective-focused psychotherapy

If the patient acutely decompensates or becomes a danger to self or others, inpatient treatment (for as short a period as possible) is warranted

No psychiatric medications are tailored specifically toward the treatment of NPD. Nevertheless, patients with this disorder often benefit from the use of psychiatric medications to help alleviate certain symptoms associated with the disorder or to manage concomitant axis I diagnoses. Agents that may be indicated include the following:

Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class (eg, citalopram)

Antipsychotics (eg, risperidone)

Mood stabilizers (eg, lamotrigine)

See Treatment and Medication for more detail.

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