The video below is the section for Narcissistic Personality Disorder from Part 1 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 1, click here.
Transcript of DSM-5 EPPP Lecture Video: Narcissistic Personality Disorder
Narcissistic Personality Disorder is a Cluster B Disorder characterized by a sense of grandiosity, lack of empathy, and excessive need for others’ approval and respect.
In order to receive a diagnosis of Narcissistic Personality Disorder, an individual must display at least five of the following nine symptoms: exaggerated sense of self-importance or feelings of superiority; preoccupation with ideas of “unlimited success, power, brilliance, beauty, or ideal love” (APA, 2013); a belief that because of his or her own uniqueness, it is appropriate only to associate with other “special” people; extreme need for admiration; a sense of entitlement; the exploitation of others in order to reach his or her own goals; lack of empathy; is often envious of others or assumes others are envious of him or her; and demonstrates arrogant or haughty attitudes and behaviors.
These symptoms must be present beginning in early adulthood and in a variety of contexts, and constitutes an enduring and inflexible pattern of inner experience and behavior that is significantly different from the expectations of the individual’s culture.
Although individuals with Narcissistic Personality Disorder appear confident and self-assured, some research contends that their self-esteem is actually very fragile. Criticism often leaves them feeling humiliated and empty inside; in order to defend against these unpleasant emotions, they may react to criticism with patronization, disdain, or rage.
In other words, the feelings of superiority and specialness appear to be compensating for a lack of self-worth at the individual’s core. Individuals with Narcissistic Personality Disorder are vulnerable to developing Persistent Depressive Disorder (previously known as Dysthymic Disorder) or Major Depressive Disorder, especially upon reaching middle age.
Other associated disorders include Anorexia Nervosa, Substance-Use Disorders (particularly cocaine), Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, and Paranoid Personality Disorder. Individuals with Narcissistic Personality Disorder have difficulty recognizing and understanding the needs and viewpoints of others. They often devalue other people’s contributions, overestimating the importance or noteworthiness of their own actions and talents.
Individuals with this disorder may take advantage of others in order to meet their own needs. They also expect others to recognize their “specialness” and thus comply with their every wish.
Indeed, they often feel quite entitled, believing that they are owed special favors or opportunities and responding with anger and dismay when their needs are not met immediately and their self-perceived unique talents are not recognized.
The etiology of Narcissistic Personality Disorder is generally believed to be rooted in childhood, although there are differing opinions on the specific mechanisms through which the disorder develops. Otto Kernberg, for example, theorizes that narcissism develops as a response to an “unempathetic and unresponsive” caregiver (Kernberg, 1975).
Narcissists generalize their feelings about their caregivers to the outside world, which is viewed as rejecting and an entity that needs to be fought against. The grandiosity and desire for recognition inherent to Narcissistic Personality Disorder are, then, defenses against feelings of worthlessness and emptiness caused by the caregiver, who valued them for skills or looks but not for their developing selves.
Heinz Kohut, on the other hand, sees this disorder as a form of arrested development rather than a maladaptive defense mechanism. Kohut posits that grandiosity is developmentally appropriate in young children; however, if the caregiver neglects to provide a realistic representation of self for the child, the grandiosity remains and the child does not learn social values (e.g., empathy, reciprocity), continuing to overestimate his or her own talents and contributions in a kind of extension of far-younger developmental patterns (Kohut, 1968).
Treatment of Narcissistic Personality Disorder focuses on the individual’s grandiosity (and underlying fragility) and gaining a more realistic perception of the self and the world. Relaxation techniques may be employed to combat the severe anxiety that accompanies criticism. Treatment of this disorder may also assist the individual in gaining empathy and respect for others. Less than 1 percent of the general population is diagnosed with Narcissistic Personality Disorder. The prevalence rate in clinical samples ranges from 2 percent to 16 percent – an admittedly wide range, bespeaking some diagnostic uncertainty regarding the Axis II disorders. Between 50 percent and 75 percent of those with the disorder are male.
Narcissistic Personality Disorder
- Related to grandiosity, entitlement, a sense of specialness, and lack of empathy for others, excessive need of approval and respect
- Symptoms present beginning in early adulthood
- Very fragile self-esteem despite self-assured presentation
- Superiority and specialness compensate for lack of self-worth (vulnerable to developing depressive disorders)
- Difficulty recognizing and understanding needs of others; devaluing of others’ contributions, over-estimate their contribution
- Take advantage of others to meet their needs; expect “specialness” to be recognized; entitled
- Etiology: Kernberg: “Unempathetic and unresponsive caregiver;” Kohut: arrested development due to unrealistic representation of self given by the caregiver
- Prevalence: less than 1%; 50-70% are male
- Treatment: focus on grandiosity and underlying fragility to gain more realistic self-impression; relaxation techniques
George is not well-liked by his co-workers. He takes credit for any success within his department, ignoring the contributions made by his peers. He is flabbergasted when others fail to recognize his superior skills and responds with anger if he is criticized. He is not averse to taking advantage of others if it will help him accomplish his goals. Whenever there is a company luncheon, George spends most of his time bragging about his accomplishments to the CEO. George would be most likely to receive a diagnosis of:
A. Antisocial Personality Disorder.
B. Histrionic Personality Disorder.
C. Narcissistic Personality Disorder.
D. Borderline Personality Disorder.
RATIONALE: The correct answer is C, as the descriptors are exemplars of the diagnostic criteria for Narcissistic Personality Disorder. Antisocial Personality Disorder A is a Cluster B Personality Disorder characterized by “a pervasive pattern of disregard for and violation of the rights of others.” Histrionic Personality Disorder B is a Cluster B Personality Disorder characterized by extreme emotionality and attention-seeking behavior. Borderline Personality Disorder D is a Cluster B Personality Disorder characterized by “a pervasive pattern of instability of interpersonal relationships, self-image, affects, and marked impulsiveness.”