Narcissistic personality disorder

Narcissistic personality disorder (NPD) is a complex and heterogeneous personality disorder characterized by patterns of grandiosity, entitlement, low empathy, and interpersonal difficulties, which can manifest as either grandiose ("thick-skinned") or vulnerable ("thin-skinned") forms. Grandiose individuals display arrogance, social dominance, and exploitative behaviors, while vulnerable individuals show shame, inferiority, hypersensitivity, and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement. It is often co-morbid with other mental disorders and associated with significant functional impairment and psychosocial disability. There are two definitions of NPD in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM); whereas the primary definition is categorical and stems from previous DSM editions, the other definition – part of the Alternative DSM-5 model for personality disorders – is based on dimensional measures of severity of the disorder as well as on specific pathological traits. The International Classification of Diseases (ICD) defines only a general personality disorder since the introduction of the latest edition; hence, it does not include an NPD category. There is no standard treatment for NPD. Its high comorbidity with other mental disorders influences treatment and outcomes. Psychotherapeutic treatments generally fall into two categories: psychoanalytic/psychodynamic and cognitive behavioral therapy, with growing support for integration of different modalities in therapy. However, there are few studies on the effectiveness of treatments. Treatment is frequently not sought; one's subjective experience of the mental disorder, as well as one's agreement to and level of engagement with treatment, are highly dependent on one's motivation to change. NPD's etiology is thought to be largely genetic and neurobiological, with structural and functional brain differences in areas related to self-processing and empathy. Assessment tools such as the Narcissistic Personality Inventory or Pathological Narcissism Inventory can help differentiate subtypes. NPD has historical roots in psychoanalytic theory and remains a subject of controversy in psychiatric classification, while its manifestations continue to appear in literature and media as exemplars of extreme self-focus and entitlement.

Signs and symptoms Individuals with narcissistic personality disorder may be grandiose or self-loathing, extraverted or socially isolated, captains of industry or unable to maintain steady employment, model citizens or prone to antisocial activities. NPD is complex and far from uniform in its presentation and consequences. Empirical evidence suggests several subtypes of NPD may exist (see the Subtypes section below), but in general, the disorder is known to have grandiose ("thick-skinned") and vulnerable ("thin-skinned") expressions. Grandiose, thick-skinned NPD patients show a sense of uniqueness or superiority, attitudes of entitlement, a belief that others envy their abilities or status, low empathy, social dominance, superficial charm, disdainfulness or snobbery, and an exploitative interpersonal style characterized by manipulation and selfishness. Vulnerable, thin-skinned individuals with NPD also show entitlement, selfishness and low empathy, but uniquely, they demonstrate feelings of shame and inferiority, are envious of others' abilities or status, tend to be shy, paranoid, vindictive, and emotionally dependent on admiration, and show extreme rage and hostility in response to rejection and criticism. This behavior stems from low self-esteem, a need for admiration and validation, and social belonging. While vulnerable-type patients typically show extreme distress and dysfunction, grandiose variants tend to be associated with greater psychological wellbeing, often manifesting dysfunction by occupational conflict, harming others, antisocial behavior or emotional strain resulting from perfectionism. It is often theorized that some patients may oscillate between grandiosity and vulnerability. While some evidence suggests that grandiose individuals show occasional reactive anger (a vulnerable trait), but narcissistically vulnerable individuals do not show signs of grandiosity, most studies show the vulnerable individuals show occasional bouts of grandiosity, narcissistically grandiose individuals show few or no signs of vulnerability.

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