Assignment: Narcissistic Personality Disorder

Assignment: Narcissistic Personality Disorder

Assignment: Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is one of the personality disorders under cluster B, generally characterized by dramatic, emotional, and erratic behavior. It is characterized by a recurring pattern of grandiosity, an elevated sense of self-importance, and obsession with fantasies of great success. Individuals with NPD often exhibit an exaggerated reaction to criticism, an excessive concern with self-esteem and self-image, and impaired interpersonal relationships(Yakeley, 2018). The commonly cited factor for the development of NPD is a lack of maternal empathy, with a person facing early rejection or loss.According to research, roughly 5% of individuals suffer from NPD. Many individuals have narcissistic traits, butNPD disorder is more severe and requires to be diagnosed by a mental health professional(Kacel et al., 2017). The purpose of this paper is to comprehensively analyze NPD and discuss associated treatment options.

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Historical Perspective

Narcissism was originally conceived in the early 20th century and described as exaggerated self-love, but it later started to be considered a personality disorder or style.

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The concept of narcissistic personality or character was initially conveyed by Wälder (1925), who described people with narcissistic personalities as haughty, feeling superior to others, obsessed with themselves and admiration, and demonstrating a significant lack of empathy(Yakeley, 2018). Wälder also described them as being most obvious in their sexuality, based on purely physical pleasure instead of a combination of emotional intimacy. NPD was first introduced into the official diagnostic system in DSM- III (1980) after narcissism was identified as a personality element in various psychological studies(Yakeley, 2018). This led to increased research on NPD based on the growing interest in the disorder at that time. However, data shows that this interest has abated over time.

Diagnostic Criteria

Persons with NPD have a grandiose feeling of self-importance in behavior or fantasy. They exhibit a huge need for admiration, lack empathy, and most have chronic, powerfulenvy. Besides, individuals deal poorly with criticism or defeat by becoming furious or depressed (Kacel et al., 2017). They also demonstrate fragile self-esteem and poor interpersonal relationships. The behaviors in NPD are triggered by stressors like occupational challenges, interpersonal difficulties, rejection, and loss. The DSM-5 diagnostic criteria for NPD requires the presence of at least five of the following features:

1. An exaggerated sense of self-worth and self-importance, like a person exaggerating their talents and achievements or expecting to be acknowledged as superior without corresponding achievements (APA, 2013).
2. An obsession with fantasies of unlimited power, achievement, beauty, brilliance, or ideal love.
3. A belief that one is special or unique and can relate with other special or individuals with high social status.
4. A need for extreme admiration.
5. A sense of entitlement or privilege with one having unrealistic expectations of being given a favorable treatment (APA, 2013).
6. Interpersonally oppressive behavior is evidenced by a person taking advantage of others to meet their needs.
7. A lack of empathy is seen by a reluctance to acknowledge or relate to others’ feelings and needs.
8. Jealousness or a conviction that other people are jealous of the person.
9. Arrogance and haughty behaviors or attitudes (APA, 2013).

Neurobiological and Other Influences

The degree of a person’s empathy is directly connected to the volume of gray brain matter of the related cortical representation in the insular region. Individuals with pathological narcissism show a structural deficit in this brain area. Some studies have found that persons with NPD have a decreased volume of gray matter in areas of the brain associated with empathy (Nenadić et al., 2021). They also exhibit increased activity on baseline images in brain regions related to self-directed and self-absorbed thinking. Narcissistic traits have been associated with structural and functional brain networks, including the insular brain structure. Functional neuroimaging studies have revealed abnormal activity in these brain areas.

Mao et al. (2018) examined the association between cortical thickness (CT), cortical volume (CV), and pathological narcissism. Study findings revealed that the Pathological Narcissism Inventory (PNI) score was negatively connected with CT and CV in the right dorsolateral prefrontal cortex, which may be linked with defects in emotion regulation processes. Besides, the PNI score demonstrated significant negative relations with CV in the left medial prefrontal cortex, right post-central gyrus, and CT in the right inferior frontal cortex. This may be associated with impairments in social cognition. Therefore, the findings indicate a distinctive structural basis in individual variations in pathological narcissism spread across various gray matter regions of the social brain network and central executive network (Mao et al., 2018). NPD is more prevalent among males than females, with 75% of those diagnosed with NPD being male. However, no racial factors have been identified to influence the development of NPD. Furthermore, no genetic links to NPD have been established so far.

Important Cultural or Genetic Issues

The development of personality disorders is closely associated with the cultural environment. Vater et al. (2018) explain that cultural environments can be categorized as individualistic or collectivistic. In light of this, individualistic cultures support a stronger focus on oneself, while collectivistic cultures stress the essence of social values. Pathological narcissism has a major focus on the self in addition to an increased need for admiration and grandiose fantasies(Vater et al., 2018). Thus, people from individualistic cultures are prone to be more narcissistic than those from collectivistic cultures.

Narcissism traits are increasing in modern Western societies, which have been termed the narcissism epidemic. Various studies have shown that individualistic values can cause narcissism. People from the US, whose culture is more individualistic, have higher scores of grandiose narcissism thanpeople from Asian countries and the Middle East, where the culture is more collectivistic (Vater et al., 2018). Similarly, Chinese have lesser self-enhancement scores than people from more individualistic Western countries, like the US, UK, Australia, Canada, and Europe. People from East Asia have been found to have lower self-esteem than those from Western cultures.

Treatment Approach and Guidelines

The treatment interventions for NPD are psychotherapy and pharmacotherapy. However, there are no standardized psychological or pharmacological treatments established for NPD. The treatment approach of choice for patients with NPD includes long-term, consistent outpatient care that combines psychotherapy and medication management(Diamond & Hersh, 2020). The mainstay therapy is individual psychotherapy, particularly psychoanalytic psychotherapy. Based on Kernberg’s approach, the therapist’s role in psychoanalytic psychotherapy is to interpret the client’s narcissistic defenses while simultaneously revealing the client’s negative transferences(Diamond & Hersh, 2020). Kernberg hypothesized that the end goal of psychotherapy is to eliminate or alleviate a person’s pathologic grandiose self via confrontation.

In addition to individual psychoanalytic psychotherapy, group, couples, and family therapy and cognitive-behavioral therapy (CBT) are also used in managing NPD.Transference-focused therapy is a type of psychoanalytic therapy that targets the personal expression of emotions toward the therapist. Since patients with NPD can easily be provoked by their view of being treated by another, their emotions toward others are important (Diamond & Hersh, 2020). Furthermore, CBT has the potential to benefit patients with NPD. Schema-focused therapy, a form of CBT, focuses on fixing narcissistic schemas as well as the impaired moods and coping styles related to the schemas (Yakeley, 2018). This is a highly active and work-intensive therapy that encourages individuals to deal with narcissistic cognitive distortions and has shown promising results in treating NPD.

No FDA-approved medications exist for treating NPD. Nonetheless, many patients have been found to benefit from treating symptoms like depression, anxiety, transient psychosis, mood lability, and impulse control. Antidepressants, like SSRIs and SNRIs, are used to alleviate depressive symptoms (Yakeley, 2018). Besides, antipsychotics like risperidone are used for psychotic symptoms, while mood stabilizers such as lamotrigine are prescribed to NPD patients with mood lability.

Recent Research Applicable To NPD

Recent research has examined the interpersonal impact of pathological narcissism on people with a close relationship with someone with NPD. People with NPD report having multiple difficulties in identity and emotion regulation within the perspective of interpersonal relationships, which has led to studies on these impacts on people close to them. Day et al. (2020) examined the reported characteristics of people with pathologically narcissistic traits from the view of those in personal relationships with these patients. The relatives described that individuals with NPD demonstrated vulnerability characterized by hypersensitivity, contingent self-esteem, insecurity, emptiness, affective instability, anger, depression, hiding the self, and victimhood. NPD affects patients’ relatives insidiously, given the main deficits of affective instability and feelings of emptiness (Day et al., 2020). The study findings support the essence of assessing the entire dimension of NPD and the associated personality pattern.

Different Views/Perspectives/Controversies Related To NPD

When NPD was added to DSM-III, there was an upsurge in interest and research on narcissism and NPD. Due to this increased attention, substantial debate has surfaced surrounding the construct of NPD. Miller et al. (2018) explain that controversies have cropped up in several areas, like thedefinition of grandiose and vulnerable features or variants. Questions have surfaced on the existence of a universal description of NPD, central versus peripheral characteristics of narcissism, differences between normal and pathological narcissism, likely etiological factors, and the role of self-esteem in NPD.Theorists have long proposed that there exist various dimensions or variants of narcissism that can be generally grouped into narcissistic grandiosity and vulnerability (Miller et al., 2018). Words used to describe people with narcissistic grandiosity-related presentations include overt, spiteful, insensible, thick-skinned, manipulative, special child, arrogant, and psychopathic. On the other hand, terms to describe persons with vulnerability-related narcissism include craving, hypervigilant, covert, thin-skinned, compensatory, shamed child, and shy.

Existing inventories of narcissism disagree on whether they examine grandiose, vulnerable narcissism, or both. They also disagree on the extent to which they sufficiently evaluate these dimensions(Miller et al., 2018). Thus, caution must be taken with regard to these issues to ensure that the clinicianemploys a suitable assessment, and if possible, multiple measures should be employed. All narcissistic presentations can be regarded as pathological to the extent to which a person is inflexible or pervasive and are associated with functional impairment and distress(Miller et al., 2018). Furthermore, the assessment of NPD has been a source of considerable debate and controversy. The criticisms have been directed at the NPI related to the inconsistent factor structure, including content some consider irrelevant or peripheral and assessment of normal or adaptive narcissism instead of pathological narcissism (Miller et al., 2018). Besides, using a forced-choice design in which all item pairs are notperipheralhas raised controversy.

Issues for APRN Practice

The treatment of narcissism and NPD is often challenging for providers, including APRNs, owing to the complexity of the disorder and inadequate empirical evidence to guide treatment. Issues for APRN practice with regard to NPD surround treatment challenges, especially with psychological treatment (Kacel et al., 2017). They include poor boundaries, cognitive distortions, ambivalence about change, patients idealizing and devaluing providers, poor behavioral health adherence, and help-rejecting behaviors. Kacel et al. (2017) explain that therapists can face poor boundaries from patients, like making unnecessary calls, requesting extra time during therapy sessions, asking for personal information, and ignoring professional rules for interaction with therapists. Patients may be ambivalent about change, which can occur when they are reluctant to complete assignments, have contradictory requests about therapeutic approaches, avoid distressing subjects, and are defensive (Kacel et al., 2017). Besides, some NPD patients may deliberately engage in activities that have previously caused distress.

Cognitive distortions are another issue in APRN practice and occur when clients exhibit unrealistic goal setting, all-or-nothing thinking, recurrent feelings of failure, and appalling thought patterns linked to interpersonal relationships. Furthermore, some NPD patients can idealize and devalue the APRNs, for example, by referring to them as very talented but humiliating (Kacel et al., 2017). In addition, some patients demonstrate help-rejecting behaviors like frequent cancellation of sessions, emotional avoidance, volatility toward the APRN, frequent criticism of APRNs, and yelling when in a vulnerable situation.

Areas within NPD Where Future Development and Research Are Needed

Literature shows that NPD is associated with culture (individualistic) and gender (male). However, few studies have examined the genetic association withNPD resulting in a lack of solid evidence describing the genetic links in NPD. Thus, future research should examine if there is a genetic predisposition toward NPD. Furthermore, no research has been conducted on the efficacy of the medications used to alleviate NPD symptoms like depression, anxiety, and mood lability(Diamond & Hersh, 2020). Future research should examine the effectiveness of these pharmacological treatments (antidepressants, anxiolytics, and mood stabilizers) in alleviating short-term and long-term symptoms. Furthermore, future research should focus on the impact of schema-focused therapy in alleviating patients’ NPD features(Diamond & Hersh, 2020). Future developments should seek to identify new psychotherapy approaches that can be used in patients with NPD, especially those with comorbid psychiatric disorders.

Summary

Patients with NPD present with a grandiose sense of self-importance and an obsession with fantasies of power, success, brilliance, and beauty. They believe they are special and unique, require unwarranted admiration, have a sense of entitlement, and lack empathy. Individuals with pathological narcissism exhibit a structural deficit in the volume of the gray brain matter. Furthermore, NPD has been associated with cultures with higher narcissism scores, which are evident in societies with individualistic cultures than those with collectivistic cultures. Individual psychoanalytic psychotherapy is the mainstay therapy for NPD. However, antidepressants, anxiolytics, and mood stabilizers are used to manage comorbid symptoms. APRN practice issues in NPD relate to poor boundaries, cognitive distortions, patients devaluing providers, and help-rejecting behaviors. Future research on NPD is needed on the genetic predisposition and the impact of pharmacological treatments and schema-focused therapy in alleviating NPD features. Besides, future developments should focus on identifying new psychotherapy approaches that can be used to manage patients with NPD.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: Author.

Day, N. J., Townsend, M. L., & Grenyer, B. F. (2020). Living with pathological narcissism: a qualitative study. Borderline Personality Disorder and Emotion Dysregulation, 7(1), 1-14. https://doi.org/10.1186/s40479-020-00132-8

Diamond, D., & Hersh, R. G. (2020). Transference-Focused Psychotherapy for Narcissistic Personality Disorder: An Object Relations Approach. Journal of Personality Disorders, 34(Suppl), 159–176. https://doi.org/10.1521/pedi.2020.34.supp.159

Kacel, E. L., Ennis, N., & Pereira, D. B. (2017). Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness. Behavioral Medicine (Washington, D.C.), 43(3), 156–164. https://doi.org/10.1080/08964289.2017.1301875

Mao, Y., Sang, N., Wang, Y., Hou, X., Huang, H., Wei, D., … & Qiu, J. (2018). Reduced frontal cortex thickness and cortical volume associated with pathological narcissism. Neuroscience, 328, 50-57. https://doi.org/10.1016/j.neuroscience.2016.04.025

Miller, J. D., Lynam, D. R., Hyatt, C. S., & Campbell, W. K. (2018). Controversies in Narcissism. Annual Review of Clinical Psychology, 13(1), 291–315. doi:10.1146/annurev-clinpsy-032816-045244

Nenadić, I., Lorenz, C., & Gaser, C. (2021). Narcissistic personality traits and prefrontal brain structure. Scientific Reports, 11(1), 1-9. https://doi.org/10.1038/s41598-021-94920-z

Vater, A., Moritz, S., & Roepke, S. (2018). Does a narcissism epidemic exist in modern western societies? Comparing narcissism and self-esteem in East and West Germany. PloS One, 13(1), e0188287. https://doi.org/10.1371/journal.pone.0188287

Yakeley, J. (2018). Current understanding of narcissism and narcissistic personality disorder. BJPsych Advances, 24(5), 305–315.https://doi.org/10.1192/bja.2018.20

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