UNIT 2 NARCISSISTIC PERSONALITY

DISORDER
Structure
2.0 Introduction
2.1 Objectives
2.2 Narcissistic Personality Disorder
2.2.1 Diagnostic Features of Narcissistic Personality Disorder
2.2.2 Subtypes of Narcissistic Personality Disorder
2.2.3 Causes of Narcissistic Personality Disorder
2.2.4 Treatment of Narcissistic Personality Disorder
2.2.5 Prognosis

2.3 Let Us Sum Up

2.4 Unit End Questions
2.5 Glossary
2.6 Suggested Readings

2.0 INTRODUCTION
In our social interactions we sometimes come across to such persons who are in love
with the self and give too much importance to it. They have great expectations of
social favours and constant attentions for others. They feel that they are very special
in brilliance, power and, beauty and take advantage of others. They consider
themselves somehow different from others and deserving special treatment. They
exhibit extreme self-importance, inability to empathize with others and heightened
sensitivity to criticism. Self-involvement and lack of empathy characterise this
personality disorder. In narcissistic personality disorder this tendency is taken to its
extreme. Narcissistic personality disorder is a pervasive disorder characterised by
self-centeredness, lack of empathy, and an exaggerated sense of self-importance. In
the present unit we will discuss the nature, diagnostic features, causes, and treatment
of narcissistic personality disorder.

2.1 OBJECTIVES
After completing this unit, you will be able to:
 Explain the meaning of narcissistic personality disorder;
 Understand the diagnostic features of narcissistic personality disorder;
 Describe the causes of narcissistic personality disorder; and
 Explain the treatment and prognosis of narcissistic personality disorder.

2.2 NARCISSISTIC PERSONALITY DISORDER

Sigmund Freud (1856-1939) is credited with the promulgation and presentation of
a first coherent theory of narcissism. He described transitions from subject directed
libido (The psychic and emotional energy associated with instinctual biological 19
Personality Disorders drives. According to Freud, all behaviour is motivated by the desire to feel
pleasure. That motivation is organised and directed by two instincts: sexuality
(Eros), and aggression (Thanatos). Freud conceptualised both these instincts as
being powered by a form of internal psychic energy that he called the Libido.
Libido is the pleasure principle, or basic psychic energy.) to object directed
libido through the intermediation and agency of the parents. To be healthy and
functional, the transitions must be smooth and unperturbed. Neuroses are the results
of such perturbations.
Freud conceived of each stage of development linked to the next stage of development.
Thus, if a child reaches out to his objects of desire and fails to attract their love and
attention, the child will regress to the previous phase, to the narcissistic phase. The
first occurrence of narcissism is adaptive.
It “trains” the child to love an object. It ensures gratification through availability,
predictability and permanence. But regressing to “secondary narcissism” is maladaptive.
It is an indication of failure to direct the libido to the “right” targets (to objects, such
as the child’s parents).
Secondary narcissism corresponds to the return of the libido to the ego , that is
withdrawn from objects. Freud described this for the first time in relation to a state
he called “paraphrenia,” which corresponded to the schizophrenia identified by Bleuler.
Withdrawal of the libidinal investment in objects, followed by a reinvestment in the
ego, was considered responsible for two characteristic manifestations, that is,
i) lack of interest in the external world and
ii) delusions of grandeur.
If this pattern of regression persists and prevails, a “narcissistic neurosis” is formed.
The narcissist prefers fantasyland to reality, grandiose self conception to realistic
appraisal, masturbation and sexual fantasies to mature adult sex , and daydreaming
to real life achievements.
Carl Gustav Jung (1875-1961) had a mental picture of the psyche as a giant warehouse
of archetypes (the conscious representations of adaptive behaviours). Fantasies to
him were just a way of accessing these archetypes and releasing them. Any reversion
to earlier phases of mental life, to earlier coping strategies, to earlier choices is
interpreted as simply the psyche’s way of using yet another, hitherto untapped,
adaptation strategy.
Actually, there is little difference between Freud and Jung. When libido investment
in objects (esp. the Primary Object) fails to produce gratification, maladaptation
results that is a default option is activated which is secondary narcissism. This default
enhances adaptation, it is functional and adaptive and triggers adaptive behaviours.
As a by product, it secures gratification.
We are at such peace when we exert reasonable control over our environment, i.e.,
when our behaviours are adaptive. The compensatory process has two results (i)
enhanced adaptation and (ii) inevitable gratification. Perhaps the more serious division
between them is with regard to introversion. Freud regards introversion as an
instrument in the service of a pathology
As opposed to Freud, Jung regards introversion as a useful tool in the service of the
endless psychic quest for adaptation strategies (narcissism being one such strategy).
20 The Jungian adaptation repertoire does not discriminate against narcissism. To Jung
it is as legitimate a choice as any. But even Jung acknowledged that the very need Narcissistic Personaity
Disorder
to look for a new adaptation strategy means that adaptation has failed. In other
words, the search itself is indicative of a pathological state of affairs. It does seem
that introversion per se is not pathological (because no psychological mechanism is
pathological per se). Only the use made of it can be pathological.
Jung distinguished introverts (those who habitually concentrate on their selves rather
than on outside objects) from extroverts. Not only was introversion a totally normal
and natural function in childhood, it remains normal and natural even if it predominates
the mental life.
Pathological narcissism is exclusive and all pervasive. Other forms of narcissism are
not. Hence though there is no healthy state of habitual, predominant introversion, it
remains a question of form and degree of introversion. Often a healthy, adaptive
mechanism goes awry. When it does, as Jung himself recognised, neuroses form.
Freud regards Narcissism as a point, while Jung regards it as a continuum (from
health to sickness).
In a way, Heinz Kohut took Jung a step further. He said that pathological narcissism
is not the result of excessive narcissism, libido or aggression. It is the result of
defective, deformed or incomplete narcissistic (self) structures. Kohut postulated the
existence of core constructs which he named: the Grandiose Exhibitionistic Self and
the Idealized Parent Image.
Children entertain notions of greatness (primitive or naive grandiosity) mingled with
magical thinking, feelings of omnipotence and omniscience and a belief in their immunity
to the consequences of their actions. These elements and the child’s feelings regarding
its parents combine and form these constructs. The child’s feelings towards its
parents are reactions to their responses (affirmation, buffering, modulation or
disapproval, punishment, even abuse). These responses help maintain the self structures.
Without the appropriate responses, grandiosity, for instance, cannot be transformed
into adult ambitions and ideals. To Kohut, grandiosity and idealisation were positive
childhood development mechanisms. Even their reappearance in transference should
not be considered a pathological narcissistic regression.
Kohut agreed with Freud that neuroses are conglomerates of defence mechanisms,
formations, symptoms, and unconscious conflicts. He even accepted the unresolved
Oedipal conflicts (ungratified unconscious wishes and their objects) as the root of
neuroses. But he identified a whole new class of disorders: the self-disorders. These
were the result of the perturbed development of narcissism.
It was not a superficial distinction. Self disorders were the results of childhood
traumas quite different from Freud’s Oedipal, castration and other conflicts and
fears. These are the traumas of the child either not being seen (an existence, not
affirmed by the Primary Objects, that is the parents) or being regarded as an object
for gratification or abuse. Such children develop to become adults who are not sure
that they do exist (lack a sense of self continuity) or that they are worth anything
(lack of self worth, or self esteem). They suffer depressions, as neurotics do. But the
source of these depressions is existential (a gnawing sensation of emptiness) as
opposed to the “guilty-conscious” depressions of neurotics.
They are individuals whose disorders can be understood and treated only by taking
into consideration the formative experiences in childhood of the total body mind self
and its self object environment as for instance, the experiences of joy of the total self
21
Personality Disorders feeling confirmed, which leads to pride, self esteem, zest, and initiative; or the
experiences of shame, loss of vitality, deadness, and depression of the self who does
not have the feeling of being included, welcomed, and enjoyed.”
This is not to say that they do not change - rather, that they are capable only of slow
change. Kohut and his Self-psychology disciples believed that the only viable
constructs are comprised of self-selfobject experiences and that these structures are
lifelong ones. Melanie Klein belived more in archaic drives, splitting defenses and
archaic internal objects and part objects. Winnicott (and Balint and other, mainly
British researchers) as well as other ego-psychologists thought that only infantile
drive wishes and hallucinated oneness with archaic objects qualify as structures.
Narcissism. Karen Horney’s Contributions
Horney is one of the precursors of the “Object Relations” school of psychodynamics.
She said that personality was shaped mostly by environmental issues, social or
cultural. She believed that relationships with other humans in one’s childhood determine
both the shape and functioning of one’s personality. She expanded the psychoanalytic
repertoire. She added needs to drives. Where Freud believed in the exclusivity of
the sex drive as an agent of transformation, Horney believed that people (children)
needed to feel secure, to be loved, protected, emotionally nourished and so on. She
believed that the satisfaction of these needs or their frustration early in chlildhood
were as important a determinant as any drive. Society was introduced through the
parental door. Biology converged with social injunction to yield human values such
as the nurturance of children.
Horney’s great contribution was the concept of anxiety. Freudian anxiety was a
rather primitive mechanism, a reaction to imaginary threats arising from early childhood
sexual conflicts. Horney argued convincingly that anxiety is a primary reaction to the
very dependence of the child on adults for its survival. Children are uncertain (of
love, protection, nourishment, nurturance) and so they become anxious.
Defenses are developed to compensate for the intolerable and gradual realisation that
dults are human. They are capricious, arbitrary, unpredictable and non dependable.
Defenses provide both satisfaction and a sense of security. The problem still exists,
even as the anxiety does, but they are “one stage removed”. When the defenses are
attacked or perceived to be attacked (such as in therapy) anxiety is reawakened.
The capacity to be alone develops out of the baby’s ability to hold onto the
internalisation of his mother, even during her absences. It is not just an image of
mother that he retains but also her loving devotion to him. Thus, when alone, he can
feel confident and secure as he continues to infuse himself with her love. The addict
has had so few loving attachments in his life that when alone he is returned to his
detached, alienated self.
This feeling state can be compared to a young child’s fear of monsters without a
powerful other to help him, the monsters continue to live somewhere within the child
or his environment. It is not uncommon for patients to be found on either side of an
attachment pendulum. It is invariably easier to handle patients for whom the
transference erupts in the idealising attachment phase than those who view the therapist
as a powerful and distrusted intruder.
So, the child learns to sacrifice a part of his autonomy, in order to feel secure.
Horney identified three neurotic strategies: submission, aggression and detachment.
The choice of strategy determines the type of personality, or rather of neurotic
22
personality. The submissive (or compliant) type is fake. He hides aggression beneath Narcissistic Personaity
Disorder
the facade of friendliness. The aggressive type is fake as well: at heart he is submissive.
The detached neurotic withdraws from people. This cannot be considered an adaptive
strategy.
Horney’s is an optimistic outlook. Because she believes biology is only one of the
forces shaping our adulthood, and culture and society being the predominant ones,
she believes in reversibility and in the power of insight to heal. She believes that if
an adult were to understand his problem (his anxiety) he would be able to eliminate
it altogether. Other theoreticians are much more pessimistic and deterministic.
They think that childhood trauma and abuse are rather impossible to reprogramme,
let alone erase. Modern brain research tends both to support this view and offer
some solution. The brain seems to be plastic. It is physically impressed with abuse
and trauma. But no one knows when this “window of plasticity” shuts. It is conceivable
that this plasticity continues well into adulthood and that later “reprogramming” (by
loving, caring, compassionate and empathic experiences) can remold the brain
permanently. Yet others believe that the patient has to accept his disorder as a given
and work AROUND it rather than attack it directly.
Our disorders were adaptive and helped us to function. Their removal may not
always be wise or necessary to attain a full and satisfactory life. additionally, we
should not all conform to a mold and experience life the same. Idiosyncracies are a
good thing, both on the individual level and on the level of the species. The word
“narcissism” comes from a Greek mythology in which a handsome young man named
Narcissus sees his reflection in a pool of water and falls in love with it. Psychoanalysts,
including Sigmund Freud, used the term narcissistic to describe people who show an
exaggerated sense of self-importance and are preoccupied with receiving attention
(Cooper & Ronningstam, 1992). Narcissistic personality disorder is one of a group
of conditions called dramatic personality disorder. People with these disorders have
intense, unstable emotions and a distorted self-image. Narcissistic personality disorder
is further characterised by an abnormal love of self, an exaggerated sense of superiority
and importance, and a preoccupation with success and power. However, these
attitudes and behaviours do not reflect true self-confidence. Instead, the attitudes
conceal a deep sense of insecurity and a fragile self-esteem. Some of the common
traits of a narcissistic type person are:
 An inability to listen to others, and
 A lack of awareness of another person’s deadlines, time frames, or interests.
 An inability to admit wrongdoing, even sometimes when presented with evidence
of their ‘wrong’ behaviour.
 Coldness or overly practical responses to interpersonal relationships,
 A sense of distance or matter of factness emotionally.
 Can be prone to severe bouts of anger.
 Has the ability to write friends off forever, over one perceived or actual
transgression.
 Pride in the accomplishments of children if they have them, often combined with
an overly developed desire for control over their directions and activities.
 An above average interest in social class and importance may be seen. 23
Personality Disorders It should be noted that narcissistic personality disorder exists as a diagnostic category
only in DSM-IV-TR, which is an American diagnostic manual. The International
Statistical Classification of Diseases and Related Health Problems, Tenth
Revision (ICD-10, the European equivalent of DSM) lists only eight personality
disorders. What DSM-IV-TR defines as narcissistic personality disorder, ICD-10 lumps
together with “eccentric, impulsive-type, immature, passive-aggressive, and
psychoneurotic personality disorders.”
Narcissistic personality disorder was introduced as a new diagnostic category in DSM-
III, which was published in 1980. Prior to DSM-II, narcissism was a recognised
phenomenon but not an official diagnosis.
At that time, narcissistic personality disorder was considered virtually untreatable
because people who suffer from it rarely enter or remain in treatment. Typically, they
regard themselves as superior to their therapist, and they see their problems as
caused by other people’s “stupidity” or “lack of appreciation.”
More recently, however, some psychiatrists have proposed dividing narcissistic patients
into two subcategories based roughly on age:
i) those who suffer from the stable form of narcissistic personality disorder described
by DSM-IV-TR, and
ii) younger adults whose narcissism is often corrected by life experiences.
This age group distinction represents an ongoing controversy about the nature of
narcissistic personality disorder whether it is fundamentally a character disorder, or
whether it is a matter of learned behaviour that can be unlearned. Therapists who
incline toward the first viewpoint usually pessimistic about the results of treatment for
patients with narcissistic personality disorder.

2.2.1 Diagnostic Features of Narcissistic Personality

Disorder
DSM-IV-TR specifies nine diagnostic criteria for narcissistic personality disorder. For
the clinician to make the diagnosis, an individual must fit five or more of the following
descriptions:
 He or she has a grandiose sense of self-importance (exaggerates accomplishments
and demands to be considered superior without real evidence of achievement).
 He or she lives in a dream world of exceptional success, power, beauty, genius,
or “perfect” love.
 He or she thinks of him or herself as “special” or privileged,
 He or she can only be understood by other special or high status people.
 He or she demands excessive amounts of praise or admiration from others.
 He or she feels entitled to automatic deference, compliance, or favourable
treatment from others.
 He or she is exploitative towards others and takes advantage of them.
 He or she lacks empathy and does not recognise or identify with others’ feelings.
 He or she is frequently envious of others or thinks that they are envious of him
24 or her.
 He or she “has an attitude” or frequently acts in haughty or arrogant ways. Narcissistic Personaity
Disorder
In addition to these criteria, DSM-IV-TR groups narcissistic personality disorder
together with three other personality disorders in Cluster B. These four disorders are
grouped together on the basis of symptom similarities, insofar as patients with these
disorders appear to others as overly emotional, unstable, or self dramatising.
The other three disorders in Cluster B are antisocial, borderline, and histrionic
personality disorders.
The DSM-IV-TR clustering system does not mean that all patients can be fitted neatly
into one of the three clusters. It is possible for patients to have symptoms of more
than one personality disorder or to have symptoms from different clusters. In addition,
patients diagnosed with any personality disorder may also meet the criteria for mood,
substance abuse, or other disorders.
People with narcissistic personality disorder have an unreasonable sense of self-
importance and are so preoccupied with themselves that they lack sensitivity and
compassion for other people (Gunderson, Ronningstam, & Smith, 1995). They are
not comfortable unless someone is admiring them. Their exaggerated feelings and
their fantasies of greatness, called “grandiosity” create a number of negative attributes.
They require and expect a great deal of special attention. They also tend to use or
exploit others for their own interests and show little empathy. When confronted with
other successful people, they can be extremely envious and arrogant. Thus narcissistic
personality disorder involves a pattern of self-centered or egotistical behaviour that
shows up in thinking and behaviour in a lot of different situations and activities.
People with narcissistic personality disorder would not (or can not) change their
behaviour even when it causes problems at work or when other people complain
about the way they act, or when their behaviour causes a lot of emotional distress
to others (or themselves). This pattern of self-centered or egotistical behaviour is not
caused by current drug or alcohol use, head injury, acute psychotic episodes, or any
other illness, but has been going on steadily at least since adolescence or early
adulthood.

2.2.2 Subtypes of Narcissistic Personality Disorder

Millon (1996) identified five subtypes of narcissist. Any individual narcissist may
exhibit none or one of the following:
i) Unprincipled narcissist including antisocial features: Such an Unprincipled
narcissist will be fraudulent, exploitative, deceptive and unscrupulous individual.
ii) Amorous narcissist including histrionic features: Such an Amorous narcissist
will be an erotic, exhibitionist.
iii) Compensatory narcissist: This includes negativistic (passive-aggressive),
avoidant features.
iv) Elitist narcissist: This is a variant of pure pattern. Corresponds to “phallic
narcissistic” personality type.
v) Fanatic type including paranoid features: A severely narcissistic individual,
usually with major paranoid tendencies and who holds onto an illusion of
omnipotence.
Some have suggested the following subcategories of narcissistic personalities:
25
Personality Disorders i) Craving narcissists: These are people who feel emotionally needy and
undernourished, and may well appear clingy or demanding to those around
them.
ii) Paranoid narcissists: This type of narcissist feels intense contempt for him- or
herself, but projects it outward onto others. Paranoid narcissists frequently drive
other people away from them by hypercritical and jealous comments and
behaviours.
iii) Manipulative narcissists: These people enjoy “putting something over” on
others, obtaining their feelings of superiority by lying to and manipulating them.
iv) Phallic narcissists: Almost all narcissists in this subgroup are male. They tend
to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies,
clothes, and overall “manliness.”
DSM-IV-TR states that 2% to 16% of the clinical population and slightly less than
1% of the general population of the United States suffers from narcissistic personality
disorder. Between 50% and 75% of those diagnosed with narcissistic personality
disorder are males. Little is known about the prevalence of narcissistic personality
disorder across racial and ethnic groups. Like most personality disorders, narcissistic
personality disorder typically will decrease in intensity with age, with many people
experiencing few of the most extreme symptoms by the time they are in the 40s or
50s.
Narcissistic personality disorder is more prevalent in males than females. The high
preponderance of male patients in studies of narcissism has prompted researchers to
explore the effects of gender roles on this particular personality disorder. Some have
speculated that the gender imbalance in narcissistic personality disorder results from
society’s disapproval of self centered and exploitative behaviour in women, who are
typically socialised to nurture, please, and generally focus their attention on others.
Some are of the view that the imbalance is more apparent than real, and that it
reflects a basically sexist definition of narcissism. Like most personality disorders,
narcissistic personality disorder typically will decrease in intensity with age, with
many people experiencing few of the most extreme symptoms by the time they are
in the 40s or 50s.

2.2.3 Causes of Narcissistic Personality Disorder

While the exact cause of narcissistic personality disorder is unknown, researchers
have identified some factors that may contribute to the disorder. Childhood experiences
such as parental overindulgence, excessive praise, unreliable parenting, and a lack of
realistic responses are thought to contribute to narcissistic personality disorder.
Although researchers today do not know what exactly causes narcissistic personality
disorder, there are many theories, however, about the possible causes of narcissistic
personality disorder.
For example, Kohut (1977) and Kernberg (1984) attempted to trace the roots of
narcissistic personality disorder to disturbances in the patient’s family of origin
specifically, to problems in the parent child relationship before the child turned three.
Where they disagree is in their accounts of the nature of these problems. According
to Kohut (1977), the child grows out of primary narcissism through opportunities to
be mirrored by (i.e., gain approval from) his or her parents and to idealise them,
26
acquiring a more realistic sense of self and a set of personal ideals and values through Narcissistic Personaity
Disorder
these two processes.
On the other hand, if the parents fail to provide appropriate opportunities for idealisation
and mirroring, the child remains “stuck” at a developmental stage in which his or her
sense of self remains grandiose and unrealistic while at the same time he or she
remains dependent on approval from others for self-esteem.
In contrast, Kernberg (1985) views narcissistic personality disorder as rooted in the
child’s defense against a cold and unempathetic parent, usually the mother.
Emotionally hungry and angry at the depriving parents, the child withdraws into a part
of the self that the parents value, whether looks, intellectual ability, or some other skill
or talent. This part of the self becomes hyper-inflated and grandiose.
Any perceived weaknesses are “split off” into a hidden part of the self. Splitting gives
rise to a lifelong tendency to swing between extremes of grandiosity and feelings of
emptiness and worthlessness. In both accounts, the child emerges into adult life with
a history of unsatisfactory relationships with others.
The adult narcissist possesses a grandiose view of the self but has a conflict-ridden
psychological dependence on others. At present, however, psychiatrists do not agree
in their description of the central defect in narcissistic personality disorder; some
think that the problem is primarily emotional while others regard it as the result of
distorted cognition, or knowing.
Other theorists maintain that the person with narcissistic personality disorder has an
“empty” or hungry sense of self while others argue that the narcissist has a
“disorganised” self. Still others regard the core problem as the narcissist’s inability to
test reality and construct an accurate view of him- or herself.
According to sociologist Lasch (1978) narcissistic personality disorder is increasing
in prevalence, primarily as a consequence of large scale social changes, including
greater emphasis on short-term hedonism, individualism, competitiveness, and success.
He further stated that the “me-generation” has produced more than its share of
individuals with narcissistic personality disorder. Indeed reports confirm that narcissistic
personality disorder is increasing in prevalence (Cooper & Ronningstam, 1992).
Some other theorists believe that narcissistic personality disorder results from extremes
in child rearing. For example, the disorder might develop as the result of excessive
pampering, or when a child’s parents have a need for their children to be talented
or special in order to maintain their own self-esteem. On the other end of the
spectrum, narcissistic personality disorder might develop as the result of neglect or
abuse and trauma inflicted by parents or other authority figures during childhood. The
disorder usually is evident by early adulthood.
Some other theorists subscribe a bio psychosocial model of causation that is, the
causes which are biological and genetic in nature, the social factors (such as how a
person interacts in their early development with their family and friends and other
children), and psychological factors (the individual’s personality and temperament,
shaped by their environment and learned coping skills to deal with stress).
This suggests that no single factor is responsible rather, it is the complex and likely
intertwined nature of all three factors that are important. If a person has this personality
disorder, research suggests that there is a slightly increased risk for this disorder to
be “passed down” to their children. 27
Personality Disorders 2.2.4 Treatment of Narcissistic Personality Disorder
It is important to note that people with this disorder rarely seek out treatment.
Individuals often begin therapy at the urging of family members or to treat symptoms
that result from the disorder. So the therapy for the persons suffering from narcissistic
personality disorder can be especially difficult because they are often unwilling to
acknowledge the disorder. In addition, the tendency of these patients to criticize and
devalue their therapists (as well as other authority figures) makes it difficult for
therapists to work with them.
Narcissistic personality disorder treatment is centered around psychotherapy. There
are no medications specifically used to treat narcissistic personality disorder. However,
if the person has symptoms of depression, anxiety or other conditions, medications
such as antidepressants or anti-anxiety medications may be helpful.
Psychotherapy helps the person learn to relate to others in a more positive and
rewarding way. Psychotherapy tries to provide the person with greater insight into
his or her problems and attitudes in the hope that this will change behaviour.
The goal of therapy is to help the person develop a better self-esteem and more
realistic expectations of others. Medication might be used to treat the distressing
symptoms, such as behavioural problems, that might occur with this disorder.
Several different approaches to individual therapy have been tried with narcissistic
personality disorder patients, ranging from classical psychoanalysis and Adlerian therapy
to rational emotive approaches and Gestalt therapy. The consensus that has emerged
is that therapists should set modest goals for treatment with narcissistic personality
disorder patients. Most of them cannot form a sufficiently deep bond with a therapist
to allow healing of early childhood injuries. Other forms of psychotherapy that may
be helpful for narcissistic personality disorder include:
i) Cognitive behavioural therapy: Cognitive behavioural techniques are often
effective to help individuals change destructive thinking and behaviour patterns.
The goal of treatment is to alter distorted thoughts and create a more realistic
self-image. In general, cognitive behavioural therapy helps to identify unhealthy,
negative beliefs and behaviours and replace them with healthy, positive ones.
ii) Family therapy: It is a type of group therapy in which the members of the
family of the patient all participate in group treatment sessions. The basic idea
is that the family, not just the individual patient has to alter behaviour to solve
the problem. By bringing the whole family together in therapy sessions, joint
efforts by all family members are made to explore conflicts. Communication
among family members and problem solving help cope with relationship problems.
iii) Group therapy: Group therapy, in which client meets with a group of people
with similar conditions, may be helpful by teaching him to relate better with
others. This may be good for the client to learn about truly listening to others,
learning about their feelings and offering support.
The goals are to help the patient develop a healthy individuality (rather than a resilient
narcissism) so that he or she can acknowledge others as separate persons, and to
decrease the need for self defeating coping mechanisms.
The first step toward developing a working alliance is empathy with the surprise and
hurt that the patient experiences as a result of confrontations within the group. The
external structuring that the group therapy provides can control destructive behaviour
28 in spite of ego weakness.
In groups, Narcissistic Personaity
Disorder
a) the therapist is less authoritative (and less threatening to the patient’s grandiosity);
b) intensity of emotional experience is lessened and
c) regression is more controlled,
d) create a better setting for confrontation and clarification.
Because personality traits can be difficult to change, therapy may take several years.
The short-term goal of psychotherapy for narcissistic personality disorder is to address
such issues as substance abuse, depression, low self-esteem or shame. The long-
term goal is to reshape the personality, at least to some degree, so that the person
can change patterns of thinking that distort his self-image and create a realistic self-
image.
Psychotherapy can also help the person to learn to relate better with others so that
his relationships are more intimate, enjoyable and rewarding. It can help the person
to understand the causes of his emotions and what drives him to compete, to distrust
others and perhaps to despise himself and others.
Narcissistic patients generally enjoy the attention they receive through involvement in
the treatment. Long-term outpatient involvement is critical to maintain a narcissistic
patient’s pro-social behaviour and sobriety. Therapists who strive to build narcissistic
patients’ strengths and who pay close attention to them in therapy will find them
active participants in the recovery process.

2.2.5 Prognosis
The prognosis for younger persons with narcissistic disorders is hopeful to the extent
that the disturbances reflect a simple lack of life experience. The outlook for long
standing narcissistic personality disorder, however, is largely negative.
Some narcissists are able, particularly as they approach their midlife years, to accept
their own limitations and those of others, to resolve their problems with envy, and
to accept their own mortality.
Most patients with narcissistic personality disorder, on the other hand, become
increasingly depressed as they grow older within a youth-oriented culture and lose
their looks and overall vitality.
The retirement years are especially painful for patients with narcissistic personality
disorder because they must yield their positions in the working world to the next
generation.
In addition, they do not have the network of intimate family ties and friendships that
sustain older people

2.3 LET US SUM UP

The word “narcissism” comes from a Greek mythology in which a handsome young
man named Narcissus sees his reflection in a pool of water and falls in love with it.
The term narcissistic is used to describe people who show an exaggerated sense of
self-importance and are preoccupied with receiving attention.
Narcissistic personality disorder is characterised by an abnormal love of self, an
exaggerated sense of superiority and importance, and a preoccupation with success
and power. 29
Personality Disorders Narcissistic personality disorder exists as a diagnostic category only in DSM-IV-TR.
DSM-IV-TR specifies nine diagnostic criteria for narcissistic personality disorder.
For the clinician to make the diagnosis, an individual must fit five or more of the
following descriptions:
A grandiose sense of self-importance (exaggerates accomplishments and demands to
be considered superior without real evidence of achievement).
He or she lives in a dream world of exceptional success, power, beauty, genius, or
“perfect” love.
He or she thinks of him- or herself as “special” or privileged.
He or she demands excessive amounts of praise or admiration from others.
He or she feels entitled to automatic deference, compliance, or favourable treatment
from others.
He or she is exploitative towards others and takes advantage of them.
He or she lacks empathy and does not recognise or identify with others’ feelings.
He or she is frequently envious of others or thinks that they are envious of him or
her.
He or she “has an attitude” or frequently acts in haughty or arrogant ways.
The exact cause of narcissistic personality disorder is unknown.
Researchers have identified some factors that may contribute to this disorder.
Childhood experiences such as parental overindulgence, excessive praise, unreliable
parenting, and a lack of realistic responses are thought to contribute to narcissistic
personality disorder.
Although researchers today do not know what exactly causes narcissistic personality
disorder, there are many theories, however, about the possible causes of narcissistic
personality disorder.
For example, Kohut (1977) and Kernberg (1984) attempted to trace the roots of
narcissistic personality disorder to disturbances in the patient’s family of origin.
Specifically, to problems in the parent-child relationship before the child turned three.
At present, however, psychiatrists do not agree in their description of the central
defect in narcissistic personality disorder.
Some think that the problem is primarily emotional while others regard it as the result
of distorted cognition, or knowing.
Some maintain that the person with narcissistic personality disorder has an “empty”
or hungry sense of self while others argue that the narcissist has a “disorganised” self.
Still others regard the core problem as the narcissist’s inability to test reality and
construct an accurate view of him- or herself.
Some other theorists believe that narcissistic personality disorder results from extremes
in child rearing.
Some other theorists subscribe a bio-psychosocial model of causation - that is, the
causes of are likely due to biological and genetic factors, social factors (such as how
30
a person interacts in their early development with their family and friends and other Narcissistic Personaity
Disorder
children), and psychological factors (the individual’s personality and temperament,
shaped by their environment and learned coping skills to deal with stress.
People with this disorder rarely seek out treatment. Individuals often begin therapy
at the urging of family members or to treat symptoms that result from the disorder.
So the therapy for the persons suffering from narcissistic personality disorder can be
especially difficult because they are often unwilling to acknowledge the disorder. In
addition, the tendency of these patients to criticize and devalue their therapists (as
well as other authority figures) makes it difficult for therapists to work with them.
Narcissistic personality disorder treatment is centered around psychotherapy. There
are no medications specifically used to treat narcissistic personality disorder. Several
different approaches to individual therapy have been tried with narcissistic personality
disorder patients, ranging from classical psychoanalysis and Adlerian therapy to
Rational-Emotive approaches and Gestalt therapy. Other forms of psychotherapy
that may be helpful for narcissistic personality disorder include cognitive behavioural
therapy, family therapy, and group therapy.
Goal of Therapy in Narcissistic Personality Disorder
Because personality traits can be difficult to change, therapy may take several years.
The short-term goal of psychotherapy for narcissistic personality disorder is to address
such issues as substance abuse, depression, low self-esteem or shame.
The long-term goal is to reshape your personality, at least to some degree, so that
you can change patterns of thinking that distort your self-image and create a realistic
self-image.
The prognosis for younger persons with narcissistic disorders is hopeful to the extent
that the disturbances reflect a simple lack of life experience.
The outlook for long standing narcissistic personality disorder, however, is largely
negative.
Some narcissists are able, particularly as they approach their midlife years, to accept
their own limitations and those of others, to resolve their problems with envy, and
to accept their own mortality.

2.4 UNIT END QUESTIONS

1) Prepare a clinical picture of narcissistic personality disorder.
2) How does narcissistic personality disorder differ from borderline personality
disorder?
3) Discuss the diagnostic features of narcissistic personality disorder.
4) Discuss the causes of narcissistic personality disorder.
5) Explain the treatment and prognosis of narcissistic personality disorder.

2.5 GLOSSARY
Cognitive-behavioural therapy : Group of treatment procedures aimed at
identifying and modifying faulty thought
processes, attitudes and attributions, and
problem behaviours. 31
Personality Disorders Craving narcissists : These are people who feel emotionally needy
and undernourished, and may well appear clingy
or demanding to those around them.
Empathy : Ability to understand and to some extent share
the feelings and emotions of another person.
Gestalt therapy : Type of therapy emphasising wholeness of the
person and integration of thought, feeling, and
action.
Manipulative narcissists : These people enjoy “putting something over”
on others, obtaining their feelings of superiority
by lying to and manipulating them.
Narcissistic personality : Personality disorder involving a pervasive
disorder pattern of grandiosity need for admiration, and
a lack of empathy.
Paranoid narcissists : This type of narcissist feels intense contempt
for him or herself, but projects it outward onto
others. Paranoid narcissists frequently drive
other people away from them by hypercritical
and jealous comments and behaviours.
Passive aggressive : Personality disorder characterised by a pattern
personality disorder of negative attitudes and passive resistance in
interpersonal situations.
Personality disorders : Characterised by enduring maladaptive patterns
for relating to the environment and oneself,
exhibited in a wide range of contexts that cause
significant functional impairment or subjective
distress.
Psychoanalysis : Method used by Freud to study and treat
patients.
Psychotherapy : Treatment of mental disorders by psychological
methods.
Phallic narcissists : Phallic narcissists tend to be aggressive, athletic,
and exhibitionistic; they enjoy showing off their
bodies, clothes, and overall “manliness.”
Rational-Emotive therapy : A cognitive-behavioural approach that seeks to
identify and eliminate irrational beliefs that may
cause maladaptive behaviours.

2.6 SUGGESTED READINGS

Carson, R., Butcher, J.N., & Mineka, S. (2005). Abnormal Psychology and Modern
Life (3rd Indian reprint). Pearson Education (Singapoer).
Durand, V. K. & Barlow, D. H. (2000). Abnormal Psychology: An Introduction.
Stamford: Thomson Learning.
32
Sarason, I.G. Sarason, B.R. (1996). Abnormal Psychology: The Problem of Narcissistic Personaity
Disorder
Maladaptive Behaviour. New Jersey: Prentice Hall Inc.
References
American Psychiatric Association (1980). Diagnostic and Statistical Manual of
Mental Disorders. 3rd edition. Washington, DC: American Psychiatric Association.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of
Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric
Association.
Cooper, A.M. & Ronningstam, E. (1992). Narcissistic personality disorder. In A.
Tasman & M. B. Riba (Eds.) Review of Psychiatry (Vol.11, pp. 80-97). Washington,
DC: Psychiatric Press.
Gunderson, J. G., and Ronningstam, E. (2001). Differentiating narcissistic and
Antisocial Personality Disorders. Journal of Personality Disorders, 15, 103-109.
Gunderson, J. G., and Ronningstam, E. & Smith, L. E. (195) Narcissistic personality
disorder. In W. J. Livesley (Ed.), The DSM-IV personality disorders (pp. 201-
212). New York : Guilford Press.
Kernberg, O. E. (1984). Severe personality disorders. New Haven, CT: Yale
University Press.
Kohut, H. (1977). The restoration of the self. New York: International University
Press.
Lasch, C. (1978). The culture of narcissism: American life in an age of diminishing
expectations. New York: W. W. Norton.
Millon, T. (1996). Disorders of Personality: DSM-IV-TM and Beyond. New York:
John Wiley and Sons. p. 393.
World Health Organisation (1992). ICD- 10 classification of mental and behaviour
disorders: Clinical descriptions and diagnostic guidelines. Geneva.

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