Narcissistic Personality Disorder (NPD) – Signs, DSM-5 Criteria and Treatment

Dr. Alexander Sidawi

Dr. Sidawi is an Orlando based, UF trained physician who is happy to be serving the community he grew up in by offering a combination of psychiatric medication management and psychodynamic psychotherapy.

Narcissistic Personality Disorder (NPD)

Narcissistic Personality Disorder is a cluster of personality traits characterized by inflated yet fragile self-esteem, perceived lack of empathy, and a need for admiration. NPD is often rooted in early life experiences, affecting self-perception and social interactions. We’ll examine the origins and symptoms of NPD from a psychodynamic viewpoint, as well as discuss DSM-5 criteria for diagnosis and treatment options.

Key Traits of NPD:

Early Childhood Experiences

From a psychodynamic standpoint, the development of NPD can often be traced back to early childhood experiences. Individuals with NPD may have experienced inconsistent or excessive admiration from caregivers, leading to the development of an inflated self-concept and sense of grandiosity. Additionally, they may have been exposed to parenting styles that failed to provide appropriate emotional attunement or empathy, hindering the development of healthy self-regulation and empathy for others.

Heinz Kohut postulated that we maintain our self esteem by oscillating between our own grandiose pole (holding ourselves in high regard) and the external idealized pole (praise by a person one looks up to). He also postulated a third pole which we rely on known as the alter-ego, where one might turn to a group they are a part of for guidance, such as a group of friends or coworkers It is postulated that while the average person oscillates between these poles, the person afflicted with narcissistic traits may have not had the adequate family support needed for the idealized pole and instead had to learn to rely heavily on the grandiose pole to maintain the self. This is postulated to cause what seems like an inflated self-esteem to the outside, while inside the person deeply struggles with insecurity and fear, to the point where any criticism may disrupt their unbalanced equilibrium.

The Narcissistic Defense Mechanism

At the core of NPD lies the use of the narcissistic defense. This defense mechanism, rooted in grandiosity, shields the individual from deep-seated feelings of inadequacy, vulnerability, and emotional pain. By adopting an inflated self-image and demanding admiration from others, individuals with NPD create a protective facade to hide their underlying insecurities.

Fragile Self-Esteem and Need for Validation

People with NPD may exhibit a need for validation and admiration. This relentless quest for external praise stems from a need for idealization, which they attempt to bolster through seeking recognition and special treatment. However, their self-worth is highly contingent on external validation, making them susceptible to feelings of worthlessness if it is not forthcoming.

Empathy Deficits and Interpersonal Challenges

One common misconceptions is that people with NPD have a lack of empathy. While at times this may be true, their inability to empathize is often rooted in the preoccupation with their own needs and self-preservation rather than the disregard of others. Consequently, individuals with NPD struggle to form deep, meaningful connections and often engage in exploitative or manipulative behaviors to meet their own desires.

Idealization and Devaluation in Relationships

In interpersonal relationships, individuals with NPD may engage in a cycle of idealization and devaluation. They might initially idolize others, attributing exaggerated positive qualities to them, but as soon as the person fails to meet their high expectations or asserts their individuality, they are devalued. This pattern can lead to tumultuous and shallow relationships.

DSM-5 Criteria for Narcissistic Personality Disorder:

NPD is defined by the DSM-5 as a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in various contexts, as indicated by five (or more) of the following:

Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
Believes that they are special and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
Requires excessive admiration.
Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with their expectations).
Is interpersonally exploitative (i.e., takes advantage of others to achieve their own ends).
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of them.
Shows arrogant, haughty behaviors or attitudes.

Treatment for Narcissistic Personality Disorder:

Treatment for NPD typically involves psychotherapy. Psychodynamic psychotherapy is particularly useful, as it helps to discover, explore, and regulate the grandiose and idealized needs at a pace that is right for the patient. From a psychodynamic perspective, it becomes evident that NPD is not merely a result of vanity or arrogance but a way to fulfill the basic human need of validation. Understanding the roots and manifestations of NPD from this perspective allows us to approach individuals with empathy and compassion, acknowledging their internal struggles while also recognizing the need for therapeutic intervention to help them develop healthier self-concepts and more authentic interpersonal relationships.