Narcissistic personality disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis
- Eve Caligor, MD
Eve Caligor, MD
- Clinical Professor of Psychiatry
- Columbia University College of Physicians and Surgeons
- Mark J Petrini, MD
Mark J Petrini, MD
- Assistant Clinical Professor of Medicine and Psychiatry
- Columbia University Medical Center
Grandiosity, which may be overt or covert, need for attention and admiration, superficial interpersonal relationships, and a lack of empathy are central features of narcissistic personality disorder (NPD) . Additional features of the disorder have a variable presentation, contributing to disagreement over the disorder’s boundaries and diagnostic criteria.
DSM-5 focuses on a more aggressive, grandiose subtype of NPD, while an alternative model, which we favor, describes additional subtypes – a healthier, high-functioning type and a vulnerable, introverted type – and places greater emphasis on problems with self-definition, self-esteem regulation, and affective reactivity.
NPD is one of the least studied personality disorders. It appears to be prevalent, highly comorbid with other psychiatric disorders, and associated with significant psychosocial disability. NPD is difficult to treat, and can complicate the treatment of co-occurring disorders.
The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of NPD are reviewed here. Treatment of narcissistic personality disorder is described separately. The epidemiology, clinical manifestations, assessment, and diagnosis of other personality disorders are also described separately. (See "Treatment of narcissistic personality disorder" and "Personality disorders" and "Borderline personality disorder: Epidemiology, clinical features, course, assessment, and diagnosis" and "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis".)
The prevalence and sociodemographic features of narcissistic personality disorder (NPD) are poorly defined, in part because of evolving diagnostic criteria.
- Caligor E, Levy KN, Yeomans FE. Narcissistic personality disorder: diagnostic and clinical challenges. Am J Psychiatry 2015; 172:415.
- Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 2001; 58:590.
- Stinson FS, Dawson DA, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2008; 69:1033.
- Hasin DS, Grant BF. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1609.
- Levy KN, Chauhan P, Clarkin JF, et al. Narcissistic pathology: empirical approaches. Psychiatr Ann 2009; 39:203.
- Kernberg OF. The narcissistic personality disorder and the differential diagnosis of antisocial behavior. Psychiatr Clin North Am 1989; 12:553.
- Gunderson JG, Ronningstam E. Differentiating narcissistic and antisocial personality disorders. J Pers Disord 2001; 15:103.
- Torgersen S, Lygren S, Oien PA, et al. A twin study of personality disorders. Compr Psychiatry 2000; 41:416.
- Blasco-Fontecilla H, Baca-Garcia E, Dervic K, et al. Specific features of suicidal behavior in patients with narcissistic personality disorder. J Clin Psychiatry 2009; 70:1583.
- Jang KL, Livesley WJ, Vernon PA, Jackson DN. Heritability of personality disorder traits: a twin study. Acta Psychiatr Scand 1996; 94:438.
- Livesley WJ, Jang KL, Jackson DN, Vernon PA. Genetic and environmental contributions to dimensions of personality disorder. Am J Psychiatry 1993; 150:1826.
- Lamm C, Decety J, Singer T. Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain. Neuroimage 2011; 54:2492.
- Fan Y, Wonneberger C, Enzi B, et al. The narcissistic self and its psychological and neural correlates: an exploratory fMRI study. Psychol Med 2011; 41:1641.
- Schulze L, Dziobek I, Vater A, et al. Gray matter abnormalities in patients with narcissistic personality disorder. J Psychiatr Res 2013; 47:1363.
- Horton RS. Parenting as a cause of narcissism: Empirical Support for Psychodynamic and Social Learning Theories. In: The Handbook of Narcissism and Narcissistic Personality Disorder, Campbell WK, Miller JD (Eds), Wiley, Hoboken 2011. p.181.
- Kohut H. The Restoration of Self, International Universities Press, Madison 1977.
- Kernberg OF. Borderline Conditions and Pathological Narcissism, Jason Aaronson, New York 1975.
- Fonagy P, Gergely G, Jurist EL, Target M. Affect Regulation, Mentalization, and the Development of the Self, Other Press, New York 2003.
- Cohen LJ, Tanis T, Bhattacharjee R, et al. Are there differential relationships between different types of childhood maltreatment and different types of adult personality pathology? Psychiatry Res 2014; 215:192.
- Afifi TO, Mather A, Boman J, et al. Childhood adversity and personality disorders: results from a nationally representative population-based study. J Psychiatr Res 2011; 45:814.
- Hoglund C. Narcissistic features, shame, anger and gender differences in adults exposed to emotionally abusive family environments. Diss Abstr Int 1997; 57:7.
- Ronningstam E. Beyond the diagnostic traits: a collaborative exploratory diagnostic process for dimensions and underpinnings of narcissistic personality disorder. Personal Disord 2014; 5:434.
- Baskin-Sommers A, Krusemark E, Ronningstam E. Empathy in narcissistic personality disorder: from clinical and empirical perspectives. Personal Disord 2014; 5:323.
- Ogrodniczuk JS, Piper WE, Joyce AS, et al. Interpersonal problems associated with narcissism among psychiatric outpatients. J Psychiatr Res 2009; 43:837.
- Lavner JA, Lamkin J, Miller JD, et al. Narcissism and newlywed marriage: Partner characteristics and marital trajectories. Personal Disord 2016; 7:169.
- Zondag HJ. Narcissism and boredom revisited: an exploration of correlates of overt and covert narcissism among Dutch university students. Psychol Rep 2013; 112:563.
- Russ E, Shedler J, Bradley R, Westen D. Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry 2008; 165:1473.
- Levy KN. Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder. J Clin Psychol 2012; 68:886.
- Cain NM, Pincus AL, Ansell EB. Narcissism at the crossroads: phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clin Psychol Rev 2008; 28:638.
- Gore WL, Widiger TA. Fluctuation between grandiose and vulnerable narcissism. Personal Disord 2016; 7:363.
- Pincus AL, Ansell EB, Pimentel CA, et al. Initial construction and validation of the Pathological Narcissism Inventory. Psychol Assess 2009; 21:365.
- Miller JD, Widiger TA, Campbell WK. Narcissistic personality disorder and the DSM-V. J Abnorm Psychol 2010; 119:640.
- Heisel MJ, Links PS, Conn D, et al. Narcissistic personality and vulnerability to late-life suicidality. Am J Geriatr Psychiatry 2007; 15:734.
- Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Pers Disord 2005; 19:487.
- Ansell EB, Wright AG, Markowitz JC, et al. Personality disorder risk factors for suicide attempts over 10 years of follow-up. Personal Disord 2015; 6:161.
- Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry 2004; 4:37.
- Gunderson JG, Ronningstam E, Bodkin A. The diagnostic interview for narcissistic patients. Arch Gen Psychiatry 1990; 47:676.
- Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. Am J Psychiatry 1995; 152:253.
- Vater A, Ritter K, Strunz S, et al. Stability of narcissistic personality disorder: tracking categorical and dimensional rating systems over a two-year period. Personal Disord 2014; 5:305.
- Pincus AL, Cain NM, Wright AG. Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personal Disord 2014; 5:439.
- Stangl D, Pfohl B, Zimmerman M, et al. A structured interview for the DSM-III personality disorders. A preliminary report. Arch Gen Psychiatry 1985; 42:591.
- First MB, Gibbon M, Spitzer RL, et al. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), 1st ed, American Psychiatric Press, Washington DC 1997.
- Loranger AW. International Personality Disorder Examination (IPDE): DSM-IV and ICD-10 Modules, Cambridge University Press, New York 1999.
- Miller JD, Campbell WK, Pilkonis PA, Morse JQ. Assessment procedures for narcissistic personality disorder: a comparison of the personality diagnostic questionnaire-4 and best-estimate clinical judgments. Assessment 2008; 15:483.
- Hopwood CJ, Donnellan MB, Ackerman RA, et al. The validity of the Personality Diagnostic Questionnaire-4 Narcissistic Personality Disorder scale for assessing pathological grandiosity. J Pers Assess 2013; 95:274.
- Raskin R, Hall CS. The Narcissistic Personality Inventory: alternative form reliability and further evidence of construct validity. J Pers Assess 1981; 45:159.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Ronningstam E. Narcissistic personality disorder in DSM-V--in support of retaining a significant diagnosis. J Pers Disord 2011; 25:248.
- First MB. The problematic DSM-5 personality disorders proposal: options for plan B. J Clin Psychiatry 2011; 72:1341.
- Skodol AE, Bender DS, Morey LC. Narcissistic personality disorder in DSM-5. Personal Disord 2014; 5:422.
- Skodol AE, Morey LC, Bender DS, Oldham JM. The Alternative DSM-5 Model for Personality Disorders: A Clinical Application. Am J Psychiatry 2015; 172:606.
- World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, World Health Organization, Geneva 2007.
- CLINICAL MANIFESTATIONS
- Core features
- - Grandiosity
- - Excessive need for admiration
- - Superficial and exploitative relationships
- - Lack of empathy
- - Identity disturbance
- - Attachment and dependence difficulties
- - Chronic emptiness and boredom
- - Life transition vulnerabilities
- - High-functioning subtype
- - Grandiose/overt subtype
- - Vulnerable/covert subtype
- Assessment instruments
- Diagnostic criteria
- - DSM-5
- - Alternative-model diagnostic criteria
- - ICD-10
- Differential diagnosis
- SUMMARY AND RECOMMENDATIONS