Narcissistic Personality Disorder: Clinical, Personality & Behavioural Characteristics

Just who are the narcissists in the room?

Gail Johnson, October 18, 2012, The Georgia Straight.

Alec Baldwin made headlines last year for getting kicked off an American Airlines flight. The 30 Rock star allegedly yelled and swore at flight attendants before slamming the door to the bathroom, where he went to use his iPad after repeatedly being asked not to. Baldwin later appeared on Saturday Night Live to mock the incident, which has since largely been dropped by gossip magazines and bloggers. But Jean M. Twenge sees it another way.

The professor of psychology at San Diego State University claims that Baldwin’s rudeness was more than just a simple case of celebrity hubris. Rather, she sees it as a striking example of narcissistic behaviour.

“When playing a [computer] game is more important than following FAA rules…a good deal of self-centered thinking is clearly involved,” Twenge wrote in Psychology Today in December 2011. “It’s the classic thought of a narcissist: The rules do not apply to me.”

But narcissism is hardly limited to the rich and famous. In fact, it affects about one percent of the population and anywhere from two to 16 percent of people in clinical settings, according to the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

And although a healthy dose of self-esteem can have many positive effects, an exaggerated sense of greatness can lead to severe problems in people’s personal and professional lives. According to two local mental-health experts, narcissistic personality disorder (NPD) is one of the most poorly understood psychiatric conditions and also one of the hardest to treat.

“There’s a difference between having self-confidence and putting yourself on a pedestal and believing it,” says UBC medical professor Kerry Jang in an interview at City Hall; Jang is also a city councillor. “People with NPD think they are destined for greater things, are preoccupied with power, and have to hear how wonderful and fantastic they are on a regular basis. But they can start being very abusive and belittling. They can use and abuse you.

“If they don’t hear what they want to hear, they fly into a rage or get very upset very quickly,” he adds. “But although people who have NPD are high on themselves, it’s really covering up deep anxiety.” 

David Kealy, clinical coordinator of adult short-term assessment and treatment at Fraser Health’s Mental Health and Substance Use Services, says that the term narcissism pops up frequently in common speech and popular media and is usually used incorrectly.

“It gets thrown around and misused all the time, and there are pejorative attitudes around it,” Kealy says in an interview at his UBC office, where he’s completing a PhD focusing on clinical perspectives on the treatment of NPD. “We tend not to feel sympathy for somebody who is trampling over other people. This is a very painful way to live for a lot of people.

“With respect to difficult behaviours, several have been linked to NPD: dominant, vindictive, and intrusive interpersonal patterns,” he notes. “Just the presence of the behaviour is not enough to indicate NPD; a consistent pattern, combined with other psychological features, would need to be confirmed. What we do see is that an inordinate sense of entitlement is commonly associated with NPD, a sense of being special and beyond ordinary social conventions and boundaries.”

The word narcissist comes from the Greek myth of Narcissus, a young man who fell in love with his own reflection. A modern-day version might be someone who loves staring at himself in the mirror or a person who is constantly taking pictures of herself to post on social media. Another example, according to George Washington University assistant psychiatry and behavioural-sciences professor Amir A. Afkhami, is Iranian president Mahmoud Ahmadinejad.

“Ahmadinejad’s exaggerated sense of himself as being uniquely special, unusually talented, and better qualified than other leaders on the world stage is typical of individuals struggling with narcissistic personality disorder,” Afkhami wrote in Psychology Today in September 2011.

Narcissists tend to make great first impressions; they can be charming and gregarious. But spend time in a relationship or share office space with someone who has NPD and they’ll prove to be self-centred, manipulative, demanding, cocky, and ruthless when it comes to getting what they want.

According to the Public Health Agency of Canada, there are other signs that a person has NPD. They may react to criticism with rage or humiliation; take advantage of other people to achieve their own, mainly selfish goals; expect and believe they deserve favourable treatment; need constant attention and admiration; exaggerate their skills and achievements; and disregard the feelings of others. They tend to be so self-absorbed they aren’t even genuinely aware of other people.

But perhaps the most telltale sign is a lack of empathy. 

“Narcissists do not consider the pain they inflict on others; nor do they give any credence to others’ perceptions,” writes Southlake, Texas, counsellor Les Carter in the 2005 book Enough About You, Let’s Talk About Me: How to Recognize and Manage the Narcissists in Your Life. “They simply do not care about thoughts and feelings that conflict with their own.”

Twenge puts it this way: “Do not expect them to listen, validate, understand, or support you.”

Although narcissism has evidently existed for centuries, psychological and scientific interest in the condition increased after NPD was first included in the third edition of the DSM, published in 1980. However, there has been so much controversy surrounding its definition and characteristics that identifying people with NPD can still be extremely difficult.

That’s partly because some of its traits overlap with those of other personality disorders, such as borderline personality disorder. The condition was almost pulled from the upcoming DSM-5, in fact, a proposition that was strongly opposed by many medical professionals and researchers who maintain that there’s a sufficient body of research to support it as a stand-alone condition.

“Current criteria for diagnosing NPD are felt to be inadequate,” Kealy says. “Because of diagnostic-criteria issues, formal estimates of prevalence are thought to be misleadingly low. I think probably every clinician would see it but may not necessarily recognize it.”
And although narcissism is typically associated with arrogant behaviour (called grandiose narcissism), there is another subtype called vulnerable narcissism. It’s marked by a weak self-image; feelings of anger, shame, or depression; self-criticism; and social withdrawal. 

“It’s rare to see one of those subtypes exclusively; usually it’s some combination of the two or there’s some fluctuation,” Kealy explains. “Someone could be more or less in a grandiose state much of the time and rely on arrogance and exploiting other people for their own purposes, but if they suffer some kind of blow, they may go into that vulnerable state and feel worthless, have very intense depressive feelings—sometimes suicidality.”

According to a study published in the Journal of Research in Personality last year, people who are narcissistic were likely to tell psychologists that they felt good about themselves. But when those same people were told they were hooked up to a lie detector, they admitted to having low self-esteem.

Besides NPD’s complexity, diagnosis is a challenge because people with the condition rarely seek treatment; why would they, given that they tell themselves they have no flaws? But sometimes they end up in group therapy or at a doctor’s office because someone close to them has suggested it or because of escalating anxiety or depression. 

The cause of NPD isn’t known, but genetic and environmental factors are thought to contribute to it. According to the Public Health Agency of Canada, people with personality disorders may have “impaired regulation of the brain circuits that control emotion”. The psychological and social effects of neglect, separation, or abuse may also play a role.

“Theoretically, there are difficulties or a traumatic experience, particularly in attachment relationships or an experience of abuse during one’s childhood,” Kealy says. “There’s debate about it. This is where the field gets complicated.…Some people feel it’s parents that contribute to it by being too lax with their children—being overindulgent, spoiling them. But, clinically, when we think of people with pathological narcissism presenting for treatment, that’s really not the picture we get; in fact, we see the opposite. We see serious emotional deprivation in their upbringing, so they develop very poor self-esteem. They need to rely on maladaptive ways to shore up a sense of self.”

Clinical interest in NPD continues to grow, and Jang ponders whether incidence rates will start to climb too as a result of the sense of entitlement that’s associated with the so-called Millennial generation.

“I wonder if we’ll see an increase in incidence partly due to how self-entitled society is these days,” he says. “We’re constantly telling people, ‘You’re the greatest’; everybody’s special. There’s that element of narcissism of ‘I deserve.’ For no other reason than they exist, people say ‘I deserve this.’

“In older generations, that didn’t exist. Everybody was poor and working. You knew humility.”

Then there’s the role of social media in feeding people’s egos.

A recent study established a relationship between the number of friends a person has on Facebook and the degree to which they’re a “socially disruptive” narcissist. Researchers examined grandiose exhibitionism (which includes vanity, self-absorption, and superiority) and entitlement/exploitativeness, two subscales on the Narcissistic Personality Inventory. Published earlier this year in the journal Personality and Individual Differences, the study found that those who had high scores on the Narcissistic Personality Inventory questionnaire had more “friends”, tagged themselves in photos more frequently, and updated their statuses more often than those with lower scores. 

Like other personality disorders, NPD takes a tremendous toll on people close to those affected by it. 

“It’s about being able to recognize when you’re being abused,” Jang says. “Abuse doesn’t have to be physical and it doesn’t have to be sexual; it can be a constant belittling. In virtually all relationships [involving someone with NPD], people realize and leave.”
Aside from work, family, and relationship problems, those with NPD can experience alcohol or drug dependence. According to the Public Health Agency of Canada, personality disorders often go hand in hand with eating disorders, anxiety or depression, obsessive-compulsive disorder, and bipolar disorder, among other problems. Other consequences can include spousal violence and gambling.

Another source of disagreement among health professionals is what constitutes the best course of treatment for NPD. Intensive, long-term individual and group psychotherapy, combined with medications such as antidepressants and mood stabilizers, however, can help some people.

“It’s about smoothing out the edges, helping people recognize when they’re hurting somebody else, recognize anger when it comes up,” Jang says. “Self-insight is a hard thing to teach.”

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The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994, pg. 661) describes Narcissistic Personality Disorder as a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of 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 he or she is "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 his or her expectations;
• is interpersonally exploitive, i.e., takes advantage of others to achieve his or her 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 him or her;
• shows arrogant, haughty behaviors or attitudes.

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There are varying degrees of Narcissism. Many people may exhibit features and not meet the criteria to be clinically diagnosed with NPD. In fact few narcissists seek treatment for this disorder. They are more likely to seek out treatment for other issues, such as depression, or anxiety, but underlying narcissistic features are unlikely to be identified because people are usually seeking help from family doctors and rarely get referred to a psychiatrist for assessment of personality. 

Personality & Behavioural characteristics:

Charismatic, charming and extroverted - These types of people are often the ones at the centre of the crowd, entertaining and engaging others, with the limelight on them. They thrive on attention and require admiration from others. 

Self-centred and self-absorbed - These people become bored when others want to talk about themselves, or their lives, and will find a way to get the conversation back to themselves, or will leave the interaction. 

Grandiose - Believe they are "special," "unique" and feel they deserve and expect special treatment because of their "status." 

Sense of entitlement - They can be quite demanding and believe that they are deserving of having their every wish and need met immediately based on their superiority.

Lack of empathy - In situations which would call for an empathic, compassionate response, they are unable and not interested in having empathy for others.They are simply unable to consider the feelings and needs of others.

Lack of reciprocity - Most relationships and interactional exchanges involve a degree of reciprocity, or give and take. Narcissists are incapable of this, everything ALWAYS about them and if it isn't, they're generally not interested. 

Rules do not apply to them - Due to their "special" status, they do not need to be concerned with social norms, such as following rules, or laws. 

Manipulative - These are the kind of people who will weasel their way in with the right people at work to get ahead of others by any means necessary. People are often blinded by their true character and although they may present as arrogant, attempts to get others to see them for who they really are often backfire on those trying to shine the light on their true character.

Narcissistic supply - These people require a constant "supply"of attention, admiration and positive feeding because their true ego is very fragile. If they perceive they aren't getting an adequate supply from the people they are involved with they will find it somewhere else, no matter the consequences. N. supply is like air to them, they must have it to live.

Narcissistic injury - When perceived, or experiencing a real slight, or anything that challenges their inflated sense of self, they will react in a very strong (often over-the-top) way, because they have experienced an injury to their fragile ego. It is not uncommon for them to feel very angry and to lash out at the perceived "abuser." They can become very black and white about people. Someone who has previously been "good" is now all "bad" due to causing them some sort of perceived (unconscious) injury.

Jealous, or Envious of others - They have a poor tolerance for others receiving more attention than themselves. They may become envious, or even angry, that others are trying to steal away the spotlight that should be shining on them. This may lead to efforts to sabotage, or take attention away, from the other person.

Mood swings - If they experience an injury, abandonment, or their supply is no longer available, they may experience a marked period of psychological distress in which they may become acutely depressed, anxious, and/or irritable. They may act impulsively to secure a new source, even temporarily, to "soothe" their internal state of emptiness. Or they may engage in other behaviour, such a substance use, to try to "fill" themselves up temporarily.