Uploaded 2019 when I was medical intern Edited 2023

1. NARCISSISTIC PERSONALITY
DISORDER
Professor: DR javanbakht
Tara Tayebi (medical intern)
December 25th 2019

2. MYTHOLOGY
One day Narcissus was walking in the woods when Echo, an Oread
(mountain nymph) saw him, fell deeply in love, and followed him.
Narcissus sensed he was being followed and shouted "Who's there?".
Echo repeated "Who's there?" She eventually revealed her identity and
attempted to embrace him. He stepped away and told her to leave him
alone. She was heartbroken and spent the rest of her life in lonely
glens until nothing but an echo sound remained of her. Nemesis (as an
aspect of Aphrodite[4]), the goddess of revenge, noticed this behavior
after learning the story and decided to punish Narcissus. Once, during
the summer, he was getting thirsty after hunting, and the goddess
lured him to a pool where he leaned upon the water and saw himself in
the bloom of youth. Narcissus did not realize it was merely his own
reflection and fell deeply in love with it, as if it was somebody else.
Unable to leave the allure of his image, he eventually realized that his
love could not be reciprocated and he melted away from the fire of
passion burning inside him, eventually turning into a gold and white
flower

3. DEFINITION
It is a personality disorder classified within cluster B by the
Diagnostic and Statistical Manual of Mental Disorders (DSM).
Narcissistic personality disorder (NPD) is a personality
disorder with a long-term pattern of abnormal behavior
characterized by exaggerated feelings of self-importance,
excessive need for admiration, and a lack of empathy.
Those affected often spend much time thinking about
achieving power or success, or on their appearance.They often
take advantage of the people around them

4. CAUSES
Genetics
• narcissistic personality disorder is
heritable, and individuals are much
more likely to develop NPD if they have
a family history of the disorder.
• moderate to high heritability for
narcissistic personality disorder.
Environments
• According to Leonard Groopman and
Arnold Cooper
•An oversensitive temperament (personality traits) at birth.
•Excessive admiration that is never balanced with realistic
feedback.
•Excessive praise for good behaviors or
excessive criticism for bad behaviors in childhood.
•Overindulgence and overvaluation by parents, other family
members, or peers.
•Being praised for perceived exceptional looks or abilities by
adults.
•Severe emotional abuse in childhood.
•Unpredictable or unreliable caregiving from parents.
•Learning manipulative behaviors from parents or peers.
•Valued by parents as a means to regulate their own self-
esteem.

5. PATHOPHYSIOLOGY
1.less volume of gray matter in the left anterior insula.
2.reduced gray matter in the prefrontal cortex
The brain regions identified above are
associated with empathy, compassion,
emotional regulation, and cognitive
functioning. These findings suggest that
narcissistic personality disorder is related to a
compromised capacity for emotional empathy
and emotional regulation

6. DIAGNOSIS
ACCORDING TO DSM IV
1.Grandiosity with expectations of superior treatment from
other people
2.Fixation on fantasies of power, success, intelligence,
attractiveness, etc.
3.Self-perception of being unique, superior, and
associated with high-status people and institutions
4.Need for continual admiration from others
5.Sense of entitlement to special treatment and to
obedience from others
6.Exploitation of others to achieve personal gain
7.Unwillingness to empathize with the feelings, wishes,
and needs of other people
8.Intense envy of others, and the belief that others are
equally envious of them
9.Pompous and arrogant demeanor

7. SUBTYPES
Theodore Millon suggested five subtypes of narcissism
subtype description Personality traits
Unprincipled
narcissist
Including antisocialfeatures. Deficient conscience; unscrupulous, amoral, disloyal,
fraudulent, deceptive, arrogant, exploitive; a con artist and
charlatan; dominating, contemptuous, vindictive.
Amorous narcissist Including histrionicfeatures. Sexually seductive, enticing, beguiling, tantalizing; glib and clever;
disinclined to real intimacy; indulges hedonistic desires; bewitches
and inveigles others; pathological lying and swindling. Tends to
have many affairs, often with exotic partners.
Compensatory
narcissist
Including negativisticand avoida
nt features
Seeks to counteract or cancel out deep feelings
of inferiority and lack of self-esteem; offsets deficits by
creating illusions of being superior, exceptional,
admirable, noteworthy; self-worth results from self-
enhancement.
Elitist narcissist Variant of pure pattern Feels privileged and empowered by virtue of special
childhood status and pseudo-achievements; entitled
façade bears little relation to reality; seeks favored and
good life; is upwardly mobile; cultivates special status and
advantages by association.
Normal narcissist Absent of the traits of the other
four
Least severe and most interpersonally concerned and empathetic, still entitled
and deficient in reciprocity; bold in environments, self-confident, competitive,
seeks high targets, feels unique; talent in leadership positions; expecting of
recognition from others.

8. Will Titshaw also suggested three subtypes of narcissistic
personality disorder which are not officially recognized in
any editions of the DSM or the ICD
Subtype Description Description
Pure Narcissist Mainly just NPD
characteristics.
Someone who has narcissistic features described
in the DSM and ICD and lacks features from other
personality disorders.
Attention
Narcissist
Including histrionic (HPD)
features.
They display the traditional NPD characteristics
described in the ICD & DSM along with histrionic
features due to the fact that they think they are
superior and therefore they should have
everyone's attention, and when they do not have
everyone's attention they go out of their way to
capture the attention of as many people as
possible.
Beyond The Rules
Narcissist
Including antisocial (ASPD)
features.
This type of narcissist thinks that because they are
so superior to everyone they do not have to follow
the rules like most people and therefore show
behavior included in the ICD for dissocial
personality disorder and behavior, included in the
DSM for antisocial personality disorder.

9. EPIDEMIOLOGY
Lifetime prevalence of NPD is estimated at 1% in the general
population and 2% to 16% in clinical populations. A
2010 systematic review found the prevalence of NPD to be
between 0% to 6% in community samples. There is a small
gender difference, with men having a slightly higher incidence
than in women.
According to a 2015 meta-analysis that looked at gender
differences in NPD, there has recently been a debate about a
perceived increase in the prevalence of NPD among younger
generations and among women. However, the authors found that
this was not reflected in the data and that the prevalence has
remained relatively stable for both genders over the last 30 years
(when data on the disorder were first collected).

10. TREATMENT
Narcissistic personality disorder is rarely the primary
reason for people seeking mental health treatment.
This is partly because individuals with NPD generally have
poor insight and fail to recognize their perception and
behavior as inappropriate and problematic due to their
very positive self-image
Treatment for NPD is centered around psychotherapy
In the 1960s, Heinz Kohut and Otto Kernberg challenged
the conventional wisdom of the time by outlining clinical
strategies for using psychoanalytic psychotherapy with
clients with NPD that they claimed were effective in
treating the disorder

11. Group treatment has its benefits, as the effectiveness of
receiving peer feedback rather than the clinician's may be
more accepted, but group therapy can also contradict
itself as the patient may show
"demandingness, egocentrism, social isolation and
withdrawal, and socially deviant behavior". Researchers
originally thought group therapy among patients with NPD
would fail because it was believed that group therapy
required empathy that NPD patients lack
No medications are indicated for treating NPD, but may
be used to treat co-occurring mental conditions or
symptoms that may be associated with it such as
depression, anxiety, and impulsiveness if present.

12. FAMOUS PEOPLE WITH NARCISSISTIC
PERSONALITY DISORDER

13. HAVEN'T WE MET BEFORE?
The Borderline/Narcissist Couple
By Shari Schreiber, M.A.
You've probably heard by now, that these two personality types are drawn to each other, but might have wondered why
this is true. t's critical to understand that both narcissistic and borderline personality disordered individuals incurred nearly
identical types of wounds to their developing sense of Self as infants and throughout childhood, and isn't it simply natural to
be drawn to someone with whom you have things in common, or who echoes personality aspects in yourself? Well, this
attraction is a lot like that~ it feels as though you've found your 'soul mate.' There's a similar vibration or frequency you two
share, due to your primal abandonment issues. While the nature of those early difficulties were alike, they've played out in
different ways for each of you~ but the scars from that time remain, unless there's been some serious core-focused
intervention.
Both Borderlines and Narcissists struggle with what I've coined, Bottomless Pit Syndrome or BPS. The codependent
narcissist has become a super-giver to compensate for feelings of inadequacy, and doesn't realize when he's given
enough. The Borderline has become a super-seducer and user, to validate/codify their sense of worth. Neither can fill
the ghastly hole in their soul with these measures~ but each will compulsively attempt to, until the day they die.
intruth, the Narcissist is no match for the Borderline. It doesn't matter how smart or powerful he is, she'll turn his world upside-down to
where he could lose his entire fortune, acquire a serious disease, and literally become a shadow of his former self.
The Narcissist's grandiosity works against him in this type of coupling, because he has an unquenchable need to win, due to poor self-
worth he's endured and tried to compensate for since early childhood. He won't let himself be one-upped by anyone, but the Borderline
is always better at this game than he is.
As the narcissistic male cannot tolerate any loss of control, he'll literally fight to the death to maintain it, never realizing what he's
losing/giving up, in terms of his good health or monetary fortune while he's ultra-distracted, and obsessively immersed in surmounting
the irresistible, intriguing challenges he faces with a borderline disordered partner.

14. Both Borderlines and Narcissists associate Love with painful longing. This is the crux of all those come here/go away
(push/pull) cycles within this coupling, and a whole lotta country western songs! In essence, love equals pain, and vice-versa.
When their intense yearning for love is met, painful sensations they've come to interpret as loving feelings, evaporate. At this
point, the Borderline feels bored or annoyed, and pushes away. With a healthy/whole partner who requires continuity of loving
feelings, the Borderline feels emotional claustrophobia, which compels her to disrupt episodes of authentic intimacy between
them.
The Narcissist deals with his needs for independence, distance and autonomy, by selecting emotionally unavailable BPD
lovers who won't consistently trigger his engulfment fears.
When closeness and engulfment fears become heightened, both NPD and BPD partners can experience anxiety, which
prompts their need to retreat or withdraw. The distance between them eases some tension, but a narcissistic perfectionist
makes it his fault, and experiences shame. This catalyzes his frantic efforts to win her over, again. It isn't that he's needing her-
-he's needing reprieve from his toxic sense of unlovability and unworthiness~ which are shame-infused emotional remnants
he's carried since boyhood.

15. The Bright, the Dark, and the Blue Face of Narcissism:
The Spectrum of Narcissism in Its Relations to the Metatraits of Personality, Self-Esteem, and the Nomological Network of
Shyness, Loneliness, and Empathy Radosław Rogoza*, Magdalena Zemojtel-Piotrowska ˙ , Maria M. Kwiatkowska and Katarzyna
Kwiatkowska Institute of Psychology, Cardinal Stefan Wyszynski University in Warsaw, Warsaw, Poland ´
Grandiose and vulnerable narcissism seem to be uncorrelated in empirical studies, yet they share at least some theoretical
similarities. In the current study, we examine the relation between grandiose (conceptualized as admiration and rivalry) and
vulnerable narcissism in the context of the Big Five personality traits and metatraits, self-esteem, and their nomological
network. To this end, participants (N = 314) filled in a set of selfreport measures via an online survey. Rivalry was positively
linked with both admiration and vulnerable narcissism. We replicated the relations of admiration and rivalry with personality
traits and metatraits—as well as extended existing knowledge by providing support for the theory that vulnerable narcissism is
simultaneously negatively related to the Stability and Plasticity. Higher scores on vulnerable narcissism and rivalry predicted
having fragile self-esteem, whereas high scores on admiration predicted having optimal self-esteem. The assumed relations
with the nomological network were confirmed, i.e., vulnerable narcissism and admiration demonstrated a contradictory pattern
of relation to shyness and loneliness, whilst rivalry predicted low empathy. Our results suggest that the rivalry is between
vulnerable narcissism and admiration, which supports its localization in the self-importance dimension of the narcissism
spectrum model. It was concluded that whereas admiration and rivalry represent the bright and dark face of narcissism,
vulnerable narcissism represents its blue face

16. Grandiose Narcissism Back et al. (2013) noted that the research on narcissism advanced
over the years but still was influenced by the existence of the Narcissistic Personality
Inventory (NPI, Raskin and Hall, 1979); thus, they proposed a new conceptualization that
integrated existing knowledge on grandiose narcissism and disentangled some of the
actual paradoxes. Within the new conceptualization of grandiose narcissism—i.e., the
Narcissistic Admiration and Rivalry Concept (NARC)—two distinct but related
dimensions exist that serve the same goal (i.e., maintenance of the grandiose self) via
different means (Back et al., 2013). The first dimension, narcissistic admiration,
represents the self-enhancing and assertive aspect of narcissism. This dimension
encompasses grandiose fantasies, striving for uniqueness, and self-promoting behaviors
that aim for social admiration and boost the narcissistic ego. The second dimension,
narcissistic rivalry, represents the
self-defensive and antagonistic aspect of narcissism. It comprises
devaluation of others, striving for supremacy, and hostile
behaviors that aim to diminish the threat to the ego and
may result in social conflicts (Back et al., 2013). Narcissistic
admiration is associated primarily with positive correlates
such as high self-esteem, grandiosity, benign envy, gratitude,
forgiveness, and lower distrust, while their motivation focuses
on achievements, self-direction, hedonism, and stimulation;
narcissistic rivalry, however, is primarily associated with negative
correlates such as low self-esteem, impulsivity, malicious envy,
loneliness, low empathy, low trust, and lack of forgiveness,
and it is driven by the motive of power
Vulnerable Narcissism As a more clinical expression of narcissism
(Cain et al., 2008), the vulnerable form, in addition to self-
absorbance and entitlement, represents pathological
psychological distress and fragility (Miller et al., 2017a). One of
the popular measures of vulnerable narcissism, the Hypersensitive
Narcissism Scale (HSNS, Hendin and Cheek, 1997), was developed
on the basis of Murray’s narcissism scale (Murray, 1938), in which
narcissism was interpreted as indicating dual dynamics: on the
one hand, it was related to self-enhancement, exploitation, and
craving for attention (i.e., reflecting grandiose narcissism), while
on the other, it was positively related to feelings of being
neglected and belittled, hypersensitivity, and anxiety (i.e.,
reflecting vulnerable narcissism). The HSNS was derived from
items that were capturing the meaning of vulnerable narcissism—
statements that were selected on the basis of correlations with
the composite MMPI-based (i.e., concerning narcissistic
personality disorder) narcissism scale. Ten items that were the
most diagnostic regarded hypersensitivity and vulnerability as
conceptualized by Wink (1991), and significantly loaded on a
single factor in three different samples (Hendin and Cheek, 1997).
Thus, the HSNS could be considered as a general unidimensional
measure of vulnerable narcissism.

17. Narcissism and Self-Esteem The issue of self-esteem is one of the most fundamental within the research on narcissism
(Brummelman et al., 2016). Numerous studies have reported that grandiose narcissism is moderately related to self-esteem (Pincus et al.,
2009; Miller et al., 2010; Okada, 2010); however, this may again be interpreted as a suppression effect, since admiration is related stably and
positively to self-esteem, while rivalry is related varyingly and negatively to it (Back et al., 2013; Rogoza et al., 2016c; Geukes et al., 2017).
Similarly, vulnerable narcissism is strongly negatively related to self-esteem (Rose, 2002; Zeigler-Hill et al., 2008; Miller et al., 2010; Okada,
2010). Although contingent self-esteem (i.e., feelings about oneself that are dependent on self- and other-based disapproval; Kernis, 2003) is
an important component of vulnerable narcissism (Pincus et al., 2009; Rubinstein, 2010), only a few studies investigated its relationship to
grandiose narcissism. Zeigler-Hill et al. (2008) reported that vulnerable narcissism was related to all domains of contingent self-esteem (i.e.,
physical appearance, competition, academic competence, others’ approval, family support, god’s love, and virtue), whereas grandiose
narcissism was only related to two domains—positively to competition and negatively to others’ approval. These results suggest that the
self-esteem of vulnerable narcissists is low, and their fragile sense of self-worth is hypersensitive and labile, while grandiose narcissists have
generally higher and more stable self-esteem. The results concerning grandiose narcissism refer to the grandiosity dimension, while little is
known about the self-importance dimension; therefore, the differentiation of admiration and rivalry may shed new light on the associations
between contingent self-esteem and grandiose narcissism. Kernis(2003) defined optimal self-esteem as a stable, authentic feeling of self-
worth, with a relative absence of defensiveness and an excessively strong desire to be liked by others, and which is not dependent upon
specific correlates. In other words, self-esteem is optimal when an individual’s self-esteem is high and contingent self-esteem is low. This
conceptualization is similar to the categorical diagnosis of mental health, in which individuals could be described as languishing (a state of
being mentally unhealthy) or as flourishing in life (a state of being mentally healthy; Keyes, 2002; Kara´s et al., 2014). Because vulnerable
narcissism is positively related to contingent self-esteem and negatively to self-esteem, while admiration is negatively related to contingent
self-esteem and positively to selfesteem, one could hypothesize that vulnerable narcissism is more present among individuals whose self-
esteem is fragile, while admiration is more present in individuals whose self-esteem is optimal.