Personality Disorder

Narcissistic personality disorder, as described in the case study below, is one of 10 clinically recognized personality disorders listed in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition-Text Revision (DSM-IV-TR). It is one of 4 Cluster B personality disorders, which are those marked by an intense degree of drama and emotionality. Historically, there has been much debate surrounding the exact definition of the disorder and competing theories exist regarding its etiology and optimal treatment.

A relatively new diagnostic entity, narcissistic personality disorder was only formally recognized as a unique personality disorder in 1980 in the DSM-III. However, the term narcissism traces its roots back to 1898 when the British psychologist Havelock Ellis first used the term to describe a pathological form of self-love or autoeroticism.[1] More than a decade later, Otto Rank published the first psychoanalytic paper on narcissism and Sigmund Freud later explored the concept in his 1914 work, On Narcissism.[2] A host of psychologists and psychiatrists since have made important contributions to our theoretical and clinical understanding of the disorder.

As defined in the 2000 edition of the DSM-IV-TR, narcissistic personality disorder is a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following criteria:[3]

A grandiose sense of self-importance (eg, the individual exaggerates achievements and talents and expects to be recognized as superior without commensurate achievements)

A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love

A belief 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).

A need for excessive admiration

A sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)

Interpersonally exploitative (ie, takes advantage of others to achieve his or her own ends)

A lack of empathy (is unwilling to recognize or identify with the feelings and needs of others)

Envy of others or a belief that others are envious of him or her

A demonstration of arrogant and haughty behaviors or attitudes

See the video below for an actor portrayal of an individual with narcissistic personality disorder.

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This is an actor portrayal of a patient with narcissistic personality disorder. This video clip was provided courtesy of Donald C. Fidler, MD, FRCP-I.

Case study

Mr. L is a 26-year-old third-year medical student who has been suffering from depression and anxiety for several years and is currently engaged in psychotherapy. Mr. L is an overachiever who has always excelled academically--he was at the top of his class at Princeton, received a Rhodes scholarship to study at Oxford, and was granted admission to many of the nation's best medical schools. In addition to his academic accomplishments, Mr. L prides himself on his physical appearance and considers himself to be much better looking than his medical school peers.

During his first therapy session with the psychiatrist, Mr. L brings in a copy of his curriculum vitae as well as copies of his medical school essays and insists that the psychiatrist read these before beginning the session. He states with a small chuckle, "I'm different than most of your clients." In addition, Mr. L asks the psychiatrist, "Exactly how long have you been doing this? You look really young, like you could be my age. I took quite a few advanced courses in psychology at Princeton. Where did you go to medical school again?"

During subsequent sessions, Mr. L talks at length about his disdain for his medical school professors, classmates, and the medical school curriculum in general. He feels that many of his professors are "not that bright" and that their understanding of fundamental medical concepts is cursory at best. He recounts an episode during one of his internal medicine rotations when the attending professor was asked a question by a junior resident but could not provide an adequate answer. Mr. L knew the answer and stated it without hesitation, declaring to the psychiatrist, "It was clear to everyone on rounds that I knew more than both the attending and the resident, I can't believe those a**holes didn't give