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Feature: CE Connection

Narcissistic personality disorder

When it's all about “me”

Cichminski, Lucille MSN, RN; Bellomo, Tamara L. MSN, RN-BC

Author Information
doi: 10.1097/01.NME.0000475165.10782.87

Abstract

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Heather, a 55-year-old married mother of two teenaged children, is employed as a marketing manager for a large corporation. She believes herself to be “the best” manager at the company and is constantly seeking attention and admiration from her peers and coworkers. She doesn't accept constructive criticism, especially from her superiors, and responds to such with temper tantrums. If a coworker receives a promotion or award, she refuses to acknowledge it and states, “I'm the one who really deserves it.” Her goal of becoming the CEO of the company in the near future seems unrealistic to her peers. She complains her coworkers don't respect her and she's resentful that she isn't particularly close with any of them. She's extremely moody when she doesn't have a “perfect” day and is subject to periods of depression when things don't go her way.

Heather's peers try to avoid her because her habit of belittling them has taken an emotional and physical toll on them. She's no longer included in social activities because she feels that she has “more important” things to do. Her arrogant manner has caused her coworkers to ostracize her. She never adheres to company policies because she feels that she's “above the rules.” Her coworkers who once admired and respected her have come to realize that she isn't the person they believed her to be. The drastic change in her personality has left many of them wondering, “What happened to the old Heather?” Where's the charming, fun loving, charismatic, and intelligent person they first met? She has been replaced with an egotistical, controlling, uncompassionate, and haughty person.

Heather didn't realize that she had a mental disorder until she experienced severe depression. While attending talk therapy, her psychiatrist diagnosed her with narcissistic personality disorder (NPD).

What's NPD?

More prevalent in men and affecting up to 6.2% of the population, NPD is a personality disorder in which an individual literally believes the world revolves around them. A person with NPD has an inflated sense of their own importance, demonstrates a lack of ability to empathize with others, and a strong desire to keep the focus solely on themself at all times. They appear to be extremely confident in front of others, but in reality possess very low self-esteem.

A person with NPD comes across as conceited, boastful, and pretentious. This person usually monopolizes most conversations and acts in a condescending manner toward others who they perceive to be inferior. They can't handle or accept any type of criticism. If they're criticized, they retaliate by acting out with rage or contempt. This person is obsessed with having “the best” of all things, such as clothes, cars, houses, office space, and medical care. They're very easily hurt and refuse to take responsibility for their flaws or failures.

The person with NPD wants others to believe that they possess natural leadership qualities that far exceed anyone else's and they're needed for others' success. Due to an overwhelming sense of insecurity, the person is often threatened by others' achievements. When in conversation, this person constantly interrupts, interjecting their own opinions and refusing to listen to or accept anyone else's.

NPD causes the affected person to behave in socially distressing ways; therefore, they find it difficult to maintain long-lasting relationships with others. Relationships are often short-lived and rocky; the person with NPD doesn't desire friendship or derive enjoyment from being with other people who may perceive them as aloof, odd, or strange. This makes it difficult for people to form positive relationships with an individual with NPD. Because they may have never experienced positive interaction with others, the person with NPD lacks important social skills that are needed to form comfortable, normal relationships with others. For this reason, attempting to form friendships becomes uncomfortable and awkward, resulting in isolation. Any time they feel the least bit ignored by a friend or coworker, they'll sever ties with that person and cut him or her out of their life entirely.

Although the exact cause of NPD is unknown, many psychologists believe that it's caused by a combination of genetic and social factors. Most research points to how children are raised affecting their chances of developing NPD. For example, if parents shower their child with endless praise and ego inflating, the child will have an increased risk of developing NPD. Interestingly enough, the opposite can also be true. Children who are abused or disregarded may develop NPD because they feel that no one else cares and they must look out for themselves.

NPD may also be linked to genetics or psychobiology. This involves the connection between the brain and behavior/thinking. Biologically, individuals with NPD are believed to have a smaller right supramarginal gyrus—the area of the brain responsible for empathy. Psychologically, they lack the ability to exhibit a self-image other than one of exaggerated positive qualities (idealization) and are unable to cope with negative qualities in themselves (devaluation). Individuals with NPD are often excessively emotionally sensitive.

Red flags alert

The symptoms of NPD are presented in the mnemonic IT IS ALL ABOUT ME:

  • insists on special favors and unquestioning compliance with their expectations
  • thinks about themself most of the time and talks about themself excessively
  • insists on being provided with constant attention
  • sense of entitlement
  • achievements and talents are exaggerated
  • lets others believe they're special
  • lets their feelings of jealously toward others consume them and believes others envy them
  • arrogant personality
  • being preoccupied with fantasies about success, power, brilliance, or beauty
  • other people's feelings and needs are ignored and go unrecognized
  • unrealistic goals
  • takes advantage of others to get what they want
  • manner is haughty in nature
  • exaggerated sense of self-importance.
  • In addition, the mnemonic RED FLAGS can be used to identify the warning signs of NPD:
  • relaxing around them is impossible
  • exaggerates personal achievements while minimizing others'
  • Dr. Jekyll and Mr. Hyde personality
  • frequently complains that whatever others do, it isn't “good enough”
  • lies and excuses abound
  • always assumes they're more knowledgeable than others
  • goes into a rage or sulks when they don't get their way
  • sees themself as “perfect” and wants others to see them that way, too.

If you recognize these red flags, you may be in contact with someone with NPD. Working or living with a person with NPD can leave you feeling exhausted and drained, especially when you try to explain your feelings or points of view to them and they tell you to “shut up” or walk away and refuse to listen to you. You may even be shocked when you try to challenge their points of view, lies, or distortions and they respond with vitriolic theatrics and threats. Those who regularly interact with a person with NPD will exhaust themselves looking for a reason behind it all, when in reality the fault isn't theirs.

Most individuals with NPD remain undiagnosed because they don't feel that anything is “wrong” with them; therefore, they rarely seek psychiatric help. Often, the person with NPD seeks treatment for a coexisting psychiatric disorder such as depression.

Diagnosis checklist

The diagnosis of NPD is often made by performing a thorough psychological exam, evaluating the signs and symptoms, and performing a physical exam to ensure that the issue isn't stemming from a physical cause such as traumatic brain injury. The psychological exam focuses on standardized questions pertaining to childhood, relationships, and goals to identify long-term patterns of thinking, feelings, and other behaviors demonstrating how the person with NPD interacts with other people.

Psychiatrists will utilize the Diagnostic and Statistical Manual of Mental Disorders (DSM) to help construct the diagnosis. According to the DSM-V, a diagnosis of NPD is determined by the presence of the following criteria:

  1. Impairments in self-functioning (must include one or both):
    • —excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or waver between extremes; emotional control mirrors fluctuations in self-esteem
    • —goal-setting is centered on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
  2. Impairments in interpersonal functioning (must include one or both):
    • —impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others
    • —relationships mainly superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others' experiences and predominance of a need for personal gain.
  3. Pathologic personality traits:
    • —grandiosity
    • —attention seeking.

In addition to the DSM-V, many professionals use the Narcissistic Personality Inventory to help diagnosis NPD. This 40-question test measures traits that may be indicative of NPD, such as how much attention and power someone craves. Statements include, “I like to be the center of attention,” “If I ruled the world, it would be a better place,” and “I will never be satisfied until I get all that I deserve.” The patient responds to these statements and the results are tallied. A score of above 20 is suggestive of NPD.

Tricky treatment

Treatment for NPD is centered on psychotherapy, also known as talk therapy. Psychotherapy helps the patient understand the cause of the disorder and focuses on learning how to establish healthy, meaningful relationships with others. It's important to note that personality traits are extremely difficult to change; therefore, therapy may take several years.

Psychotherapy seeks to help the person with NPD in several ways, including:

  • understanding the causes of their emotions and what it is that drives them to compete in such a ruthless way
  • understanding why they distrust others so vehemently
  • accepting responsibility for their actions and learning to release their desire for unattainable goals and accept what's attainable
  • recognizing and accepting their actual competency and potential so that they can tolerate criticisms and failures
  • maintaining real personal relationships, friendships, and collaboration with coworkers.

There are no medications specifically for the treatment of NPD. However, individuals with NPD often benefit from the use of psychiatric medications to help alleviate depression, anxiety, mood lability, and poor impulse control. Medications that may be prescribed include antidepressants (citalopram), antipsychotics (risperidone), and mood stabilizers (lamotrigine).

The person with NPD typically only seeks treatment when they become completely desperate. If there's an event (a trigger) that threatens their status, such as a major defeat or rejection, they may be motivated to seek therapy. However, after they start feeling better or the threat is gone, they may forego therapy and resume their behavior.

What can you do?

As a nurse, you'll most likely come into contact with patients with NPD. These are often difficult patients who aren't likely to be socially cooperative. You must use your therapeutic communication and self-awareness skills when interacting with patients with NPD. Understanding that the patient truly doesn't see themself at fault may help you sympathize with their behavior.

Set goals for yourself to help you care for the patient. These goals should include:

  • developing a relationship with the patient based on empathy and trust while also maintaining appropriate boundaries
  • ensuring care responsibilities are appropriately addressed
  • encouraging effective and functional coping and problem-solving skills in a way that's empowering to the patient
  • promoting the patient's development of and engagement with their support network
  • ensuring collaboration and communication with other members of the interprofessional team for consistency in treatment and approach
  • supporting and promoting self-care activities for the patient's family and caregivers.

The mnemonic I LOVE U can help you remember the goals of treatment for your patient with NPD:

  • increase the ability to understand and regulate their feelings
  • learn to relate better to others
  • omit feelings of superiority and arrogance
  • vacate feelings of distrust and envy
  • elevate the ability to establish long-lasting relationships
  • understand the causes of the disorder and its impact on their self-esteem.

If the patient is unable to attain these goals or doesn't adhere to the treatment plan, focus on the rewards of treatment. Teach the patient relaxation and stress management techniques, such as meditation. It's important to keep an open mind and not give up.

Much needed help

Because the cause of NPD is unknown, there's no proven way to prevent this condition. Unfortunately, individuals with NPD have a higher rate of substance abuse (alcohol/drugs), depression, and difficulty dealing with people in all life aspects. They may also express suicidal thoughts or behaviors at some point during their lifetime. Because the person with NPD believes “I'm okay and everybody else isn't okay,” seeking treatment is rare. Some wait until things are so bad they need to be hospitalized. Although there's no cure for NPD, psychotherapy can help. However, the patient must be willing to seek treatment and learn how to relate to others in a more positive way. This depends largely on their acceptance of constructive criticism and how much they're willing to change.

memory jogger

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Figure

When recalling the symptoms of NPD, think IT IS ALL ABOUT ME.

Insists on special favors and unquestioning compliance with their expectations

Thinks about themself most of the time and talks about themself excessively

Insists on being provided with constant attention

Sense of entitlement

Achievements and talents are exaggerated

Lets others believe they're special

Lets their feelings of jealously toward others consume them and believes others envy them

Arrogant personality

Being preoccupied with fantasies about success, power, brilliance, or beauty

Other people's feelings and needs are ignored and go unrecognized

Unrealistic goals

Takes advantage of others to get what they want

Manner is haughty in nature

Exaggerated sense of self-importance

memory jogger

F3-9
Figure

To recognize the warning signs of NPD, think RED FLAGS.

Relaxing around them is impossible

Exaggerates personal achievements while minimizing others'

Dr. Jekyll and Mr. Hyde personality

Frequently complains that whatever others do, it isn't “good enough”

Lies and excuses abound

Always assumes they're more knowledgeable than others

Goes into a rage or sulks when they don't get their way

Sees themself as “perfect” and wants others to see them that way, too

did you know?

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Figure

NPD derives its name from a Greek myth in which a handsome young man named Narcissus sees his own reflection in a pool of water and falls in love with it.

memory jogger

F5-9
Figure

To remember the goals of treatment, think I LOVE U.

Increase the ability to understand and regulate their feelings

Learn to relate better to others

Omit feelings of superiority and arrogance

Vacate feelings of distrust and envy

Elevate the ability to establish long-lasting relationships

Understand the causes of the disorder and its impact on their self-esteem

on the web

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Figure

Cleveland Clinic:http://my.clevelandclinic.org/services/neurological_institute/center-for-behavorial-health/disease-conditions/hic-narcissistic-personality-disorder

Mayo Clinic:www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/basics/definition/con-20025568

MedlinePlus:https://www.nlm.nih.gov/medlineplus/ency/article/000934.htm

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