Other people perceive them as arrogant, cold and incapable of true emotional reciprocity. They expect admiration, look down on people they perceive as inferior, display snobbish or patronizing attitudes and are convinced of their exalted position in the world. When they don’t receive the special treatment to which they feel entitled, they become very impatient or angry. They insist on having “the best” of everything –the best car, medical care or social circles, for instance. But behind this mask of ultra-confidence often lie a fragile self-esteem, insecurity and a sense of secret shame. Other “ideal” people are sought out but quickly abandoned if their radiance should dim, or worse, outshine their own. The medical term for this disorder is narcissistic personality disorder, is more common in males than in females, typically starts in the teenage years and affects less than 1% of the general population. The term “narcissism” was originally coined after Narcissus who, in Greek mythology, was a pathologically self-absorbed young man who fell in love with his own reflection in a pool.

Personality disorders arise when personality traits are so inflexible and maladaptive across a wide range of situations that they cause significant distress and impairment of social, occupational and role functioning. Narcissistic personality disorder is one of several personality disorders defined in the DSM IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Review). It is characterized by a pattern of grandiosity, need for admiration and lack of empathy. Affected people have a grandiose sense of self-importance; fantasies of unlimited success, power, brilliance, beauty or ideal love; and believe that they are “special” or unique and can only be understood by, or should associate with, other special or high-status people. They require excessive admiration, have a sense of entitlement, are interpersonally exploitative (i.e., take advantage of others to achieve their own ends), are often envious of others and show arrogant behaviors or attitudes.

The causes of narcissistic personality disorder are not known, but a combination of dysfunctional childhood, genetics and psychobiology has been suggested. The course of the disorder is chronic and depression is common in later years due to the person’s inability to adapt to the inevitable decline that comes with age.

Recommended treatment for narcissistic personality disorder typically involves long term psychotherapy (cognitive behavioral, family, group) with only anecdotal reports of success. Psychotropic medications are used only to treat concurrent psychiatric illness. Some of the difficulties encountered in the treatment of people with narcissistic personality disorder are their lack of insight (They don’t believe there is something wrong with them) and their perception that therapy or the therapist is not worth their time and attention.

By Ana C. Posada-Diaz, MD., Psychiatrist