Narcissistic Personality Disorder

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Classification according to ICD-10
F60.8 Other specific personality disorders: Personality (disorder): narcissistic
ICD-10 online (WHO version 2019)

The narcissistic personality disorder (NPS) is characterized by a lack of empathy , overestimation of their own abilities and increased desire for recognition from. It is typical that the affected persons are overly busy impressing others and soliciting admiration for themselves, but themselves have little interpersonal empathy and give back little emotional warmth to other people.

Narcissistic personalities show clear problems in adapting to their living conditions and environment and in the autonomous regulation of self-esteem . Such adjustment difficulties can manifest themselves in a variety of ways and appear in different forms of NPS. The excessive urge for validity can either be staged with confidence or shyly hidden. Accordingly, those affected can appear arrogant or act humble.

Pathological narcissism can manifest itself through bragging and imposture as well as insatiable demands and expectations. People with NPS tend to emotionally abuse people in their immediate environment (especially sexual partners and children) in order to increase their own self-worth (their "ego") at the expense of others. Other forms of narcissistic personality disorder are characterized by an unstable, rapidly changing self-esteem, which in the extreme can oscillate between grandiosity and shameful contrition. There can also be an anger that is chronically smoldering internally and can explode at the slightest cause (especially in the event of criticism or subjectively felt hurt ).

"[T] he [NPS] is the most egocentric of all personality disorders" (Sachse, 2019, p. 127). The people have the impression that everything revolves around them. Subjectively, they see themselves as the “center of the universe” (ibid.).

Personalities with an NPS think they are special. From this they also derive the right to be able to determine how other people have to deal with them and what behavior of others they can expect. That means they set different rules. Because of these rules, which are usually not communicated at all, they often come into conflict with third parties because these rules cannot be easily provided. (Sachse, 2019, p. 126ff, p. 131)

In the classification system of the World Health Organization (the ICD-10 ), narcissistic personality disorder is only listed in a residual category (F60.8. Other specific personality disorders) . In the DSM-5 of the American Psychiatric Association , however, it is included as an independent disorder and belongs there to cluster B , which includes the “moody, dramatic, emotional” personality disorders . In either case, it must be distinguished from normal narcissism as an actual or ascribed trait .

Concept history

The term “ doxomania ”, which early Christian theologians used to describe the sin of pride and glory, belongs to the prehistory of the formation of the term .

In 1894, Sigmund Freud coined the term narcissistic neuroses (meaning: psychoses ), which he distinguished from actual neuroses that can be treated with psychoanalytic technology . This term is no longer used in modern psychiatry. Freud, like many of his contemporaries, described the symptom picture of narcissistic personality disorder as “ megalomania ” - a term that no longer occurs in the current psychiatric category systems either.

Normal vs. pathological narcissism

One of the first authors to make an explicit distinction between “normal” and pathological narcissism was the psychoanalyst Isidor Sadger in the early 20th century . A little later, Otto Rank worked out that narcissism is part of normal human development . Sigmund Freud admitted in 1914 that narcissism could indicate a pathology, but conceived it - like Rank - more as a process of normal development than as a clinical picture. His student Karl Abraham, on the other hand, saw a pathology in narcissism as a given as soon as envy came into play.

In Great Britain , the psychoanalyst Ernest Jones had already written in 1913 about a “God complex”, a pathology that is characterized by aloofness, self-admiration, exhibitionism and fantasies of omnipotence and omniscience. Like Otto Rank before him, Jones also assumed that this behavior could be explained as an attempt by an individual who felt threatened to protect himself. Annie Reich later went even further, believing narcissism to be a pathological form of regulation of self-esteem, in which self-infliction and aggression are used to protect the concept one has made of oneself.

The assumption that narcissism is based on fragile self-esteem or an unrealistic self-image is increasingly being questioned. Everyone has narcissistic parts that need to be recognized. The psychiatrist and neuroscientist Raphael M. Bonelli worked out that narcissistic elements are not fate, but changeable. Narcissism is therefore a continuum until diagnosis of narcissistic personality disorder, but all narcissism is harmful. There is no such thing as good or healthy narcissism (as Alice Miller postulated). Narcissism always has the tendency to idealize itself by suppressing its weaknesses , exaggerating its strengths and thus devaluing others.

Narcissistic character

The concept of a narcissistic personality or a narcissistic character was first described in 1925 by the psychoanalyst Robert Waelder . Freud followed him in 1931 and now also described a "narcissistic character type" with a dynamic connection between narcissism and aggressiveness in response to criticism , hurt or lack of attention. Wilhelm Reich took up this suggestion and in 1933 himself described a “ phallic- narcissistic character”, which he had observed especially in men and with a whole range of abnormalities; In addition, he presented in detail the dynamics of narcissism and aggressiveness that Freud only mentioned in general.

In 1939, Karen Horney distinguished three subtypes of narcissistic characters (aggressive-expansive, perfectionist, arrogant-vengeful) and made a precise distinction between healthy self-confidence and pathological narcissism, with narcissists loving, admiring and appreciating themselves especially where nothing is lovable . Unlike Freud, Horney found narcissists incapable of love , including love of the actual self; More consistently than Freud, she assumed that narcissistic grandiosity was based more on defensive than on authentic self-love. Donald Winnicott followed her in 1965, characterizing narcissists as individuals who protectively identify with a grandiose false self. As early as 1960, Annie Reich had identified the cause of this reaction as the narcissist's inability to regulate his self-esteem autonomously , due to repeated traumatic experiences that created a persistent basic feeling of weakness and powerlessness in him. Reich's contribution to the narcissistic character is also important because she was the first to describe the constant fluctuations to which narcissistic self-consciousness is subject; Narcissists find it difficult to endure ambivalence, mediocrity, and failure and therefore see themselves either as perfect or as complete failure.

Mental disorder

The first author to see narcissism not only as a personality trait, but also explicitly as a mental disorder and thus a disease, was the American psychiatrist John C. Nemiah , who was influenced by Freud . In his Foundations of Psychopathology (1961) he spoke of a "narcissistic character disorder". Erich Fromm proposed in 1964 the concept of a malignant narcissism (Engl. Malignant narcissism ) before whose symptom picture narcissistic, antisocial and united sadistic; contemporary psychiatry has made many references to it, but this concept has not caught on in diagnostics.

Nemiah's suggestion of a “narcissistic character disorder” was followed by the American psychoanalyst Otto F. Kernberg , who was born in Vienna , who proposed the term “narcissistic personality structure” in 1967 and provided a comprehensive description of the symptoms in various publications. The American psychoanalyst Heinz Kohut , also from Vienna, finally introduced the term “narcissistic personality disorder” in 1968, which is also the basis of this article.

Kohut and Kernberg's conceptions do not differ in the description ( diagnosis ), but rather in the explanation of the causes ( etiology ):

Kernberg understood pathological narcissism as the result of an upbringing by empathic, emotionally selfish parents who treat the child with rejection and coldness and only pay attention to it when this corresponds to their own needs. As a compensation, the child develops a grandiose self-concept. This serves him as a place of retreat where he can at least imagine in his imagination the admiration that his parents do not give him. In addition, however, the negative self-image that the rejected child has of himself remains; this is split off and leaves behind a feeling of shame and emptiness on the one hand, and an insatiable hunger for admiration and excitement on the other.

In contrast to Kernberg, Kohut understood narcissistic personality disorder as a failed turn in normal development. While narcissism is usually a kind of motor for creating realistic ambitions based on realistic goals through early childhood identification with idealized parents, in the pathological case this process remains incomplete, since here the child does not sufficiently idealize and idealize the rejecting parents as a result, certain self-regulatory skills are not achieved; Instead, it remains dependent on employing other people who are devoted to it and who show empathetic attention to maintain its self-confidence on a day-to-day basis .

Kernberg and Kohut presented their publications at a time when an increased interest in pathological narcissism was noticeable; they therefore received great international attention. Although they disagreed on the etiology and therapy , they agreed on the diagnosis . Together they created the basis for a conception of narcissistic personality disorder, which found widespread use beyond psychoanalysis and was incorporated into the influential classification system of the American Psychiatric Association ( DSM-III ) in 1980 .

Differentiation into subtypes

The characterization of the narcissistic personality disorder in DSM-III and DSM-IV soon aroused criticism from researchers, who pointed out that the descriptions there only considered the most conspicuous form of this disorder: a grandiose, unwavering, idiosyncratic, exhibitionistic, thick-skinned and phallic narcissism. Another, second form of pathological narcissism - characterized by vulnerability, oversensitivity, reservedness and thin-skinnedness - cannot be diagnosed with the given instruments and therefore falls through the cracks.

Both types, whose occurrence has also been empirically proven, have in common an extraordinarily high degree of self-centeredness and unrealistically grandiose demands on themselves.

In the latest version of its classification system ( DSM-5 , 2013), the American Psychiatric Association reformulated its definition of narcissistic personality disorder so that it can now also be used to diagnose covert narcissistic personality disorders.

diagnosis

ICD-10

The narcissistic personality disorder is only listed in the ICD-10 under the heading Other specific personality disorders (F 60.8) . It is not further characterized there, although it is often used in practice as a personality diagnosis. Preliminary research criteria are included in Appendix 1 in the green ribbon of ICD-10.

However, they almost literally correspond to the corresponding official criteria text of the DSM-5 (see below). The ICD-10 particularly emphasizes that the general criteria for a personality disorder (F60) must be met.

DSM-5

In the current classification system of the American Psychiatric Association ( DSM-5 ), the disorder is listed under reference number 301.81. Accordingly, Narcissistic Personality Disorder is a profound pattern of greatness (in fantasy or behavior), a need for admiration, and a lack of empathy. It starts in early adulthood and the disorder manifests itself in a variety of situations.

At least five of the following criteria must be met:

  1. Has a terrific feeling of importance (e.g. exaggerates own achievements and talents; expects to be recognized as superior without corresponding achievements).
  2. Is overwhelmed by fantasies of limitless success, power, splendor, beauty or ideal love.
  3. Believes of himself to be “special” and unique and to be understood only by other special or respected persons (or institutions) or to be able to only associate with them.
  4. Desires excessive admiration.
  5. Demonstrates a sense of entitlement (ie exaggerated expectations of particularly preferred treatment or automatic response to one's own expectations).
  6. Is exploitative in interpersonal relationships (ie, taking advantage of others to achieve goals).
  7. Shows a lack of empathy: unwilling to recognize or identify with the feelings and needs of others.
  8. Often jealous of or thinks others are jealous of him / her.
  9. Shows arrogant, arrogant behaviors or attitudes.

Alternative model

In the alternative model of DSM-5, the NPS is characterized by difficulties in identity, self-control, empathy and closeness, together with specific maladaptive personality traits in the domain of antagonism. Conditions A and B must be met.

A. Moderate or severe impairment in the functional level of the personality, which is manifested by typical difficulties in at least two of the following areas:

  1. Identity: Excessive comparison with others for self-definition and self-esteem regulation; excessive overestimation or underestimation of oneself or fluctuating between extremes; the regulation of emotions depends heavily on fluctuations in self-esteem.
  2. Self-control : personal goal setting is based on gaining recognition from others; the personal standards are inappropriately high to be able to experience oneself as extraordinary, or too low due to excessive demands; the person is often unaware of their own motivations.
  3. Empathy : Impaired ability to recognize or identify with other people's feelings and needs; Exaggerated focus on other people's reactions, but only if they are seen as important to yourself.
  4. Proximity : Interpersonal relationships are largely superficial and serve to regulate self-worth; reciprocity is constrained by a lack of genuine interest in the experiences of others and a predominant need for personal gain.

B. Presence of the following two problematic personality traits:

  1. Grandiosity (a facet of the domain of antagonism): attitude of claim, either evident or hidden; Selfishness; strong clinging to the belief that you are better than others; condescending attitude towards others.
  2. Seeking Attention (a facet of the domain of antagonism): Excessive effort to stand out and be the center of others' attention; Desire for admiration.

criticism

By Rainer Sachse the objection comes that the diagnostic criteria in the DSM were related mostly only on successful narcissists, why it can not be based on its criteria. Sachse differentiates those affected into successful, failed and unsuccessful narcissists. However, he sees these types specifically for Western culture, as it is essentially based on differences with the performance behavior that is strongly interwoven with it. (Sachse, 2019, pp. 122–123)

The symptoms in detail

Lack of empathy and sensitivity

One of the most noticeable symptoms of the disorder that narcissists incur in others is a lack of empathy. Empirical studies found that in narcissists the cognitive aspects of empathy were largely intact, but the emotional aspects of empathy showed considerable impairments. In everyday life this means that you can perceive the feelings and needs of other people, but cannot emotionally empathize with them and want to take note of them; they also lack the willingness to respond to it or to take it into account. They do not listen to personal messages from others, they do not heed, understand or support them. The behavior of other people and their statements are therefore often drastically misinterpreted; often behind this is the desire not to let the belief that one is liked and respected (although one may have put a whole story of ruthlessness on the other) destroyed.

Narcissists can learn to fake empathetic responses and have such gestures on hand in case they can benefit from them. However, it remains with mere gestures; Promises of understanding and consideration are not kept, empathic reactions do not lead to consistently carried out considerate actions, and as soon as the narcissist feels frustrated or humiliated (" narcissistic insult "), the mask falls completely.

Narcissists show - especially with regard to vulnerability, sadness, empathy and compassion, but also with happiness and joy - a low emotional depth; which in rare extreme cases can go as far as alexithymia .

Exaggerations, lies, deception and self-deception

Many narcissists, for example in their professional life, are actually often overachievers and thus justify their high self-assessment. In general, however, narcissists tend to portray their talents, personal accomplishments, and contributions to community work as larger than they actually are. Occasionally they pass off the accomplishments of others as their own. They seek personal closeness to " VIPs " and people of high social status and portray such acquaintances as closer and more intimate than they really are. Some technical authors, but more often the sexual partners and family members of narcissists, report habitual lying . Self-deception , as well as deception and manipulation of the environment and gaslighting , are among the means that many narcissists use to support their self-concept . Manipulation essentially refers to the exploitation of interaction partners to achieve one's own goals (Sachse, 2019, p. 127).

Dealing with criticism and rejection

Narcissists react much more intensely than other people to criticism, defeat, rejection, shame or humiliation. A popular assumption is that behind narcissists' positive conscious opinion of themselves, in reality, subconsciously, is hidden low self-esteem. This assumption can usually be traced back to psychodynamic theories, particularly from Kohut. However, recent empirical research that has used both conscious (explicit) and unconscious (implicit) measures of self-worth suggest that narcissists have a positive opinion of themselves in areas of personal aptitude (such as status and intelligence) and only a neutral one View in areas of community (such as friendliness and morals). The reaction to criticism is usually a sharp attack by the person who is questioning the narcissist, less often in depression and withdrawal. Their justification and lack of empathy predestine narcissists for misunderstandings and interpersonal conflicts, which can escalate very quickly and lead to tantrums. Depression, on the other hand, contains strong moments of narcissistic indignation and feelings of being humiliated.

Exploitation, manipulation and abuse

Many narcissists engage in emotional abuse of people close to them, especially their sexual partners and children. This phenomenon was first described by Sándor Ferenczi , later followed by Karen Horney , Alice Miller and Heinz Kohut . The focus of this abuse is the narcissistic confirmation (English narcissistic supply , narcissistic feed ), a term that Otto Fenichel coined in 1938 to denote the admiration and support that narcissists draw emotionally from and that they obtain from their surroundings. The victims who are supposed to ensure this narcissistic confirmation are coolly selected, courted and cared for ( love bombing ) according to their presumed fitness until they begin to provide confirmation, manipulated to maintain it, and dropped once they cease supply. Those affected, who are sometimes characterized as 'co-narcissists' or co-narcissists , can suffer considerable emotional damage and appear far more frequently in psychotherapy than the narcissists themselves. Self-help forums exist on the German and even more so on the English-speaking web specifically deal with this problem.

Differential Diagnosis and Differentiation

Narcissistic personality disorder can be confused with the following mental disorders:

Accompanying problems (comorbidities)

People with narcissistic personality disorder also often suffer from depression or eating disorders such as anorexia nervosa and are prone to substance abuse , particularly cocaine . Other personality disorders that are often diagnosed at the same time as the narcissistic personality are paranoid , antisocial , borderline, and histrionic personality disorder .

Narcissistic personality disorder is easy to confuse with borderline personality disorder (BPD), with which it is comorbid in 25–37% of cases. H. together, occurs.

NPS, which appears as vulnerable narcissism, is easily confused with BPD because both are associated with unstable self-esteem, conflicting interpersonal relationships, and fear of abandonment. Both disorders can be accompanied by irrational shame. While narcissists show consistently little empathy towards their counterpart, people with BPD exhibit cyclical behavior in which periods of excessive concern alternate with periods of disappointment and withdrawal. While narcissists want others to reinforce the illusions they have about themselves, people with BPD most of all want someone to "save" them from abandonment.

In its grandiose form, and especially with men, NPS can also be confused with BPS, because the latter also has a tyrannical form in which people close to you are aggressively held responsible for their own problems. With both disorders, a tremendous anger smoulders inside, which can explode without notice.

Both disorders lack the ability to observe oneself and to get a realistic idea of ​​how others will perceive one's own behavior. The attitude towards important caregivers fluctuates in both of them suddenly between idealization and devaluation. However, people with BPD are more likely than narcissists to have strong emotions (affection, sadness, fear), clingy and self-harming behavior and suicide attempts. More than people with BPD, narcissists are more likely to manipulate, exploit, and drop other people when they are no longer benefiting from them. NPS is more likely to be diagnosed in men, and BPS more likely to be diagnosed in women.

Shapes and dimensions

After narcissistic personality disorder was included in the DSM-III classification system in 1980, many psychiatrists came to the conclusion that the diagnostic criteria mentioned there were too narrow and that there were variants that must also be attributed to the disorder. Some authors first tried to work out typologies, including Theodore Millon and Roger D. Davis, who in 1996 distinguished five forms of disorder, namely a characterless, an amorous, a compensatory, an elitist and a fanatical narcissism.

Such typologies are obsolete today; More recently, it has been replaced by the insight that narcissistic personality disorder is a multi-dimensional phenomenon, the dimensions of which have now also been operationalized for research (i.e. converted into measuring scales ). The following dimensions of the disturbance have been described so far:

Open and covert narcissism

In 1938 differed Henry Murray , a psychologist at Harvard University , between open (Engl. Overt ) and hidden ( covert ) narcissism; recent research has taken up this distinction again. In open narcissism - the classic, arrogant narcissism - the high self-assessment is quite blatantly on display. Open narcissists are self-confident, extroverted , charming and deliver high achievements when they think they can gain fame through it. In work groups and in love affairs, they often arouse high appreciation at the beginning, but when they get to know each other better, they are then perceived as cold, arrogant, boastful, dominant and hostile.

Covert narcissists, on the other hand, have learned to suppress their impulses for cocky appearances and to demand the tribute of admiration ( "feed" ), on which they are emotionally dependent, in a quieter and more indirect way. Covert narcissists are humble, friendly, generous, and altruistic , but are also wholly driven by the desire to always put themselves in the best possible light. Many covert narcissists have a strong victim mentality and are convinced that their (imagined or actual) talents and abilities are underestimated and not appreciated enough. Often they employ their children or other family members for self-expression. Although their empathy and interest in other people is just as low as that of open narcissists, many covert narcissists are involved - often in leading positions - in charitable or religious communities or in sects , where they can gain respect and admiration without being offensive by arrogance. Concealed narcissists are more prone to manipulation than open narcissists, to instilling insecurity and feelings of guilt, to victim blaming , to secrecy and to lying. Victim of covert narcissists, d. H. Sex partners and family members who are emotionally abused by a covert narcissist find it particularly difficult to articulate what is happening to them.

Adapted and non-adapted narcissism

Many narcissists are well integrated into their social environment and can be extraordinarily successful professionally. Their ambition gives them the drive to creativity, inner growth and high performance. There is evidence that a certain level of narcissism protects against sadness, depression, neuroticism, and anxiety and is conducive to subjective well-being, although this only applies to overt narcissism.

Other narcissists have massive emotional and social problems. Not only covert narcissists are affected, but also open narcissists who, instead of fantasies of omnipotence and invulnerability, cultivate the idea of ​​being unique and therefore believe that they are not understood. Typical problems are emotional instability, hypersensitivity to criticism, overwhelming feelings of shame, depression, divorce, alienation from children, job loss, drug and alcohol abuse, and occasionally delinquency (especially falsification and fraud, but also violence).

Grandiose narcissism and justification thinking

In the ICD-10, a narcissistic type is in the foreground, which is referred to as “grandiose” in the specialist literature. He is cocky and determined and dominant in dealing with others. Many great narcissists manage to occupy influential positions in work or society. Attention and admiration are more important to this type than approval.

In addition to grandiose narcissists, there are narcissists whose appearance is not so much arrogant as it is excessively demanding. Those affected have extremely exaggerated and unrealistic expectations of their surroundings, for example that they will only be treated by the most important people (the highest-ranking waiter, the highest-ranking doctor, etc.). They are convinced that they deserve only the best and that they are not bound by rules that apply to everyone else. They do not dominate their surroundings, but exploit them. For people in the personal environment, this can be e.g. B. If constant attention, service or financial support is expected, it can be extremely stressful. Many narcissists of this type do not make their demands openly, but indirectly, for example by staging their vulnerability, playing out or inventing ailments, diseases or problems, and instilling feelings of guilt and shame in other people. Many narcissists make their demands not because they value their own importance high, but because they are convinced that they are being disadvantaged. In 2013, Robert Ackerman ( University of Texas ) and Brent Donnellan ( Texas A&M University ) presented a scale ( Psychological Entitlement Scala , PES) that can be used to measure narcissistic entitlement.

Robust and vulnerable narcissism

It is widely believed that behind the robust demeanor of many narcissists there is hidden inner insecurity. A meta-study carried out in 2008 did not confirm this “mask thesis”. Grandiose narcissists invest their energy not in friendships, love relationships and family, but preferably in those areas of life in which they can outstrip others.

Many narcissists are not of the robust, but of the vulnerable type. They suffer from low self-esteem and excessive self-doubtful brooding. Outwardly, too, they appear less confident and are overly sensitive to feedback on their behavior. If they don't get what they think they can claim, they feel even further devalued. Vulnerable narcissists are far more prone to envy than grandiose narcissists . Because success means a lot to you, you are also highly susceptible to feelings of shame , which you internalize to such an extent that your expectations of self-efficacy can be impaired. Shame, because it is difficult to endure as a permanent state, often turns into aggression, in which the shame is temporarily forgotten and emotional pressure is released, so that vulnerable narcissists are often caught in a vicious cycle of shame and anger. They react particularly aggressively when they think they are not getting what they deserve.

Vulnerable narcissists find it weak and shameful to have to rely on other people to satisfy their wants and needs, and compensate for this shame by blaming others. Vulnerable narcissists are less inclined to make amends for others because of perceived guilt after misconduct . Instead, they more often experience self-devaluation and social withdrawal through perceived shame . In contrast, in grandiose narcissists, shame-induced behavior is no more common than guilt-induced behavior.

Grandiose narcissism has a significant correlation with extraversion , while vulnerable narcissism has a strong correlation with introversion. Subclinical personality research therefore regards grandiose and vulnerable narcissism as independent traits. On the other hand, clinical evidence suggests that grandiosity is accompanied by vulnerable aspects, suggesting a common basis for both forms. If one considers intro / extraversion as a masking factor, it becomes clear that grandiose and vulnerable narcissism have a common “core”.

Narcissism and perfectionism

Bonelli sharply demarcates narcissism from perfectionism : While the perfectionist is self-insecure and fearful and circling around himself and slips into the mask of the perfect in order to please, the narcissist sees himself boundlessly superior to others due to self-idealization and external devaluation. For this reason, he acts exploitative, manipulative and ruthless. In contrast to the perfectionist, he does not have a fragile, but an excessive self-esteem: According to new studies, narcissists have an excessively positive opinion of themselves even in the unconscious , which refutes the theory of allegedly low self-esteem and lack of self-love (see Erich Fromm ). The narcissist is not incapable of empathy at all , but rather unwilling.

A meta-analysis examined the relationship between perfectionism and narcissism on the basis of 30 studies with a total of over 9,000 participants. The result showed that grandiose narcissists expect perfection from others and portray themselves as perfect. Vulnerable narcissists, on the other hand, try to hide from others any mistakes or weaknesses that they assume in themselves.

distribution

The prevalence of narcissistic personality disorder has been determined in different studies with very different results. While many samples did not contain a person at all who corresponded to the symptom profile, a prevalence of 0.4% and 5.7% was found in others, although to date there are no studies based on the current DSM-5 definition .

As a team of researchers at the University of Illinois showed in 2010, people's narcissistic tendencies are changeable over a lifetime. Pathological narcissism is most pronounced in young adults; H. in the late second and third decade of life. In later years, especially after establishing a stable partnership or a family, it usually subsides; the self becomes less important with this lifestyle change, and attention shifts to loved ones.

People with a narcissistic personality do not seek deep interpersonal closeness, they lack interpersonal trust , so that narcissists may visit a therapist in an acute crisis, such as depression, but may not reveal themselves to him about the deeper problem, so that the disorder may be systematically inadequately captured by statistics.

causes

assumptions

The causes of narcissistic personality disorder have been considered since the early 20th century. Because people with narcissistic personality disorder rarely seek treatment, so that psychiatrists and psychologists have little opportunity to provide therapeutic care for narcissists over a long period of time and to get to know them closely, descriptions of the causes tend to be theoretical and speculative.

The basic assumption that many explanations have in common is that the causes of childhood home education are to be found and that the child is prevented from parents because outgrow the phase of the original infantile narcissism so that it remains permanently in this state and uses it in self-defense, in the absence of alternative means which children usually gradually over-grow.

What the parents do in detail, however, and with what effect, is understood very differently by different authors and schools. Heinz Kohut suspected that parents of narcissists fail to expect a healthy amount of frustration (“optimal frustrations”) from the child, which will help him gradually to find a realistic self-image from the child's grandiosity. Otto Kernberg, on the other hand, classified the parents as cold, strict or even hostile and explained the child's excessive narcissism as a defensive reaction. The loveless parents are not idealized so that the child does not identify with them; in doing so it misses the opportunity to mature and gain strength and to outgrow the original naive grandiosity; the narcissistic child is left to fend for himself. On the other hand, narcissistic children are often those to whom their parents have particularly high hopes and expectations. Arnold Rothstein hypothesized in 1979 that parents of narcissistic children used their child excessively to satisfy their own ambitious pursuits. Theodore Millon proposed a completely different explanation in 1981 , who assumed that narcissists had been accustomed by their parents to be allowed to expect devotion from other people. These authors disagree on the question of whether parental warmth and supervision favor or, on the contrary, prevent the development of narcissistic personality disorders.

It is believed that genetic and psychobiological factors play a role in addition to educational factors. Furthermore, macrocultural (socially sanctioned belief systems, media) and microcultural factors ( peer group influences) must be taken into account.

research

The empirical research focuses on the causes of narcissistic personality disorder only since the early 21st century and has and in addition to social media , especially the parents education in mind.

In the case of Narcissistic Personality Disorder, root cause research has to deal with some specific problems, such as: E.g. that narcissistically disturbed persons may systematically perceive, interpret and remember the behavior of their parents differently than clinically inconspicuous persons. Occasionally it has been criticized that in relevant studies for the assessment of parental home education only the child's representations were used, while the parents were not heard.

A Canadian research team showed in 2008 that narcissistic traits often run through families like an inheritance. Comprehensive, methodologically sound studies on the causes of narcissistic personality disorder are still pending. However, initial data suggest that grandiose narcissism often coincides with parental indulgence , and vulnerable narcissism with emotionally controlling or manipulative parents.

therapy

Although there is little agreement about the causes of narcissistic personality disorder, the most important goal of therapy is promoting the patient's ability to regulate his self-esteem autonomously and to develop a self-concept that is less susceptible to narcissistic insults. This should be achieved through a cautious, step-by-step demonstration of the real limitations of the patient, who at the same time is empathically absorbed in order to be able to accept the disillusioning experiences and incorporate them into his self-concept. More helpful than a confrontational questioning of the patient's need for self-exaggeration is to reinterpret the narcissistic character traits and to use them to build an intact self-image. However, the successes achieved in therapy are usually modest.

Talk therapy is considered to be a suitable form of treatment . A challenge for many therapists is the tendency of narcissistic patients to either question the therapist's authority or, on the contrary, to extremely overestimate him. An alternative is group therapy ; the group gives the narcissist honest feedback on his behavior, but also intercepts him, helping him to develop a more realistic self-image. The therapist also takes a back seat and is seen less as a threat to the patient's grandiosity.

The declaration oriented psychotherapy by Rainer Sachse has developed specific therapeutic approaches, as well as trouble-free and therapy theoretical concepts for the treatment of difficult to treat personality disorders. It is of fundamental importance for therapy that the therapist first perceives the client's central (relationship / interaction) motives and the strongest schemata and reacts to them correctly in order to establish a trusting and productive therapeutic relationship. The therapist can then make the client's previously unconscious and uncontrollable schemas transparent and the disadvantages (“costs”) of his rigid, dysfunctional behavior patterns (explication process, generation of motivation to change). This allows these patterns to be worked on and changed therapeutically with the client, and more sensible alternative courses of action can be developed and stabilized.

Psychotherapeutic treatment is sought by people with narcissistic personality disorder, for example, when they become seriously physically ill, which can sometimes shatter their illusion of being invulnerable and create a feeling of collapse for the entire person. In general, they seek help in acute crises rather than due to the personality disorder; In treatment, therefore, the focus is usually not on the latter, but on the respective crisis. After coping with the crisis, some narcissists continue therapy to better deal with less short-term problems such as depression or interpersonal difficulties.

literature

  • Raphael M. Bonelli : Male Narcissism. The drama of love revolving around itself. Kösel-Verlag, Munich 2016, ISBN 978-3-466-34639-4 .
  • Eva Dieckmann: Treating narcissistic personality disorder with schema therapy. Klett-Cotta, Stuttgart 2011, ISBN 978-3-608-89116-4 .
  • Liebenauer brochures mental health. Volker Faust (Ed.), With the collaboration of Walter Fröscher and Günter Hole and the Psychosocial Health Working Group. Liebenau Foundation, since 2007. Flyer special edition: Narcissism . Foundation Liebenau, Mensch - Medizin - Wirtschaft, Meckenbeuren-Liebenau, approx. 2018. (Can narcissism be treated?).
  • Otto F. Kernberg : Narcissistic personality disorders. Schattauer, Stuttgart 1996, ISBN 3-7945-1692-3 .
  • Otto F. Kernberg, Hans-Peter Hartmann (Ed.): Narcissism. Basics - disorders - therapy. Schattauer, Stuttgart 2006, ISBN 3-7945-2466-7 .
  • Claas-Hinrich Lammers : Psychotherapy of narcissistically disturbed patients: A behavior-oriented approach. Schattauer, Stuttgart 2014, ISBN 978-3-7945-2600-0 .
  • Rainer Sachse , Meike Sachse, Jana Fasbender: Clarification-oriented psychotherapy of narcissistic personality disorder. Hogrefe, Göttingen u. a. 2011, ISBN 978-3-8017-2386-6 .
  • Rainer Sachse : Personality Disorders, Hogrefe, 3rd updated and expanded edition, Göttingen 2019, ISBN 978-3-8017-2906-6 .
  • Winfrid Trimborn: The betrayal of the self. On the violence of narcissistic defense . In: Psyche . tape 57 , no. 11 , 2003, p. 1033-1056 .

documentary

The British television broadcaster Channel 4 first broadcast the documentary Egomania , directed by Mark Soldinger, in 2007 , which deals with the subject using the examples of cult leader David Berg , Brian Blackwell, who was convicted of manslaughter of his parents, and Sam Vaknin, the author and self-victim.

Individual evidence

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  3. ↑ Rainer Sachse, Meike Sachse, Jana Fasbender: Clarification-oriented psychotherapy of narcissistic personality disorder . Hogrefe, Göttingen 2011.
  4. ↑ a b Sachse, Rainer, 1948-: Personality disorders: guidelines for psychological psychotherapy . 3rd, updated and expanded edition. Göttingen, ISBN 978-3-8017-2906-6 .
  5. ↑ a b c d DSM-5 : Descriptive text and criteria for narcissistic personality disorder. In: Diagnostic and statistical manual of mental disorders. Hogrefe, Göttingen et al. 2015, ISBN 978-3-8017-2599-0 , p. 918.
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