Understanding Narcissistic Personality

Impacts, Diagnosis, Contributing Factors, Treatment & Prognosis

Courtney Snyder MD

Jun 02, 2024

Why This Understanding Matters

Everyone is impacted: We all have or will be impacted by someone with narcissistic traits.
Incidence of Narcissistic Personality Disorder (NPD): 0.5%-5%. As with anything, this occurs on a spectrum. Not everyone with traits will meet the criteria for a disorder.
Suffering: For those with NPD, significant suffering can result from relationship and work difficulties or losses. There is also a greater risk of legal issues.
The suffering of others: Those in a relationship with someone with narcissistic personality traits also suffer. Many would argue they suffer more. They can experience damage to their self-worth, confidence, sense of reality, other relationships, and even financial security.
Avoidance of mental health services: Those with narcissistic traits don’t see themselves as having a problem.
Can be covert: The traits are not always obvious. It may take years for children, partners, spouses, and friends to realize how much of their own energy and resources have gone to serve the fragile ego of a person with narcissistic traits.

Terminology

“Narcissism” comes from Greek mythology; Narcissus is a hunter captivated by his reflection in water.
Diagnostic & Statistical Manual-5 describes Narcissistic Personality Disorder as a “pervasive pattern of grandiosity, need for admiration, and lack of empathy, with interpersonal entitlement, exploitativeness, arrogance, and envy.”
Disorder: To be defined as a disorder, the traits must be “inflexible, maladaptive and persisting and cause significant functional impairment or subjective distress.”
Criticism of the DSM criteria: This definition relies on external social features. It doesn’t consider internal states of vulnerability, insecurity, self-criticism, shame, feelings of loneliness, emotional dysregulation, identity confusion, or fear.
Empathy: Despite the DSM definition, many with NP are aware of others' emotions. The problem is how they use that understanding in a self-serving way.

Diagnosis: Five of Nine Traits Required

Grandiose sense of self-importance, e.g. exaggerates achievement and talents
Fantasies of unlimited success - power, brilliance, beauty, or ideal love
Believe they are “special” and can only be understood by other special or high-status people or institutions
Require excessive admiration
Sense of entitlement, i.e., unreasonable expectations of especially favorable treatment
Take advantage of others to achieve his/her own ends
Lack empathy; are unwilling to recognize or identify with the feelings and needs of others
Envious of others or believes that others are envious of him/her
Arrogant, haughty behaviors or attitudes

Contributing Factors

Alignment of factors: There appear to be genetic, biochemical, and structural differences.
Genetic: Those with NPD are more likely to have family members with NPD. Narcissistic parents, however, can contribute more than their genes.
Early childhood experiences also appear to contribute.
Psychoanalytic theory describes parent(s) lacking warmth, affection, and expressed appreciation.
Other psychological models reflect two ends of a parenting spectrum - trauma, rejection, lack of support on one end, and overindulgence and overprotection on the other end.
Opposing Constructs: While these two types of parenting may seem in opposition, both reflect a lack of attunement to the appropriate emotional needs of the child. Such parents likely had their own insecure attachment experiences.
Attachment: Naturally, children align their thoughts and behaviors to increase proximity to and responsiveness from their caregiver. In the case of NPD, there may have been a need to go to lengths for attention from a disengaged parent - as if to exaggerate their worthiness. With overindulgent (and thus anxious parents), a child may only feel secure when aligning with the parent's need to overindulge. In a healthier dynamic, a child doesn’t need to focus on their parent's emotions. They are confident in their connection to their parent and can pay attention to their own internal states.
Left brain tendencies: The right brain is activated (and thus strengthened during the attachment experience.

‘The left’s hemisphere’s world is ultimately narcissistic’. It is ‘driven forward by a desire for power and control’. It has a tendency for ‘dangerously unwarranted optimism’. It ‘sees itself as the passive victim of whatever it is unaware of having willed’. - Ian McGilcrest (Psychiatrist and author of the “Master and His Emissary, The Divided Brain & the Making of the Western World”.

Culture: Cultural values such as prioritizing the individual over the collective may also contribute.

Is Undermethylation at Play?

Undermethylation Traits: Methylation is a biochemical process that does several things in the body and brain. Those who under-methylate are more likely to be driven, competitive, perfectionistic, strong-willed, and have obsessive and addictive tendencies (among other traits).
Likely Undermethylated: From the Walsh Research (WRI) Institute, we know that 95% of those with antisocial personality disorder are undermethylated. WRI does not have data for NPD, however, it is very like most are undermethylated. Some may have pyrrole disorder and or high copper. Most of the conditions listed below that can co-occur with NPD align with undermethylation.

What Other Conditions May Be Present?

Personality disorder comorbidities: Antisocial, histrionic, borderline, paranoid, obsessive-compulsive, and schizotypal personality disorder
Mood comorbidities: Major depressive disorder, dysthymia, and bipolar disorder
Substance use comorbidities: Alcohol abuse, alcohol dependence, and drug dependence
Other comorbidities: Anorexia nervosa, generalized anxiety disorder, specific phobia, and PTSD

Are There Differences in the Brain?

Subtle structural brain differences, especially in areas associated with empathy, emotional regulation, and processing about the self. *
Seeming alternations in neuronal connections, especially in regions that appear to be involved in social understanding.*
Linguistics research (into what people say and how they say it) is being examined in the context of structural and functional brain research.*

Can NPD Be Treated?

Treatment involves psychotherapy: The most studied and effective therapies share common aspects, including:
Setting clear, realistic goals to counter grandiose and unrealistic goals.
Attention to relationships to increase the recognition of the experience of others.
Attention to self-esteem so they can learn worth beyond titles, accomplishments, appearance, money, etc.
Learn how to work with a therapist: This can be difficult for someone who feels most secure when in control of others (and difficult if they are not in therapy).
There is no medication for NPD, though some of the comorbidities, such as depression, can benefit from medication.
Address nutrient imbalances: In my work, priorities (in addition to therapy) would be to assess for and address the Walsh nutrient imbalances, which, again, would likely be undermethylation in combination with pyrrole disorder and/or copper-zinc imbalance.

Prognosis & Course

Prognosis: Based only on the use of psychotherapy, studies show that those with NPD can improve, though it can be relatively slow. The biggest challenge is that most with NPD avoid treatment.
Alzheimer's Risk: There is evidence that there is an increased risk of Alzheimer's in those with narcissistic traits. *
Frontal Temporal Dementia (FTD) is another form of dementia. Rather than memory problems, as seen in Alzheimer’s, early symptoms can include acting inappropriately or impulsively, appearing selfish or unsympathetic, neglecting personal hygiene, overeating, or loss of motivation. Problems with language, attention, and planning begin before obvious memory problems.*
Differential Diagnosis: If there is a new onset of narcissistic traits in an adult, FTD should be considered.*
Prodrome: For some, narcissistic personality may be a prodromal condition - an earlier manifestation of frontal lobe dementia.*

I hope I’ve helped broaden your understanding of this often-referenced topic.

In the next newsletter, I’ll discuss:

Cultural implications, references, and terms related to narcissism.
Preferred partners, spouses, and friends (not necessarily who you’d think)
Traits of those who find themselves in these relationships
Collateral damage and how narcissistic traits harm others
Tools for self-preservation and healing for those who know or have been harmed by someone with narcissistic traits.

I welcome any comments or questions I may incorporate into the next newsletter.

Until next time,

Courtney

Holistic Psychiatry

Discussion about this post