Pretty much everyone believes that positive self-esteem, or a positive attitude toward one’s own self-worth and personal value, is healthy.
The notion of self-esteem is a bit of a slippery concept. Certainly, people should feel positive about themselves, but at the same time, they should also be realistic regarding their own capabilities and importance. What happens when people chronically regard themselves as overly important and as being entitled to things just because they are who they are? One consequence may be the diagnosis of a personality disorder in the person.
Narcissistic personality disorder is a psychiatric/psychological disorder that is characterized by the individual having an inflated and unrealistic sense of self-importance and entitlement. This article will discuss the basic presentation of narcissistic personality disorder and how it differs from just having good self-esteem as well as its relationship to substance abuse or substance use disorders.
Disorders of Personality
Personality disorders represent dysfunctional, longstanding, pervasive, and inflexible characteristics that drive nearly every aspect of an individual’s behavior and result in a number of negative consequences for the person and others who interact with that person. The major features of personality disorders are typically observed in individuals who are eventually diagnosed with them relatively early in their development: during adolescence or young adulthood. These patterns of behavior often represent normal qualities of personality, except that they are inflexible, occur in nearly every situation, and are much more intensified than normal variations in personality.
These patterns of behavior violate cultural norms and societal standards, and go far beyond what is expected from normal behavior.
The American Psychiatric Association (APA) recognizes 10 formal personality disorders that are grouped into three different clusters based on their most outstanding features. Narcissistic personality disorder belongs to the Cluster B personality disorders that are perceived as being erratic, emotional, and/or dramatic in nature. The personality disorders recognized by APA are supposed to be mutually exclusive categorical diagnoses; however, there is quite a bit of overlap in different personality disorders, and individuals are often diagnosed with more than one personality disorder. This makes the whole diagnostic system both controversial and at the same time results in diagnosis and treatment of these individuals being somewhat cumbersome. Nonetheless, it remains the current approach to diagnosing personality disorders in the United States.
Narcissistic Personality Disorder
People diagnosed with narcissistic personality disorder have displayed a long-term and overarching pattern of the need to be admired, a feeling of grandiosity or inflated self-importance, and a lack of ability to experience empathy over nearly every context in their lives. This pattern of behavior is evident in early adulthood or adolescence, and results in numerous issues with relationships and ability to function in everyday contexts.
APA has listed nine total diagnostic criteria that are used in the diagnosis of narcissistic personality disorder. An individual must meet at least five of these. The diagnostic criteria will not be presented here, but short descriptions of the behavior observed in this personality disorder are based on the diagnostic criteria. It is important to understand that having inflated self-esteem is not necessarily the sign of a personality disorder and only a licensed mental health care professional can diagnose narcissistic personality disorder in anyone. This information is presented for informational purposes.
According to APA, people diagnosed with narcissistic personality disorder often display the following features.
- They display an inflated or grandiose sense of self-importance such that they exaggerate any achievements or potential talents and constantly expect others to recognize them as superior individuals. This leads to numerous fantasies of having unlimited power, success, or brilliance in their endeavors, and constant fantasies about being idolized.
- Fantasies about being idolized are carried out to the point that individuals with narcissistic personality believe they are special and unique, and they can only be understood by other special and unique individuals. They expect to be admired in every situation or nearly every situation.
- They have a sense of entitlement that is unreasonable, and they expect automatic compliance with their expectations. This results in them being quite exploitative, and they tend to take advantage of others for their own needs.
- These individuals are often envious of other people who achieve things and harbor the belief that other people are envious of them.
- They often demonstrate a definite lack of empathy and cannot recognize or identify the feelings of others. This lack of empathy results in them presenting as arrogant and condescending to others.
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Disorders Comorbid with Narcissistic Personality Disorder
When two disorders are comorbid, this means that they co-occur together. Narcissistic personality disorder is often comorbid with other personality disorders and with substance use disorders. One disorder in particular that is similar to narcissistic personality disorder, and often comorbid with it, is antisocial personality disorder. The primary difference between antisocial personality disorder and narcissistic personality disorder is that individuals with narcissistic personality disorder feel entitled to admiration and having their way and often expect things to come to them; individuals with antisocial personality disorder are more apt to actively work hard and manipulate others to achieve their own goals. People with narcissistic personality disorders alone do often not violate the rights of others; they have expectations of admiration from them. Nonetheless, there is quite a bit of overlap between these two personality disorders.
According to APA, slightly over 60 percent of individuals diagnosed with narcissistic personality disorder have a co-occurring substance use disorder, most often an alcohol use disorder. In men diagnosed with narcissistic personality disorder, this co-occurrence is increased to nearly 70 percent. A little over half of females diagnosed with narcissistic personality disorder have some co-occurring substance use disorder. Individuals diagnosed with a personality disorder and a co-occurring substance use disorder, or two comorbid personality disorders and a substance use disorder, are particularly difficult treatment prospects.
Treatment for Narcissistic Personality Disorder
As might be expected, individuals with narcissistic personality disorder do not actively seek out treatment as their general outline of the world is that they are competent and the rest of the world is dysfunctional. Typically, individuals with this disorder who end up in treatment are referred from other sources or referred to treatment as part of a couple that is experiencing significant issues.
There are no medications that are designed to treat narcissistic personality disorder. The use of medications in the treatment of this disorder is aimed at symptom management and controlling issues with anxiety and depression. Individuals are often given antidepressants or anxiolytic (anti-anxiety) medications.
Standard treatment protocols for these individuals are aimed at getting them to investigate their assumptions about themselves and the world, challenge these assumptions to determine if they are true, and then find more realistic and rational exhalations of their own self-worth, abilities, and potentials. The majority of treatments used for these individuals are cognitive behavioral treatments or cognitive treatments. They include a number of different techniques and approaches that can help them to reach these goals.
Individuals diagnosed with narcissistic personality disorder and a co-occurring substance use disorder require an integrated treatment program to address both issues at the same time. This requires that individuals participate in withdrawal management if necessary, inpatient or outpatient treatment for substance abuse issues as well as issues related to the personality disorder, support group participation, and long-term aftercare treatment for both disorders.