History
Patients with narcissistic personality disorder (NPD) often present to the healthcare professional after hitting “rock bottom” in their careers or personal lives or at the strong urging of a family member who insists that they get professional help for their behavior.
Because NPD, by its nature, involves a haughty disregard for others and an insistence on one’s own innate superiority, narcissistic patients are unlikely to recognize their need for treatment and even less likely to seek help of their own accord. For this reason, patients with a diagnosis of NPD alone (ie, with no concomitant axis I diagnoses) make up a very small percentage of the total patient population seen by mental health professionals.
To be diagnosed with NPD, a patient must demonstrate a consistent and long-standing pattern of maladaptive behavior, starting in adolescence or early adulthood, that exemplifies 5 or more of the 9 criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). [1] (See Overview.) Although many people display these criteria to some degree, NPD is diagnosed only when the symptoms are pervasive, debilitating, and socially and personally destructive.
Patients with NPD are also acutely sensitive to rejection or criticism and may avoid people or situations where there is the possibility of feeling “less than.” When criticized, such patients may become furious and lash out or withdraw into a shell of sullen hate. At their core, both of these reactions are thought to be due to intrinsically low self-esteem or a feeling of inferiority. [1]
Physical Examination
Narcissistic personality disorder (NPD) is not associated with any specific defining physical characteristics. [15] However, physical consequences of the abuse of substances (particularly cocaine and alcohol), with which NPD is often associated, may also be apparent on examination.
Mental status examination (MSE) may reveal depressed mood due to dysthymia or major depressive disorder, both of which may be related to the paradoxically low self-esteem often present in patients with NPD. Conversely, patients in the throes of narcissistic grandiosity may display signs of hypomania or mania. [1]
The following is a sample MSE for a patient with NPD:
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General appearance and behavior - Well-groomed, well-dressed male in no acute distress
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Attitude - Resistant and haughty
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Psychomotor activity - Normal, no agitation or retardation
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Eye contact - Intense
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Affect - Restricted
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Mood - Angry
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Speech - Normal rate and tone, high volume; no pressured speech
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Thought process - No evidence of thought blocking, flight of ideas, loose associations, or ideas of reference; some tangentiality present
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Thought content - Denies suicidal ideation and homicidal ideation; denies audiovisual hallucinations; no paranoid delusions elicited or endorsed
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Orientation - Oriented to person, place, and time
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Attention and concentration - Good
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Insight - Poor
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Judgment - Limited
The video below includes an actor’s portrayal of an individual with NPD.
Complications
In general, patients with cluster B personality disorders (including narcissistic, borderline, antisocial, and histrionic personality disorders) are at substantially greater risk for suicide. In patients with narcissistic personality disorder (NPD) in particular, sudden life stressors (eg, job loss or unexpected financial misfortune) can lead to “surprise” or “shame” suicides. [16] Patients with NPD are also at increased risk for substance abuse—specifically, abuse of cocaine and alcohol.
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This is an actor portrayal of a patient with narcissistic personality disorder. This video clip was provided courtesy of Donald C. Fidler, MD, FRCP-I.
