History

Fact Explanation
Need for admiration and other impairments in self functioning of identity. Individuals with narcissistic personality disorder (NPD) have excessive reference to others for self-definition and self-esteem regulation, their exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes and their emotional regulation mirrors fluctuations in self-esteem. According to DSM -5 to diagnose narcissistic personality disorder, an individual must have a significant impairment in personality functioning in both self functioning and interpersonal functioning. Identity is one of the two categories in self functioning in which one of the impairments described above need to be present to diagnose NPD.[1][2]
Impairments in self-direction Because of their need for admiration, in individuals with NPD, goal-setting is based on gaining approval from others and their personal standards are unreasonably high in order of seeing oneself as exceptional, or too low based on a sense of entitlement. They are often unaware of one's own motivations. Self direction is one of the two categories in impairment of self functioning, which is needed to diagnose NPD. [1][2]
Lack of empathy Empathy is the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another. Though Individuals with NPD are excessively attuned to reactions of others, they have impaired ability in recognising or identifying the feelings and needs of others; as they are attentive only if subject is perceived as relevant to self and also because they tend to over- or underestimate of own effect on others. Lack of empathy is an impairment in interpersonal functioning, which needs to cause significant impairment of personality functioning for diagnosis of antisocial personality disorder.[1][2]
Lack of intimacy Individuals with NPD hasve an Incapacity for mutually intimate relationships, as their relationships are largely superficial and exist to serve self-esteem regulation. Relationships are mutuality constrained with little genuine interest in others' experiences and the predominance of a need for personal gain. Lack of intimacy is an impairment in interpersonal functioning, which needs to cause significant impairment of personality functioning for diagnosis of antisocial personality disorder.[1][2]
Grandiosity Individuals with NPD are self-centered,firmly holding to the belief that one is better than others and have feelings of entitlement, either overt or covert, leading to condescending attitudes and behaviour toward others. It is one of the two pathological personality traits in the domain of antagonism, which is needed for a diagnosis of NPD to be made.[1][2]
Attention seeking trait Individuals with NPD make excessive attempts to be the focus of the attention and attract others because of their admiration seeking tendencies.[1][2]
References
  1. DSM-IV and DSM-5 Criteria for the Personality Disorders. American Psychiatric Association. 2012. [viewed on 06 June 2014] Available from: http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_personalidad_psicosis/material/dsm.pdf
  2. Alternative DSM-5 Model for Personality Disorders. Focus [online] 2013 March [viewed 07 June 2014] Available from: doi:10.1176/appi.focus.11.2.189

Examination

Fact Explanation
Mental State Examination: Appearance and Behaviour Individuals take great care in appearance because of need for admiration and exaggerated sense of self value and self importance. May tend to overdress as method of gaining admiration and due to grandiosity. May demonstrates condescending behavior and behavior that is inappropriate to station due to sense of exaggerated self importance. Attention seeking behavior is prominent.[1]
Mental State Examination: Speech Speech will be coherent rational but content maybe condescending or inappropriate due to grandiosity.[1][2]
Mental State Examination: Mood Mood will be euthymic,euphoric or dysphoric depending on situation as emotional regulation mirrors fluctuations in self-esteem.[1][3]
Mental State Examination: Thoughts Grandiosity will be the most prominent content in thought. No abnormalities in form of thought will be present.[1]
Mental State Examination: Perception No perceptual abnormalities are associated with antisocial personality disorder.
Mental State Examination: Cognitive functions Orientation,attention,concentration and memory will be within normal range. [1]
Insight Will often not accept the presence of a disorder or need for treatment.[1][2]
References
  1. Alternative DSM-5 Model for Personality Disorders. Focus [online] 2013 March [viewed 07 June 2014] Available from: doi:10.1176/appi.focus.11.2.189
  2. RUSS E., SHEDLER J., BRADLEY R., WESTEN D.. Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes. American Journal of Psychiatry [online] 2008 November, 165(11):1473-1481 [viewed 16 July 2014] Available from: doi:10.1176/appi.ajp.2008.07030376
  3. RONNINGSTAM E, BASKIN-SOMMERS AR. Fear and decision-making in narcissistic personality disorder-a link between psychoanalysis and neuroscience. Dialogues Clin Neurosci [online] 2013 Jun, 15(2):191-201 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24174893

Differential Diagnoses

Fact Explanation
Narcissistic personality traits According to DSM-5, certain pathological personality traits and significant impairments in personality functioning in the categories of self and interpersonal functioning needs to be present for a diagnosis of narcissistic personality disorder (NPD) to be made. The impairments in personality functioning and the individual's personality trait expression should also be relatively stable across time and consistent across situations. An individual may have one or many of the personal traits associated with narcissistic personality disorder without them being significant enough to be classified into a personality disorder. [1][2][3]
borderline personality disorder An individual with histrionic personality disorder will have attention seeking behaviour similar to NPD, but it will be associated with insecurities of a markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism and chronic feelings of emptiness.[1][4][5]
Antisocial personality disorder An individual with antisocial personality disorder may display self centeredness and lack of empathy similar to NPD. But unlike in NPD , it stems from a lack of concern for feelings, needs, or suffering of others complete disregard for others.[1] [2][5]
Histrionic personality disorder Histrionic personality disorder is associated with attention seeking behavior, self centeredness and craving for admiration,but unlike in NPD it is characterized by self dramatization, over concern for with physical appearancee and easy suggestibility.[1][4]
References
  1. Alternative DSM-5 Model for Personality Disorders. Focus [online] 2013 March [viewed 16 July 2014] Available from: doi:10.1176/appi.focus.11.2.189
  2. ROTTMAN B. M., AHN W.-K., SANISLOW C. A., KIM N. S.. Can Clinicians Recognize DSM-IV Personality Disorders From Five-Factor Model Descriptions of Patient Cases?. American Journal of Psychiatry [online] 2009 April, 166(4):427-433 [viewed 16 July 2014] Available from: doi:10.1176/appi.ajp.2008.08070972
  3. WESTEN DREW. A Prototype Approach to Personality Disorder Diagnosis. Am J Psychiatry [online] 2006 May [viewed 16 July 2014] Available from: doi:10.1176/appi.ajp.163.5.846
  4. RUSS E, SHEDLER J, BRADLEY R, WESTEN D. Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry [online] 2008 Nov, 165(11):1473-81 [viewed 16 July 2014] Available from: doi:10.1176/appi.ajp.2008.07030376
  5. DSM-IV and DSM-5 Criteria for the Personality Disorders. American Psychiatric Association. 2012. [viewed on 06 June 2014] Available from: http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_personalidad_psicosis/material/dsm.pdf

Management - General Measures

Fact Explanation
Develop a successful relationship among patient and psychiatrist/therapist. As insight is poor and treatment is often refused by patients with personality disorders building up an effective therapeutic relationship is crucial as the first step of management. [1][2]
Insight oriented approach Poor insight is one of the main barriers to treatment, therefore building insight is essential in treating personality disorders.[1]
treatment of coexistent psychiatric symptoms antidepressants,mood stabilizers and antipsychotic drugs are sometimes prescribed in the management of individuals with Narcissistic personality disorder ,who have prominent symptoms of other psychiatric disorders.
References
  1. RUSS E., SHEDLER J., BRADLEY R., WESTEN D.. Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes. American Journal of Psychiatry [online] 2008 November, 165(11):1473-1481 [viewed 16 July 2014] Available from: doi:10.1176/appi.ajp.2008.07030376
  2. TYRER P, MULDER R, CRAWFORD M, NEWTON-HOWES G, SIMONSEN E, NDETEI D, KOLDOBSKY N, FOSSATI A, MBATIA J, BARRETT B. Personality disorder: a new global perspective World Psychiatry [online] 2010 Feb, 9(1):56-60 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816919

Management - Specific Treatments

Fact Explanation
psychotherapy Psychodynamic psychotherapy and short-term objective-focused psychotherapy is used in treatment of personality disorders.[1] [2]
cognitive behavioral therapy Cognitive and behavioral interventions include reasoning and rehabilitation and enhanced thinking skills. Cognitive therapy maybe as effective as psychotherapy in the treatment of personality disorders. [1][2]
Training in social skills and problem solving When combined with cognitive behavioral interventions, has a high efficacy.
References
  1. TYRER P, MULDER R, CRAWFORD M, NEWTON-HOWES G, SIMONSEN E, NDETEI D, KOLDOBSKY N, FOSSATI A, MBATIA J, BARRETT B. Personality disorder: a new global perspective World Psychiatry [online] 2010 Feb, 9(1):56-60 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816919
  2. RUSS E, SHEDLER J, BRADLEY R, WESTEN D. Refining the construct of narcissistic personality disorder: diagnostic criteria and subtypes. Am J Psychiatry [online] 2008 Nov, 165(11):1473-81 [viewed 16 July 2014] Available from: doi:10.1176/appi.ajp.2008.07030376