Greg Smith

Greg Smith

You know what it looks like, but you may not know what it is called.

You know, the kind of person who is always thinking on a grandiose scale, espousing that he is the best thing ever, that he has powers and skills above mere mortals, and that the earth, moon, sun and all the stars revolve around him. He needs, no, craves, no, requires inordinate amounts of attention to feed his massive ego and just to keep himself on an even keel. He wants everybody to admire him and to marvel at his skills, which he thinks have no equal. He inflates his prowess to giddy heights, even though sometimes the fact of the matter does not quite live up to the myth.

He is a narcissist.

A review of multiple sources found in UpToDate 2019 tells us that he may have many relationships, but almost all of them are superficial, shallow and meaningless. They do nothing but serve him, prop him up and make him feel even more special. When they stop doing this for him, God forbid, he tosses them out like so much trash upon the heap, never to think of them again. He has an exaggerated sense of self-importance, views himself as superior to almost everyone, and feels that he deserves special treatment. He surrounds himself with only the most beautiful, intelligent and wealthy people. He needs to constantly experience himself as the center of attention, regardless of the setting. When others receive the attention that he feels should be directed towards him, he feels slighted, mistreated, depleted and betrayed. He has no empathy. He may have difficulty with attachment and dependency and making himself vulnerable to others.

He values relationships only based on surface attributes, not on anything unique about the other person. If being in a relationship to another person benefits him, all is well. The moment that stops, he discards the other like yesterday’s newspaper. According to two pieces in Personality Disorders from 2014, the narcissist lacks the empathy to feel what others feel. He may be excessively attuned to the reaction of others, but only if reading these reactions benefits him directly.

Narcissistic people may feel profound emptiness, restlessness, or boredom. If attention and praise are not readily available to them, they do not feel or act well. Normal aging and reaching normal milestones may be very hard for narcissists, in that they may find themselves functioning less optimally physically or receiving less praise from others. When they find that they are not as unique or special as they once thought in their youth, this can be devastating.

How common is this condition? According to UpToDate, in the United States and Europe the prevalence of narcissistic personality disorder by DSM-IV criteria is estimated to be up to 6.2 percent. Rates were higher in men than in women. NPD can also occur along with other mental health conditions including mood disorders, anxiety disorders and even other personality disorders. What causes it? An exact cause is not known, but it is thought that genetic vulnerability and heritability might play a part, as could psychosocial issues like parenting, as well as other factors that might affect the provision of care fostering the fulfillment of developmental needs of a small child.

Now, all of this might sound familiar to you, but there is more. The clinical picture I outlined for you above is not the only way that clinical narcissism might express itself. NPD can present in various ways, including a grandiose or overt subtype and a vulnerable or covert subtype. The first you recognize. The second, maybe not so easily. Covert narcissists may be thin-skinned, anxious, distressed and not able to function well in society. They may feel deficient and inferior, might be very inwardly looking and self absorbed, and might be constantly evaluating themselves in relation to those around them. I have seen those who actually change back and forth between one type and the other, and since they tend to be rather rigid and have a hard time coping at the best of times, they are prone to depression, mood swings and poor performance. As you might expect, these folks may be at very high risk for suicide attempts and completed suicides. Add in substance abuse and normal aging, and the risk for suicide goes even higher. When these souls are stressed to the maximum and have burned many relationship bridges, their ability to reach out for help is limited, and things go from bad to worse.

What happens over time to those with narcissistic personality disorder? These clinical features tend to persist over time, and those who have them are often resistant to treatment and meaningful change. A thorough evaluation of someone who presents for treatment might include assessments of personality functioning, a look at relationships and their quality and stability, assessment of capacity for empathy and intimacy, ability to pursue long term goals, and how stable a sense of self already exists. Treatment of co-occuring disorders, which is after all how many of these patients tend to present to a treatment provider in the first place, is important. Help with mood changes, suicidal thoughts, and substance abuse is indicated.

In summary, according to UpToDate, narcissistic personality disorder has the most variable presentation and the widest range of severity of any of the personality disorders. The prevalence in the United States and Europe has been as high as 6.2 percent. Patients often present for treatment of some other, co-occuring disorder. Although the characteristics of grandiosity, arrogance, need for admiration and praise, superficial and exploitative relationships, and lack of empathy are well known, some patients may present with feelings of inferiority, emptiness and boredom and are at risk for self harm or suicide.

Gregory E. Smith, MD, serves as Chief of Psychiatric Services at Aiken Barnwell Mental Health Center. He has been practicing psychiatry for 30 years since he finished a residency in psychiatry at the Medical College of Georgia in Augusta.