Narcissistic personality disorder

This article is about the medical condition. For more information on clinical research and types of narcissism, see Narcissism.
Narcissistic Personality Disorder

Narcissus by Caravaggio, gazing at his own reflection.
Classification and external resources
Specialty Psychiatry
ICD-10 F60.8
ICD-9-CM 301.81
MedlinePlus 000934
MeSH D010554

Narcissistic personality disorder (NPD) is a personality disorder, characterized by exaggerated feelings of self-importance, excessive need for admiration, and lack of empathy for others.[1] People with the disorder often come across as arrogant, callous, and envious, tend to be exploitative in their interpersonal relationships, and can be excessively preoccupied with personal adequacy, power, prestige and vanity. As a personality disorder, those with NPD generally have poor insight into their condition and may not acknowledge that their behavior causes problems for others or themselves.

It is estimated that NPD affects between zero and five percent of the population.[1] Males are affected more often than females. First formulated in 1968, NPD was historically called megalomania, and is a form of severe egocentrism.[2]

It is classified as a cluster B personality disorder by the Diagnostic and Statistical Manual of Mental Disorders.[3]

Signs and symptoms

People with narcissistic personality disorder are characterized by their persistent grandiosity, excessive need for accolades, and willful lack of empathy for others.[4][5] These individuals often display arrogance, a sense of superiority, and power-seeking behaviors.[6] Narcissistic personality disorder is different than having a strong sense of self-confidence; people with NPD value themselves over others to the extent that they disregard the feelings and wishes of others and expect to be treated as superior regardless of their actual status or achievements.[4][7] In addition, people with NPD may have fragile egos, an inability to tolerate criticism, and a tendency to belittle others in an attempt to validate their own superiority.[7]

According to the DSM-5, individuals with NPD have most or all of the following symptoms, typically without commensurate qualities or accomplishments:[4][7]

NPD develops by adolescence or early adulthood.[4] It is not uncommon for children and teens to display some traits similar to NPD, but these are typically transient without meeting full criteria for the diagnosis.[7] True NPD symptoms are pervasive and apparent in various situations, as well as rigid, remaining consistent over time. Symptoms are severe enough that they significantly impair the individual's ability to develop meaningful relationships with others or their ability to function at work, school, or in other important settings. According to the DSM-5, these traits must differ substantially from the cultural norms of the individual's society in order to qualify as symptoms of NPD.[4]

Associated features

People with NPD tend to exaggerate their skills and accomplishments as well as their level of intimacy with people they consider to be high-status. Their sense of superiority may cause them to monopolize conversations[7] and to become impatient or disdainful when others talk about themselves.[4] In the course of conversation, they may purposefully or unknowingly disparage or devalue the other person by overemphasizing their own success. When they are aware that their statements have hurt someone else, they tend to react with contempt and to view it as a sign of weakness.[4] When their own ego is wounded by a real or perceived criticism, their anger can be disproportionate to situation,[7] but typically, their actions and responses are deliberate and calculated.[4] Despite occasional flare-ups of insecurity, their self-image is primarily stable (i.e., overinflated).[4]

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others' needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen.[4] Narcissistic individuals use various strategies to protect the self at the expense of others. They tend to devalue, derogate, insult, blame others and they often respond to threatening feedback with anger and hostility.[8] Since the fragile ego of individuals with NPD is hypersensitive to perceived criticism or defeat, they are prone to feelings of shame, humiliation and worthlessness over minor or even imagined incidents.[7] They usually mask these feelings from others with feigned humility, isolating socially or they may react with outbursts of rage, defiance, or by seeking revenge.[4][5] The merging of the "inflated self-concept" and the "actual self" is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defense mechanisms of denial, idealization and devaluation.[9]

According to the DSM-5, "Many highly successful individuals display personality traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute narcissistic personality disorder."[4] Although overconfidence tends to make individuals with NPD ambitious, it does not necessarily lead to success and high achievement professionally. These individuals may be unwilling to compete or may refuse to take any risks in order to avoid appearing like a failure.[4][5] In addition, their inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional relationships with superiors and colleagues.[10]

Subtypes

While the DSM-5 regards narcissistic personality disorder as a homogeneous syndrome, there is evidence for wide variations in its expression and psychopathology among people who fall under the diagnosis.[1] Two major presentations of narcissism are typically identified, a "overt" or "grandiose" subtype, characterized by grandiosity, arrogance and boldness, and a "covert" or "vulnerable" subtype characterized by defensiveness and hypersensitivity.[1] Those with "narcissistic grandiosity" express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."[11] "Narcissistic vulnerability" entails (on a conscious level) "helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behavior as being socially avoidant in situations where their self-presentation is not possible so they withdraw, or the approval they need/expect is not being met."[11] In addition, a "high-functioning" presentation, where there is less impairment in the areas of life where those with a more severe expression of the disorder typically have difficulties in, is suggested.[1]

Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes.[12] He saw the "oblivious" subtype as being grandiose, arrogant, and thick-skinned, and the "hypervigilant" subtype as being easily hurt, oversensitive, and ashamed. In his view, the oblivious subtype presents for admiration, envy, and appreciation of a powerful, grandiose self that is the antithesis of a weak internalized self, which hides in shame, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers. It has been suggested that narcissistic personality disorder may be related to defenses against shame.[13] Jeffrey Young, who developed schema therapy based on the work of psychiatrist Aaron T. Beck and others, also links NPD and shame. He sees the so-called Defectiveness Schema as a core schema of NPD, along with the Emotional Deprivation and Entitlement Schemas.[14]

Causes and mechanisms

The cause of this disorder is unknown.[7][15] Experts tend to apply the biopsychosocial model,[16] meaning that a combination of environmental, social, genetic and neurobiological factors likely play a role.[16][15]

Genetic

There is evidence that narcissistic personality disorder is heritable, but the specific genes that contribute to its etiology have yet to be determined.[16][17] Studies on the occurrence of personality disorders in twins determined that there is a moderate to high heritability for narcissistic personality disorder.[17][18] Individuals are much more likely to develop NPD if they have a vulnerability to the disorder in their genetic profile.[16]

Environment

Environmental and social factors are also thought to have a significant influence on the onset of NPD.[16] In some people, pathological narcissism may develop from an impaired attachment to their primary caregivers, usually their parents.[19] This can result in the child's perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.[20] Overindulgent, permissive parenting as well as insensitive, over-controlling parenting, are believed to be contributing factors.[7][15]

According to Groopman and Cooper (2006), the following factors have been identified by various researchers as possible causes of NPD:[21]

Cultural elements are believed to influence the prevalence of NPD as well since NPD traits have been found to be more common in modern societies than in traditional ones.[16]

Neurobiology

There is little research into the neurological underpinnings of narcissistic personality disorder. Nevertheless, recent research has identified a structural abnormality in the brains of those with narcissistic personality disorder, specifically noting less volume of gray matter in the left anterior insula.[22][23] Another study has associated the condition with reduced gray matter in the prefrontal cortex.[24] The brain regions identified in these studies are associated with empathy, compassion, emotional regulation, and cognitive functioning. These findings suggest that narcissistic personality disorder is related to a compromised capacity for emotional empathy and emotional regulation.[25]

Diagnosis

DSM-5

The formulation of narcissistic personality disorder in DSM-IV was criticised for failing to describe the range and complexity of the disorder. Critics say it focuses overly on "the narcissistic individual's external, symptomatic, or social interpersonal patterns—at the expense of ... internal complexity and individual suffering," which reduces its clinical utility.[26]

The Personality and Personality Disorders Work Group originally proposed the elimination of NPD as a distinct disorder in DSM-5 as part of a major revamping of the diagnostic criteria for personality disorders,[27][28] replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains.

Some clinicians objected to this, characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice.[29]

In July 2011, the Work Group came back with a major revision to their original proposal. In this revision, NPD was reinstated with dramatic changes to its definition.[30] The general move towards a dimensional (personality trait-based) view of the Personality Disorders has been maintained despite the reintroduction of NPD.

ICD-10

The World Health Organization's ICD-10 lists narcissistic personality disorder under (F60.8) Other specific personality disorders.[31]

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Other

Theodore Millon identified five subtypes of narcissism.[32][33] However, there are few pure variants of any subtype,[33] and the subtypes are not recognized in the DSM or ICD.

Subtype Description Personality Traits
Unprincipled narcissist Including antisocial features. Deficient conscience; unscrupulous, amoral, disloyal, fraudulent, deceptive, arrogant, exploitive; a con artist and charlatan; dominating, contemptuous, vindictive.
Amorous narcissist Including histrionic features. Sexually seductive, enticing, beguiling, tantalizing; glib and clever; disinclines real intimacy; indulges hedonistic desires; bewitches and inveigles others; pathological lying and swindling.
Compensatory narcissist Including negativistic and avoidant features Seeks to counteract or cancel out deep feelings of inferiority and lack of self-esteem; offsets deficits by creating illusions of being superior, exceptional, admirable, noteworthy; self-worth results from self-enhancement.
Elitist narcissist Variant of “pure” pattern. Feels privileged and empowered by virtue of special childhood status and pseudo achievements; entitled façade bears little relation to reality; seeks favored and good life; is upwardly mobile; cultivates special status and advantages by association.
Malignant narcissist Including antisocial, sadistic and paranoid features. Fearless, guiltless, remorseless, calculating, ruthless, inhumane, callous, brutal, rancorous, aggressive, biting, merciless, vicious, cruel, spiteful, ; hateful and jealous; anticipates betrayal and seeks punishment; desires revenge; Has been isolated, and is often suicidal, and is homicidal.

Will Titshaw also identified three sub-types of narcissistic personality disorder which are not officially recognized in any editions of the DSM or the ICD.

Subtype Description Description
Pure Narcissist Mainly just NPD characteristics. Someone who has narcissistic features described in the DSM and ICD and lacks features from other personality disorders.
Attention Narcissist Including histrionic (HPD) features. They display the traditional NPD characteristics described in the ICD & DSM along with histrionic features due to the fact that they think they're superior and therefore they should have everyone's attention, and when they don't have everyone's attention they go out of their way to capture the attention of as many people as possible.
Beyond The Rules Narcissist Including antisocial (ASPD) features. This type of narcissist thinks that because they're so superior to everyone they don't have to follow the rules like most people and therefore because of this reason shows behavior included in the ICD for dissocial personality disorder and behavior included in the DSM for antisocial personality disorder.

Comorbidity

NPD has a high rate of comorbidity with other mental disorders.[16] Individuals with NPD are prone to bouts of depression, often meeting criteria for co-occurring depressive disorders.[15] In addition, NPD is associated with bipolar disorder, anorexia, and substance use disorders,[5] especially cocaine.[4] As far as other personality disorders, NPD may be associated with histrionic, borderline, antisocial, and paranoid personality disorders.[4]

Treatment

Narcissistic personality disorder is rarely the primary reason for people afflicted with the disorder for seeking mental health treatment. When people with NPD enter treatment, it's typically prompted by life difficulties or to seek relief from another disorder, such as major depressive disorder, substance use disorders, bipolar disorder, or eating disorders,[5] or at the insistence of relatives and friends. This is partly because individuals with NPD generally have poor insight and fail to recognize their perception and behavior as inappropriate and problematic.

Treatment for NPD is centered around psychotherapy.[7] In the 1960s, Heinz Kohut and Otto Kernberg challenged the conventional wisdom of the time by outlining clinical strategies for using psychoanalytic psychotherapy with clients with NPD that they claimed were effective in treating the disorder. Contemporary treatment modalities commonly involve transference-focused, metacognitive, and schema-focused therapies. Some improvement might be observed through the treatment of symptoms related to comorbid disorders with psychopharmaceuticals, but as of 2016. According to Elsa Ronningstam, psychologist at Harvard Medical School, "Alliance building and engaging the patient’s sense of agency and reflective ability are essential for change in pathological narcissism."[5]

Pattern change strategies, done over a long period of time, are used to increase the ability of those with NPD to become more empathetic in everyday relationships. To help modify their sense of entitlement and self-centeredness schema, the strategy is to help them identify how to utilize their unique talents and to help others for reasons other than their own personal gain. This is not so much to change their self-perception of their "entitlement" feeling but more to help them empathize with others. Another type of treatment would be temperament change.[34]

Anger, rage, impulsivity and impatience can be worked on with skill training. Therapy may not be effective because patients may receive feedback poorly and defensively. Anxiety disorders and somatoma dysfunctions are prevalent but the most common would be depression. Psychoanalytic psychotherapy may be effective in treating NPD, but therapists must recognize the patient’s traits and use caution in tearing down narcissistic defenses too quickly.

Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted, but group therapy can also contradict itself as the patient may show "demandingness, egocentrism, social isolation and withdrawal, and socially deviant behavior." Researchers originally thought group therapy among patients with would fail because it was believed that group therapy required empathy that NPD patients lack. However, studies show group therapy does hold value for patients with NPD because it lets them explore boundaries, develop trust, increase self-awareness, and accept feedback. Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: "...effective expression, empathy, discussion and problem solving/conflict resolution."

No medications are indicated for treating NPD, but may be used to treat co-occuring mental conditions, or symptoms that may be associated with it such as depression, anxiety and impulsiveness if present.[7]

Marital/relationship therapy is most beneficial when both partners participate.[34]

Prognosis

The effectiveness of psychotherapeutic and pharmacological interventions in the treatment of narcissistic personality disorder have yet to be systematically and empirically investigated. Clinical practice guidelines for the disorder have not yet been created, and current treatment recommendations are largely based on theoretical psychodynamic models of NPD and the experiences of clinicians with afflicted individuals in clinical settings.[1]

The presence of NPD in patients undergoing psychotherapy for the treatment for other mental disorders is associated with slower treatment progress and higher dropout rates.[1]

Epidemiology

Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.[21][35]

In 2009, Twenge and Campbell conducted studies suggesting that the incidence of NPD had more than doubled in the US in the prior 10 years, and that 1 in 16 of the population have experienced NPD.[36]

"A nationwide study in the United States found that 7.7 percent of men and 4.8 percent of women could be diagnosed with narcissistic personality disorder (Stinson et al., 2008). These data also suggest that narcissistic personality disorder is more prevalent among younger adults, possibly supporting the impression that narcissistic personality disorder is on the rise as a result of social and economic conditions that support more extreme versions of self-focused individualism (Bender, 2012)."[37]

Narcissistic personality disorder in fiction

In the film To Die For, Nicole Kidman's character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder."[38]

Other examples in popular fiction include television characters Adam Demamp[39] (portrayed by Adam DeVine in Workaholics) and Dennis Reynolds (portrayed by Glenn Howerton in It's Always Sunny in Philadelphia).

History

The use of the term "narcissism" to describe excessive vanity and self-centeredness predates by many years the modern medical classification of narcissistic personality disorder. The condition was named after Narcissus, a mythological Greek youth who became infatuated with his own reflection in a lake. He did not realize at first that it was his own reflection, but when he did, he died out of grief for having fallen in love with someone that did not exist outside of himself.

The term "narcissistic personality structure" was introduced by Kernberg in 1967[40] and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.[41]

Criticism

A Norwegian study concluded that narcissism should be conceived as personality dimensions pertinent to the whole range of PDs rather than as a distinct diagnostic category.[42] Alarcón and Sarabia concluded that narcissistic personality disorder shows such inconsistency that it should be considered as a trait domain instead of as a type of disorder.[43]

See also

References

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  2. ↑ R. Kayne, ed. L.S. Wynn (4 March 2013). "What is Megalomania?". Wise Geek. Conjecture. Archived from the original (Internet Archive) on 11 March 2013. Retrieved 16 April 2014.
  3. ↑ Narcissistic personality disorder – Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000)
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Arlington: American Psychiatric Publishing, pp. 669–672, ISBN 0890425558
  5. 1 2 3 4 5 6 Ronningstam, Elsa (2016), "New Insights Into Narcissistic Personality Disorder", Psychiatric Times 33 (2): 11
  6. ↑ Ronningstam E (2011). "Narcissistic personality disorder: a clinical perspective". J Psychiatr Pract 17 (2): 89–99. doi:10.1097/01.pra.0000396060.67150.40. PMID 21430487.
  7. 1 2 3 4 5 6 7 8 9 10 11 Mayo Clinic Staff (18 Nov 2014), "Narcissistic personality disorder: Symptoms", Mayo Clinic (Mayo Foundation for Medical Education and Research), retrieved 29 Apr 2016
  8. ↑ Ronningstam, Elsa F, Identifying and understanding the narcissistic personality, Oxfard University Press Inc
  9. ↑ Siegel JP (2006). "Dyadic splitting in partner relational disorders". J Fam Psychol 20 (3): 418–22. doi:10.1037/0893-3200.20.3.418. PMID 16937998.
  10. ↑ Golomb, Elan (1992), Trapped in the Mirror, New York: Morrow, p. 22
  11. 1 2 Pincus AL, Ansell EB, Pimentel CA, Cain NM, Wright AG, Levy KN; Ansell; Pimentel; Cain; Wright; Levy (2009). "Initial construction and validation of the Pathological Narcissism Inventory". Psychol Assess 21 (3): 365–79. doi:10.1037/a0016530. PMID 19719348.
  12. ↑ Gabbard GO (1989). "Two subtypes of narcissistic personality disorder". Bull Menninger Clin 53 (6): 527–32. PMID 2819295.
  13. ↑ Wurmser L, Shame, the veiled companion of narcissism, in The Many Faces of Shame, edited by Nathanson DL. New York, Guilford, 1987, pp. 64–92.
  14. ↑ Young, Klosko, Weishaar: Schema Therapy – A Practitioner's Guide, 2003, p. 375.
  15. 1 2 3 4 Berger, FK (31 Oct 2014), "Medical Encyclopedia: Narcissistic personality disorder", MedlinePlus (U.S. National Library of Medicine)
  16. 1 2 3 4 5 6 7 Paris, Joel (2014), "Modernity and narcissistic personality disorder", Personality Disorders: Theory, Research, and Treatment 5 (2): 220, doi:10.1037/a0028580
  17. 1 2 Torgersen, S; Lygren, S; Oien, PA; Skre, I; Onstad, S; Edvardsen, J; Tambs, K; Kringlen, E (December 2000). "A twin study of personality disorders.". Comprehensive psychiatry 41 (6): 416–25. PMID 11086146.
  18. ↑ Reichborn-Kjennerud, Ted (1 March 2010). "The genetic epidemiology of personality disorders". Dialogues in Clinical Neuroscience 12 (1): 103–114. ISSN 1294-8322. PMID 20373672.
  19. ↑ Ken Magid (1987). High risk children without a conscience. Bantam. p. 67. ISBN 0-553-05290-X. Retrieved 17 November 2012.
  20. ↑ Stephen M. Johnson (1 May 1987). Humanizing the narcissistic style. W.W. Norton. p. 39. ISBN 978-0-393-70037-4. Retrieved 29 October 2013.
  21. 1 2 Groopman, Leonard C. M.D.; Cooper, Arnold M. M.D. (2006). "Narcissistic Personality Disorder". Personality Disorders – Narcissistic Personality Disorder. Armenian Medical Network. Retrieved 2007-02-14.
  22. ↑ Schulze L, Dziobek I, Vater A, Heekeren HR, Bajbouj M, Renneberg B, Heuser I, Roepke S; Dziobek; Vater; Heekeren; Bajbouj; Renneberg; Heuser; Roepke (2013). "Gray matter abnormalities in patients with narcissistic personality disorder". J Psychiatr Res 47 (10): 1363–9. doi:10.1016/j.jpsychires.2013.05.017. PMID 23777939.
  23. ↑ "Narcissists’ Lack of Empathy Tied to Less Gray Matter". PsychCentral. Retrieved 2014-04-24.
  24. ↑ Nenadic, Igor; Güllmar, Daniel; Dietzek, Maren; Langbein, Kerstin; Steinke, Johanna; Gader, Christian (February 2015). "Brain structure in narcissistic personality disorder: A VBM and DTI pilot study". Psychiatry Research Neuroimaging (Elsevier Ireland) 231 (2): 184–186. doi:10.1016/j.pscychresns.2014.11.001. PMID 25492857.
  25. ↑ Ronningstam, Elsa (19 January 2016). "Pathological Narcissism and Narcissistic Personality Disorder: Recent Research and Clinical Implications". Current Behavioral Neuroscience Reports (Springer International Publishing) 3 (1): 34–42. doi:10.1007/s40473-016-0060-y.
  26. ↑ Ronningstam E (2010). "Narcissistic personality disorder: a current review". Curr Psychiatry Rep 12 (1): 68–75. doi:10.1007/s11920-009-0084-z. PMID 20425313.
  27. ↑ "DSM-5: Proposed Revisions: Personality and Personality Disorders". American Psychiatric Association. 2010-02-13.
  28. ↑ Holden C (2010). "Psychiatry. APA seeks to overhaul personality disorder diagnoses". Science 327 (5971): 1314. doi:10.1126/science.327.5971.1314. PMID 20223959.
  29. ↑ Shedler J, Beck A, Fonagy P, Gabbard GO, Gunderson J, Kernberg O, Michels R, Westen D; Beck; Fonagy; Gabbard; Gunderson; Kernberg; Michels; Westen (September 2010). "Personality Disorders in DSM-5". American Journal of Psychiatry 167 (9): 1026–1028. doi:10.1176/appi.ajp.2010.10050746. PMID 20826853. Retrieved 30 November 2010.
  30. ↑ http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=19
  31. ↑ Narcissistic personality disorder – International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
  32. ↑ Millon, Theodore (1996). Disorders of Personality: DSM-IV-TM and Beyond. New York: John Wiley and Sons. p. 393. ISBN 0-471-01186-X.
  33. 1 2 "Millon, Theodore, Personality Subtypes". Millon.net. Retrieved 2013-12-10.
  34. 1 2 Sperry, Lynn (1999), Narcissistic Personality Disorder, Cognitive Behavior Therapy of DSM-IV Personality Disorders: Highly Effective Interventions for the Most Common Personality Disorders, Ann Arbor, MI: Edwards Brothers, pp. 131–138
  35. ↑ Megalomaniacs abound in politics/medicine/finance Business Day 2011/01/07
  36. ↑ Twenge, Jean M. & Campbell, W. Keith The Narcissism Epidemic: Living in the Age of Entitlement (2009)
  37. ↑ "McGraw-Hill Connect". Connect.mcgraw-hill.com. Retrieved 2014-04-25.
  38. ↑ Hesse M, Schliewe S, Thomsen RR; Schliewe; Thomsen (2005). "Rating of personality disorder features in popular movie characters". BMC Psychiatry (London: BioMed Central) 5: 45. doi:10.1186/1471-244X-5-45. PMC 1325244. PMID 16336663.
  39. ↑ "‘Workaholics’ Star Recounts Dangerous Situations, Weird Gestures".
  40. ↑ Kernberg O, Borderline Conditions and Pathological Narcissism, 1967
  41. ↑ Kohut H The Psychoanalytic Treatment of Narcissistic Personality Disorders: Outline of a Systematic Approach, 1968
  42. ↑ Karterud, Sigmund (September 2011). "Validity aspects of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, narcissistic personality disorder construct". Comprehensive psychiatry 52 (5): 517–526.
  43. ↑ Alarcón RD, Sarabia S (2012). "Debates on the narcissism conundrum: trait, domain, dimension, type, or disorder?". J Nerv Ment Dis (200): 16–25.

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