Could you recognise a narcissist?

This highly topical Freudian Script explores Narcissistic Personality Disorder, and is brought to you by my friend and colleague, forensic psychiatrist Dr Bernard Chin.

DISCLAIMER: This blog post is designed for writers of fiction. If you are concerned that you or someone you know has symptoms of mental health problems, please see your doctor. Or your local government representative.

There once was a hunter from Thespiae, who was famed for his beauty. As he was so beautiful, many loved him. However, he only had disdain for those that loved him, as none could be as beautiful as he was.

He grew proud and one day he was drawn to a pool where he saw a reflection of himself. Not realising it was merely an image of himself, he fell in love with it (or perhaps coming to the realisation that he could only truly love himself) and was unable to leave the beauty of his own reflection. Losing the will to live, he stayed there, staring at his own image until he died.

His name was Narcissus.

What is narcissism?

Narcissism is a personality trait and Narcissistic Personality Disorder is a recognised mental disorder in the American Psychiatric Association’s biblical tome, the Diagnostic and Statistical Manual of Mental Disorders 5th Edition.

(The World Health Organisation did not include Narcissistic Personality Disorder in its International Classification of Diseases Version 10 as a distinct entity but instead chose to include it as almost a side-note in the Other Specific Personality Disorders category. Think of that what you will about the Americans.)

So what do we mean when we say someone is narcissistic? Do lay members of the public have a similar definition for narcissism as me, a forensic psychiatrist?

I work with people with severe and enduring mental illness as well as people with severe personality disorders who end up on the wrong side of the law – sometimes through a series of unfortunate events relating to their mental illness and sometimes entirely through their own devices completely unrelated to mental illness.

Narcissism as understood today was first publicised by the psychoanalyst, Otto Rank in the early 1910s, who linked it to vanity (egocentrism) and self-admiration. It is a descriptive term used widely in our daily lives. It is often used in a derogatory manner to indicate that someone is “full of themselves”, indicating that one has passed miles beyond being confident and self-assured into the realms of egotism.

We often use public figures as examples of “narcissists” – someone so full of themselves that they have essentially failed to recognise their own failures or absurdity. Case in point, a particularly “esteemed” Health Secretary or an exceptionally “bright” president-elect. Do these individuals have Narcissistic Personality Disorder? Many would like to believe so but it is dangerous to speculate without substantiated evidence or data to prove it.

Diagnosing someone with a personality disorder takes time – roughly three hours to interview the individual and a further two-three hours to locate and absorb any other information one can find on their background and relationship history.

This is, of course, if you are trained to diagnose individuals with a mental disorder in the first place. It also helps if one receives specific training to diagnose personality disorder, such as in the use of the International Personality Disorder Examination (IPDE).

But in a nutshell…

To understand Narcissistic Personality Disorder, we first need to ask what is a personality disorder? One explanation is included in this post on emotionally unstable personality disorder (EUPD).

To recap:

Personality is a set of characteristics that makes a person who they are. It is essentially the way that a person sees the world, interacts with the world and those in it. It also governs the way we feel and think about things.

Personality disorder (PD) is when our personality is different from what it should be, which then leads to the development of distress or conflict within ourselves or with others. It usually starts in our developing years due to some form of trauma which forces us to develop in such a way so as to protect ourselves whilst growing up.

Unfortunately, this may lead to a pattern of behaviour which is unhelpful when we are expected to be “fully functional” and “productive” members of society, despite it being helpful when growing up in a deprived or physically, psychologically, emotionally, and/or sexually traumatic environment.

Now that we have a rough understanding of PD, let’s delve into Narcissistic PD.

According to DSM 5, Narcissistic PD is:

A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognise or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviours or attitudes.

This can be someone who routinely overestimate or inflate their own abilities and accomplishments – appearing boastful and pretentious. They expect or assume others attribute the same value to their efforts and abilities and would often be surprised when they are not praised as they feel they deserve. They would also underestimate or devalue the contribution of others purely because they do not see the worth in others or does so to inflate their own achievements.

They can often be preoccupied with fantasies of power and unlimited success in whatever they do – love, beauty and so forth. They believe that they are superior, special or unique and they expect others to agree and recognise them as such. Often they will only mingle with the best of the best because only the “gifted” can understand them whereas the hoi polloi are just that.

However, these gifted people may be devalued themselves if they were to disappoint the individual with Narcissistic PD. Case in point – a patient of mine would rather speak to me instead of my junior doctor as I have more seniority but as soon as I disagree with him, my value immediately drops to just another doctor who isn’t the best in the country or the top expert in the field.

What causes narcissism and how does it manifest?

The narcissist’s overdeveloped sense of self and constant need for excessive admiration likely stems from an incredibly fragile self-esteem. They would constantly be preoccupied with how well they are doing and how favourably others regard them, constantly fishing for compliments using that great charm of theirs.

All this ego would of course be accompanied by a great sense of entitlement – they expect to be treated like gods. For, in their minds, they are nothing less and cannot understand why others do not or cannot see them that way.

Some people with Narcissistic PD have a predilection for the exploitation of others due to their great sense of entitlement and underdeveloped empathy. Friendships and romantic relationships are formed if it serves their purpose – to advance in society or somehow enhance their self-esteem.

They find it difficult to recognise the desires or feelings of others – children and “loved ones” become extensions of their selves. The only purpose these individuals served is to advance the narcissist’s own needs.

Envy is the emotion most often felt by those with Narcissistic PD – they feel that the successes of others are better served being theirs. They often come across as snobbish, disdainful or patronising.

Their fragile self-esteems make them particularly sensitive to criticism. Criticism may cause what psychologists term a narcissistic injury (essentially, an injury to the person’s ego and sense of self), leaving them feeling humiliated, degraded, hollow and empty. In order to repair or obliterate the injury, individuals with severe Narcissistic Personality Disorder may react with disdain, a defiant comeback or, on rare occasions, extreme rage. This could lead to social withdrawal, a façade of humility masking the grandiosity or sometimes, even violence.

That isn’t to say that overwhelming ambition and confidence has no place in society. On the contrary, these traits are useful and can lead to high achievement and progression if tempered with a suitable amount of humility and grounding.

Unfortunately, those with a disordered personality have difficulties managing their traits. The incessant need to protect their over-developed sense of selves may lead to avoidance of situations that would paradoxically lead them to achieving what they desire. If a narcissistic injury were sustained, the overwhelming feelings of shame and humiliation would often lead to persistent low mood and potentially a depressive disorder

Would you be surprised to learn that 50% to 75% of those diagnosed with Narcissistic PD are male? Probably not.

The core of the disorder is the intense fluctuation in self-esteem and the need to refer to others to regulate this and to define themselves.

Narcissistic PD in fiction

One example of Narcissistic Personality Disorder in fiction is Patrick Bateman, the titular character from American Psycho. He isn’t a pure example, although he shows certain traits one would find in a real life individual suffering from the disorder. Lacking empathy, utilising “friends” for his own goals to advance his self-esteem, grandiose sense of self-worth, associating only with “important people”, and highly sensitive to criticism and setbacks (for example – the business card scene as depicted in the movie).

Like in real life, there are features of other personality disorders evident in Patrick Bateman – Antisocial Personality Disorder being the other prominent feature. He is also likely suffering from a psychotic episode near the end of the novel and movie adaptation.

He is probably one of the more extreme and malignant examples I have come across in fiction. There are other examples that are slightly more benign and “played for laughs”, such as How I Met Your Mother’s Barney Stinson, although Barney’s attachment to his friends appear to be genuine friendship which goes against one of the more common traits in Narcissistic PD.

Narcissistic PD in reality

What are individuals with Narcissistic PD like in real life?

Depending on the severity of their personality disorder, they can be very much like you or me. There are certain points in my life when I thought that I displayed narcissistic traits. Whether I can be diagnosed with the disorder though remains to be seen.

As patients, people with Narcissistic PD can be difficult to manage. This difficulty stems from whether someone sees what he has as distressing to him or not. If I were told that I had a Narcissistic Personality Disorder and this was becoming a problem for other people but I do not see this as a problem for me, then I am less likely to engage in treatment. They may also have unrealistic expectations of the treatment, the service delivering the treatment, the outcome, the doctor that deals with them and a whole range of things.

I think what doesn’t come across well in fiction is the difference between narcissism and Narcissistic Personality Disorder. Narcissism is a personality trait which can be extremely useful in certain trades (such as mine) where overwhelming ambition and, to a certain extent, self-confidence and even a little bit of vanity can lead to a good outcome.

Narcissistic Personality Disorder is like it says on the cover – a disorder. There has to be a level of impairment or distress that goes with it (for the individual or for others in their lives, which would eventually lead to some form of impairment in their lives).

So, is America’s president-elect narcissistic? Oh god yes.

Does he have a mental disorder? I have no idea and I am afraid to comment… (wink)

Bernard Chin is a Forensic Psychiatrist with a background in genetics and psychology. He has worked with individuals diagnosed with personality disorders throughout his career in psychiatry and is specifically trained in understanding and assessing personality disorders as well as psychopathy. In his free time he enjoys torturing medical students and other junior doctor colleagues with lectures and role play. He also rants at the government on twitter (@berniebchin).

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