Narcissistic personality disorder: ‘There’s a difference between being boastful and having this clinical disorder’

Disorder is believed to stem from a lack of nourishment in childhood, which results in the person being unable to care for themselves in later life

Narcissist and other variations of the label are often used to describe someone who displays arrogance, dominance and superiority over others due to their exaggerated sense of self-importance and unrelenting need for admiration.

These traits and other noticeable characteristics consistent with narcissism are often conflated with narcissistic personality disorder, a clinical term that comes from the Diagnostic and Statistical Manual of Mental Disorders.

Dr Damien Lowry, chartered member of the Psychological Society of Ireland, says there isn’t a clear psychological consensus on what percentage of the population suffer from the disorder. “You’ll find inconsistencies in terms of clinicians’ reliable diagnoses of someone with any mental health mental disorder, let alone something like narcissistic personality disorder,” he says, “and narcissists typically don’t really recognise that they have a problem so they tend not to necessarily present clinically”.

Dr Lowry, who works predominantly in hospital psychology, says the numbers of diagnosed cases of narcissistic personality disorder are relatively low. “It’s estimated to be somewhere between less than 1 per cent and around 6 per cent and that’s lifelong prevalence, so that means we encounter someone meeting this diagnostic checklist over the course of our lives.”

While studies suggest similar estimates, the Dublin-based psychotherapist says significant thinkers and contributors to the area of narcissism agree on there being “at least two distinct clusters” of narcissistic personality disorder. “The first one [cluster] being the one that is recognised most easily, which is characterised by grandiosity and is more overt,” he says. “There’s another cluster which is the less recognised cluster, which is sometimes called the vulnerable/covert.”

New research published in the Current Directions in Psychological Science suggests that the two types of narcissism – grandiose narcissism and vulnerable narcissism – can be further broken down into a three-factor model of narcissism: antagonism, agentic extraversion and neuroticism.

Author Ian Hughes, who has done extensive research in the area of personality disorders for his book Disordered Minds: How Dangerous Personalities Are Destroying Democracy, says there’s a very specific meaning in terms of how a psychiatrist would determine that someone has narcissistic personality disorder. “Often when you hear about narcissistic personality disorders, you hear about people that are extremely narcissistic or seeking attention all the time,” he says, “Of course, people can be narcissistic. But there’s a difference between being boastful and having this clinical disorder.”

Hughes, who has a background in psychotherapy, says narcissistic adults who did not get nourishment from caregivers in childhood don’t develop the internal psychic structures that allow them to care for themselves. “If you can imagine a young child saying to their parents, ‘look at me, look at me’, which is what children do all the time, and we need to do that when we’re young to get the sustenance,” he says. “But as we get older, we tend to internalise the ability to get some of that sustenance ourselves. People with narcissistic personality don’t internalise the nourishment that you can give yourself.”

Hughes, who says people with narcissistic personality disorder are “constantly fearing” a lack of attention will cause their world to collapse, also says the lack of nourishment leads them to internalise criticism. “It’s as if the young child brings some artwork home and says, ‘look at me, isn’t this wonderful?’ It’s as if the parent says ‘no, it’s actually rubbish, and you’re rubbish,’ and they internalise this parental superego that tells them that they’re worthless.

“There’s a balance between this part of them that is constantly looking for satisfaction from others, and there’s this other part of them telling them no matter what they do, they’re worthless. That’s the personality structure that someone with a narcissistic personality lives with.”

This dichotomy is widely observed by principal psychotherapist Philip Malone, who has worked with specialist personality disorder services in the United Kingdom. “Narcissistic people deeply hold the internal belief that they’re exhausting, they’re worthless, they have very low self-esteem, a powerful sense of insufficiency, and at some point they were made to feel that way,” he says. “So the narcissistic personality is a defence against that because over here is their internal sense of themselves; the shameful, horrid awful person, and over here is the personality they create; that wonderful person who should be admired.

“They generate this [personality] and the mechanism by which they generate it – which is about the only mechanism they have – is they elevate themselves by pushing you down. That’s why when you’re dealing with them, they want to control and put you in your place.”

The UK-based psychotherapist who believes “there’s a pronounced frenzy underneath the narcissistic personality”, says he’s worked with psychiatrists in Ireland who can be reluctant to diagnose a personality disorder if other symptoms exist. “Generally speaking, you don’t diagnose a personality disorder if another disorder is better able to explain the symptoms. The rule of thumb is you wouldn’t diagnose a personality disorder until the person is 25 because they say the personality is still forming.”

Malone, who has worked with patients with narcissistic personality disorder in a forensic setting, makes a clear distinction between people who have narcissistic traits and people with the disorder. “You wouldn’t say you’ve got a narcissistic personality disorder, if you’re just narcissistic in relationships, but everything is fine with your family and work. It’s pervasive. It’s enduring. It goes on over a long period of time,” he explains.

Much like Malone, Hughes describes the fixity of the disorder across a spectrum. “If you think of this in terms of a spectrum where on the left hand side you have this coldbloodedness, incapable of care and then on the right hand side, you’ve got very empathic, most of us are able to go up and down that spectrum,” says Hughes, “but what characterises personality disorder is the fixity of it. They’re on the left hand side and unable to go anywhere else, regardless of the circumstances”.

Dr Lowry says, there isn’t a “perfectly agreed consensus”, but there are some visible signs that someone may have narcissistic personality disorder. “Usually, you’re looking at someone who runs aground over and over. They can’t hold down a job reliably, they suffer interpersonally across relationships, and it never really translates into any meaningful, successful attainment across the lifespan,” he says.

In dealing with one, Dr Lowry says it’s important to not to be overly bound to someone or get baited by them or react in a way that has a negative impact.

“If you’re thinking of the person who is exhibiting this profile or personality, that’s who they are. Trying to change them or challenge them repeatedly is unlikely to really work too well,” he says, “so in a way, there’s got to be some degree of acceptance that that’s who they are.”