Narcissistic++Personality++Disorder

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//Narcissistic Personality Disorder// is where an individual is characterized to obtain an exaggerated sense of self importance. They believe that they are significantly superior to others while the world is revolving around them, so therefore they deserve advantageous privileges. People with //Narcissistic Personality Disorder// are often arrogant, having lack of empathy for others, and constantly desires excessive admiration from others. It is defined in the Axis II, cluster B, under the Fourth edition of Diagnostic and Statistic Manual of Mental Disorders, DSM IV-TR. It's prevalence is less than1% in the general population, and it affects men more often than women. Related Personality Disorders: [|Antisocial], Borderline, Histrionic, which are also grouped into Axis II, Cluster B Personality Disorders of the DSM.

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=**Psychological evaluation** =

**1) DSM**
Narcissistic Personality Disorder is defined in the Axis II, cluster B, under the Fourth edition of Diagnostic and Statistic Manual of Mental Disorders, DSM IV-TR. 1 A pervasive pattern of grandiosity (in fantasy or behavior), 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) Exaggeration of self success, and self importance
 * 2) Solipsistic views of success, power, beauty, intelligence, and love
 * 3) Believes that they are special, and will only associate with other high-status, or special people
 * 4) Requires excessive admiration
 * 5) Has a sense of entitlement, believes they have favorable privileges and automatic agreement
 * 6) Takes advantage of others to meet their own needs
 * 7) Unwilling to recognize the feelings and needs of others, lacks empathy
 * 8) Is envious of others, and believes others are envious of him
 * 9) Is arrogant, contemptuous and condescending to others

**2) Going beyond the DSM**
<span style="font-family: Tahoma,Geneva,sans-serif;">Going beyond the DSM psychological evaluation, there are three identifiable different subtypes of Narcissistic personality disorders.

<span style="font-family: Tahoma,Geneva,sans-serif;">a) Grandiose/malignant type: often characterized by anger, manipulation, power and control over others, exaggeration of self importance, sense of entitlement. Grandiose/malignant types have little psychological insight on remorse and are unaware of their own narcissistic behavior, therefore often blaming others for their faults 3 . They also do not have sense of inadequacy. Grandiose/malignant types have the highest rate of substance abuse and externalizing behavior, such as domestic violence 2 . <span style="font-family: Tahoma,Geneva,sans-serif;">b) Fragile type: often characterized by grandiosity to serve as a defensive mechanism to defend against feelings of inadequacy, loneliness, smallness and anxiety. They will feel a sense of entitlement and uniqueness when their defenses are working, however, when these defenses fail, negative thoughts of inadequacy are often associated by anger. Fragile types have the highest rates of major depressive disorder and also have very poor adaptability. Often depressed, and unsatisfied and victimized. They also tend to feel helpless and powerless. This type of narcissism is known to suffer the most. 2

<span style="font-family: Tahoma,Geneva,sans-serif;">c) High-functioning/exhibitionistic: often characterized by grandiosity and self importance. Highly functioning narcissists are out going, energetic, and are also highly adaptive. They use others primarily as an audience to witness their own brilliance. They are driven by their own narcissism as their motivation for success. Highly functioning types are relatively good at adapting to new environments and are less prone to other psychiatric disorders. 2

=<span style="font-family: Tahoma,Geneva,sans-serif;">** Causes ** =

<span style="font-family: Tahoma,Geneva,sans-serif;"> Narcissistic Personality Disorder does not have direct cause, however, many contributing factors may cause this personality disorder.

<span style="font-family: Tahoma,Geneva,sans-serif;">** Genetic **
<span style="color: #000000; font-family: Tahoma,Geneva,sans-serif;">A certain variation in the gene tryptophan hydroxylase-2 may be responsible for narcissistic personality disorder. Tryptophan hydroxylase-2 is an enzyme involved in synthesis of serotonin 5. Serotonin is an important neurotransmitter responsible for mood regulation 7. Synthesis of serotonin can be induced by tryptophan, causing an antidepressant effect. Deficient levels of serotonin lead to anxiety, panic, fear, and obsession. Inhibition of this enzyme may lead to depression. Tryptophan hydroxylase-2 can therefore stabilize the levels of serotonin 6.



<span style="font-family: Tahoma,Geneva,sans-serif;">**Environmental**
<span style="font-family: Tahoma,Geneva,sans-serif;">Narcissistic personality disorder can originate from childhood abuse. It is four times more likely for an individual to develop a personality disorder when they have been abused as a child. Verbal abuse, physical abuse, sexual abuse, excessively condescending environment, neglect, and unpredictable care giving, and manipulative behaviors will increase the likelihood of developing a personality disorder 4. A characteristic trait of narcissism is the lack of empathy for others, a child may learn this trait through repeated teachings of not to show vulnerability from their parents. Other contributing factors can include psychological trauma, chronic insomnia, and overworking, extremely high levels of stress, substance abuse, and difficulties with personal relationships 8.

<span style="font-family: Tahoma,Geneva,sans-serif;">**MAO-A**
<span style="font-family: Tahoma,Geneva,sans-serif;">There have been reports that X-linked monoaminoxidase A (MAO-A) gene lead structural brain abnormalities and also emotional and irregular behavior. MAO-A is an important enzyme for the catalysis of serotonin. Aggressive behavior is linked to low levels of MAO-A gene. A low expression of MAO-A is found to be linked to a high reduction in the volumes of grey matter in certain areas of the limbic organs, including the cingulate gyrus, amyglada, anterior cingulate cortex, insula, and the hypothalamus 9. The cingulate cortex is responsible for emotion formation, and processing, and also a region with a very high serotonin transporter density. The anterior cingulate cortex is responsible for error detection and conflict resolution. Reduced gray matter in these areas can lead to insufficient serotonin levels as well as anger. X-linked mutations generally affect men more so than women, therefore explaining a higher frequency of narcissistic disorders in men than women 9.



<span style="font-family: Tahoma,Geneva,sans-serif;">** Temporal Limbic Areas **
<span style="color: #231f20; font-family: Tahoma,Geneva,sans-serif;">Temporo-limbic structures are associated with interpersonal relationships and emotional behavior regulation. Psychopaths have a significantly reduced amount of grey matter in the right superior temporal gyrus 9. This area is responsible in perspective awareness and empathy. Deficiencies in the superior temporal gyrus could be linked to the lack of empathy and the unwillingness to recognize feelings of others that narcissists portray. Impairment to this area of the brain can lead to hypo-functioning processes that display emotions such as love, guilt, remorse, or empathy.

<span style="font-family: Tahoma,Geneva,sans-serif;">**Anterior Insula Cortex**
<span style="font-family: Tahoma,Geneva,sans-serif;">Highly narcissistic patients tend to show irregular activity in the anterior insula cortex. This area of the brain is associated with feelings of empathy for others as well as affective emotions. The anterior insula cortex exhibited an extremely low level of activation during empathy for narcissistic individuals. Other regions in the brain are also involved in processing complex emotions such as empathy. The left inferior frontal cortex, and the premotor cortex, and the dorsolateral prefrontal cortex are other core regions demonstrate empathy 10. However, significance of the anterior insula cortex has not only been shown to be involved with empathy, but also in focusing of oneself. The right anterior is specifically involved in self representation, particularly the bodily self. Altered activity in the anterior insula cortex may lead to over representation of one’s self.

=<span style="font-family: Tahoma,Geneva,sans-serif;">**Possible Treatment Options** =

<span style="color: #000000; font-family: Tahoma,Geneva,sans-serif;"> There are various forms of treatment for Narcissistic Personality Disorder with psychotherapies and medication being the major treatments which are commonly used together. Psychotherapies are based on emotional experiences; pyscho-dynamic therapy is conducted between the patient and a group of individuals. Medication is used through the psychotropic drugs that target specific neuro–transmitters and receptors in the brain that affect mood regulation. A combination of different treatments are often used for maximum efficiency. The goal of most treatments are to integrate the patient into the dynamic society.

<span style="font-family: Tahoma,Geneva,sans-serif;">This is treatment is a type of counseling, it may help the person relate to others in a more positive way. Psychotherapies help the patient by talking to them, and encouraging more positive attitudes, and teaching them better social behaviors. Group therapy can be helpful in ways that the narcissist to relate with others, and have more realistic outlook on others. Not all therapies are helpful, in some cases, the narcissistic patient may treat the therapist with contempt. These underlying problems are a narcissist’s ways to defend themselves from being vulnerable, it is the therapists job to gradually address these underlying fears 10. Prognosis for the grandiose/malignant type is very poor, they do not experience emotional pain that would encourage them to continue therapy. This type of patient would try to manipulate the therapist. Psychotherapies work best with the fragile narcissist. The fragile narcissist would feel the vulnerability, and would see the therapists help to accept these feelings without condescending the therapist 2.

<span style="font-family: Tahoma,Geneva,sans-serif; font-size: 90%;">Medication
<span style="font-family: Tahoma,Geneva,sans-serif;"> SSRI’s are selective serotonin re-uptake inhibitors. SSRI’s are normally used to treat depression. Narcissistic individuals usually have a low level of serotonin, and d <span style="color: #000000; font-family: Tahoma,Geneva,sans-serif; font-size: 90%;">eficient levels of serotonin lead to anxiety, panic, fear, and obsession. Severely narcissistic individuals experience seething anger and aggression to mask their vulnerability. Fluoxteine is a SSRI’s can dramatically decrease the level of aggression and hostility in an individual 12.

=<span style="color: #000000; font-family: Tahoma,Geneva,sans-serif; font-size: 16px;">References =


 * 1) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">American Psychiatric Association. (2000) Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
 * 2) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Russ, E., Shedler, J., Bradley, R., Western, D,. (2008) Refining the Construct of Narcissistic Personality Disorder: Diagnostic Criteria and Subtypes. The American Journal of Psychiatry.
 * 3) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Westen, D. (1990) The relations among narcissism, egocentrism, self-concept, and self-esteem: experimental, clinical, and theoretical considerations. Psychoanalysis and Contemporary Thought.
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 * 5) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">McKinney, J., Teigen, K., Froystein, N.A., et al. (2001) Conformation of the Substrate and Pterin Cofactor Bound to Human Tryptophan Hydroxylase. Important Role of Phe313 in Substrate Specificity. Biochemistry. 40: 15591-15601.
 * 6) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Friedman, P.A., Kappelman A.H., Kaufman, S,. (1972) Partial purification and characterization of tryptophan hydroxylase from rabbit hindbrain. J Biol Chem. 247(13):4165-73.
 * 7) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Gutknecht, L., Jacob, C., Strobel, A., et al. (2006) Tryptophan hydroxylase-2 gene variation influences personality traits and disorders related to emotional dysregulation. The International Journal of Neuropsychopharmacology. 10: 309-320
 * 8) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Psychological Care & Healing. Narcissistic Personality Disorder. Retrieved on March 9, 2012, from http://www.pchtreatment.com/narcissistic-personality-disorder-treatment-center/.
 * 9) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Weber S., Habel, U., Amunts, K., Schneider, F. (2008). Structural Brain Abnormalities in Psychopaths – a Review. Behavioral Sciences and the Law. 26: 7-28.
 * 10) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Fann, Y., Wonneberger, C., Enzi, B., et al (2010) The narcissistic self and its psychological and neural correlates: an exploratory fMRI study. Psychological Medicine.
 * 11) <span style="color: #000000; display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Sarkar, J., Adshead, G. (2006). Personality disorders as disorganization of attachment and affect regulation. Advances in Psychiatric Treatment. 12: 297-305
 * 12) <span style="display: block; font-family: Tahoma,Geneva,sans-serif; text-align: left;">Tausher, S., Nilsson, M., Caldwell, C., et al. (2007) Meta-Analysis of Aggression and/or Hostility-Related Events in Children and Adolescents Treated with Fluoxetine Compared with Placebo Journal of Child and Adolescent Psychopharmacology. Journal of Child and Adolescent Psychopharmacology. 17(5) : 713 - 718