An Overview of Narcissistic Personality Disorder

Advances in Social Science, Education and Humanities Research, volume 615 Proceedings of the 2021 4th International Conference on Humanities Education and Social Sciences (ICHESS 2021) An Overview of Narcissistic Personality Disorder Fengning Deng1, *, †, Liuqing Ding2, *, †, Chris Chenghao Liao3, *, † 1 Guangzhou University, Guangdong, China; Crean Lutheran High School, Irvine CA, United States Of America 3 Fort Bend Christina Academy, Texas, United States Of America * Corresponding author. Email: guanghua.ren@gecacademy.cn † These authors contributed equally. 2 ABSTRACT Narcissistic personality disorder (NPD) is a personality disorder that seriously impairs mental health and affects an individual's life. This review aims to provide an overview of NPD. This article summarizes the etiology, subtypes and psychotherapy of narcissistic personality disorder. In the results and discussion, we categorize a variety of treatment options, focusing on Transference-Focused-Psychotherapy and other supportive Psychotherapy and therapeutic models and other treatment options that can help patients with NPD return to normal social life. Overall, this article can serve as a preliminary understanding of narcissistic personality disorder for anyone with an academic interest in this issue. At the same time, our study provides basic concepts for future research on NPD's cause, pathogenesis, and treatment. Keywords: Narcissistic personality disorder, Etiology, Impact, Treatment. 1. INTRODUCTION Narcissistic personality disorder (NPD) is an individual seeking admiration and lack of empathy when not being admired [1]. This means the person constantly seeks attention from others and feels sad and depressed when many ignore them. Some even go as far as being disapproving or mad at others since they are not getting the attention they need. NPD symptoms can start to show in young adults. However,, the person will not recognize the symptoms merely because it will go against their ego [2]. Some of the symptoms of this disorder are: being extremely arrogant, thinking you are superior to everyone around you, not able to maintain a relationship for a long time, and getting frustrated when things don't go according to plan. It is more often found in males than females, and the usual age that it begins in is teen or early adulthood. There are three subgroups of NPD: Grandiose (Overt), Fragile/Vulnerable (Covert), and highfunctioning (Exhibitionist) [3, 4]. In the Grandiose type, the person diagnosed will not be able to interact with others within society and show aggression toward others when they try to talk to the person. Treating them will be harder within this group since they will not allow others to talk to them. Then there is the Fragile/vulnerable type. These people have a chance of starting a relationship. However, when faced with criticism, the individual will either experience a fluctuation within their self-esteem [3]. However, this group is more likely to get mental health treatment due to a higher risk of developing depressive and anxiety disorders. When interacting with this type of people, the individual interacting with them needs to make sure that the words they are saying are not sensitive (like criticism) to them and try to slowly develop them to accept criticisms. The third type is high-functioning. In this group, the people can interact with people (although it is still hard for them to form relationships), but they won't be extreme like the grandiose type. However, if they are experiencing a serious crisis (like a loss of someone or divorce), they will immediately react so that they can have an impairment. However, their ego is under control but still experiencing self-centeredness. There are several ways a person can develop narcissistic personality disorder from their environment. One way is by abuse. A person who is (or has been) going through verbal or physical abuse from their parents or spouse can eventually lead them to develop NPD. Another way that a person can develop this is from genetics. Any family members that have been diagnosed with this disorder can cause them to be passed down from one generation to another. Copyright © 2021 The Authors. Published by Atlantis Press SARL. This is an open access article distributed under the CC BY-NC 4.0 license -http://creativecommons.org/licenses/by-nc/4.0/. 1605 Advances in Social Science, Education and Humanities Research, volume 615 NPD is highly rated comorbid with borderline, antisocial [5], particularly with BPD, with a rating of 80% meeting the criteria both BPD and NPD [6]. Besides the axis II of PDs, NPD has found a high rate in patients with substance use disorder (12-38%) or bipolar disorder (4-47%) [7]. Patients with NPD comorbid with BPD likely feel the shame of feedback of therapist's ability in the session in treatment, increase their negative affective thought, and draw out of treatment. In the research of patients with NPD comorbid with BPD, they found that most of them are characterised by dismissing or cannot classify attachment, and it's a kind of oscillate state that changes within the patient between different attachment styles. Therapists need to instantly identify their attachment working models, which are multi and unintegrated representations and how they work and change [8]. Comparing with patients with BPD, an article has found that patients with BPD/NPD may have more likely to not classify the attachment state of mind, which is most often characterized as oscillating between dismissing devaluation and angry preoccupation [9]. Patients with demonstrate NPD have been recognized as a grant challenge as a therapist for so long. They hard to produce the healthy dependency and attachment from their therapist, they are likely to have the influence of feeling unsafety and under threat, which makes them project the "good one" to self, and give the "bad one" to the object (therapist in the treatment) by using projective identification that seems to control the therapist make them feel despair to continue the treatment and withdraw of it (such as being provoked, aggressive uncomfortable). 2. METHOD Conceptualization of "narcissistic personality disorder" and "pathological narcissism", some researchers define them into two meanings which are high associate with each other about narcissism [7, 10]. In contrast, others use them as synonymy, so we chose the conception of "narcissistic personality disorder" or "NPD" as keywords when we searched to avoid ambiguous meaning and research. Our search aims to investigate NPD's treatment, including the etiology and influence or impart of NPD in Web of science, google scholar. Using keyword "narcissistic personality disorder" OR "NPD" AND "etiology" OR "inheritance" OR" Heredity" OR "environment" OR "theory" to search the cause of NPD, "NPD" AND "treatment" OR "therapy" OR "psychotherapy" in treatment of NPD. As NPD have high comorbidity with axis II, particularly with BPD, they have some common features that we also used the keyword "NPD" with "BPD" OR "comorbid BPD". Some standards should be followed as we search: (1). Articles must be full-text punished, accessible, and peer-view in English. (2). Article should be original and have its evidence scaffolding to prove it (3). The research participant must be human, the measure of use should be scientific. (4). Article should include NPD, a minimum of personality disorder. (5). Diagnosis of patients should be reasonable and up to diagnosis criterion. 3. RESULT 3.1. Etiology To get more further information on NPD, we should know how it happened the first time to help we do prevention and treatment whereas the mechanism. The findings suggest that twin studies suggest that both environmental and genetic factors are involved in the cause of narcissistic personality disorder [11]. Talking about narcissism, some classical theories give their interpretation to elaborate the causing based on their case observation, which are the attachment of Bowlby, object-relationship theory of Kernberg and Kohut. In this part, we focus on attachment theory significantly to figure out how attachment can affect narcissistic people and how working pattern works. The core of the attachment theory is the interaction of infant-parent in early life. Its effective interaction is the kernel of identifying formulation, intrapersonal regulation and interpersonal attitudes following the development [12, 13]. Bowlby estimated that attachment style results from the individual in childhood with their caregiver, which different style can affect their ability to integrate self-representation and the pattern of interpersonal relationship with others. Narcissism is the consequence of an insecure attachment style, and difficulties of it will increase the vulnerability of psychology [14]. To confirm attachment theory, Ainsworth et al. designed research, a procedure of experience separation and reunion for infants and caregivers consistently [15]. The result showed that there are three attachment styles, which include: secure, anxious-ambivalent, and avoidant attachment styles. The fourth infant attachment style has been found disorganized by Main et al. [16]. Fraley found that attachment style in the infant can predict their adult attachment style properly [17]. Generally using adult attachment interview [18] to measure and assess attachment style in adult by researchers, which is classify adult attachment pattern as four styles: secure, preoccupied, dismissing and disorganized or unresolve. For the attachment figures, who have experienced rejection consistently and/or emotionally unavailable, 1606 Advances in Social Science, Education and Humanities Research, volume 615 dismissing the state of mind of avoidant. These people with an internal working model of avoidant-dismissing may attempt to live without love and support from others, which would cause diagnosis "narcissism" [19]. A research found that psychiatrically hospitalized adolescents overwhelming have insecure attachment with their mother and are highly concordant by consistency check [20]. Adolescents with dismissing attachment were more likely to result from NPD and self-report narcissism[ref]. Another research showed that the majority reported adult attachment styles reflective of negative self-representations [3]. For subtypes of NPD, they found that vulnerable narcissism was positively associated with both fearful and preoccupied attachment and negatively associated with secure and dismissive attachment. In contrast, grandiose narcissism was significantly related to preoccupied attachment [21] 3.2. impact Narcissistic personality disorder can give you difficulty with relationships since the person will tend to ignore other people's feelings and feel entitled most of the time. Adults can also suffer from problems at work, feeling depressed, and resorting to drug or alcohol misuse. It's worth noting that studies have shown that narcissistic behavior in leaders can promote unethical behavior in colleagues and undermine an organization's culture and goals. Narcissistic behavior can also promote unethical behavior in co-workers. Narcissists lack empathy and empathy for others at work, which leads to many problems, such as disharmony between colleagues [22]. Children who attend school might be bullied, have problems interacting with teachers, and could possibly have suicidal thoughts and commit suicide. Researchers have used a theory called contemporary integrative Interpersonal Theory of personality to have a framework of how antisocial people are diagnosed with narcissism. It is found that in a study done by Dr. Stinson and his colleagues found that in a span of a year, people who were suffering NPD fell into substance abuse (40.6% of participants), mood swings (28.6%), and some even developed anxiety disorder (40%) (Wright). People with NPD feel this way due to feeling lonely, self anger, helplessness, and higher admiration of themself. Even in some extreme cases, suicide has occurred due to a break-up or getting laid off from a job. People that have NPD are more likely to develop cardiovascular disease and also gastrointestinal diseases. Additionally, people who developed NPD are harder to treat since talking with a therapist and doctors will take longer, and the patient will most likely not talk. Worse, if a person with NPD is not treated, they could commit a serious crime in the future that will affect others. 3.3. Therapies 3.3.1. Transference-focused psychotherapy Cause the comorbidity of NPD common co-occurred with borderline personality disorder (BPD), TFP is wisely used in the NPD as treatment, even though it was the main use of therapy for BPD at first [23] and based on the theory of object-relations from Kernberg and attachment by Bowlby. TFP focuses on exploring and integrating split-off self and object representation as defense behavior to identify patients with NPD to help patients tolerate the negative effects of life and improve their reflective capacity gradually during the session process. In addition to that, TFP also helps the severe patients turn their dismissive in the attachment state of mind (thick-skinned) to preoccupied in attachment state of mind (think-skinned) more possible by the implications [8]. Meanwhile, during the session coming, the therapist allows patients to have chances to analyze systemic to self to improve and reflect their interpersonal relationship. TFP is a psychodynamics therapy used twice a week, particularly designed to fix the spitting, defensive division between self and object or Separation characterization, suitable for patients with moderate or severe NPD, particularly co-morbid with BPD [23]. TFP is a treatment transformed from BPD, which can treat PATIENTS with NPD and patients with comorbidities between NPD and BPD. Some case reports showed that TFP has its effectivity, particularly in patients with NPD/BPD [8]. Comparing with patients only with BPD of two random clinical traits [9], both individuals with BPD and NPD/BPD showed that significant improvement in their capacity mentalization after finishing TFP for 1-year. Unlike simple NPD patients, NPD/BPD patients will be in the borderline status, become more complications and difficulties in treatment, and are easy to drop out. At this time, TFP should constantly study their characteristics and make appropriate changes and developments. Only in this way can patients with NPD and NPD/BPD recover their normal lives more effectively. 3.3.2. Schema psychotherapy The main concept of early ST is the early maladaptive schema and coping style. Schema is the cognitive structure used by children to adapt to the environment. It is the core and foundation of cognitive development, and other cognitive development needs to develop on the original schema through other mechanisms. When the maladaptive schema is activated, it triggers some strong emotions. ST deals with these emotions in three ways: overcompensating or acting as if the opposite is true; Act as if these schemas were true; Avoid the people and things that cause these schemas. 1607 Advances in Social Science, Education and Humanities Research, volume 615 Young pointed out that this is a very promising treatment for personality disorders, but there is insufficient clinical evidence, evidence-based evidence, and multiple cases reports to explore it. Only the Schema therapy for violent PD has been conducted and has been proved effective. A randomized clinical trial), he proposed a new concept: Scheme modes can help us better understand the schema model structure of various personality disorders, which is the empirical response to the development of unmet needs. These needs have been affecting the subsequent life of individuals. These developments can protect individuals from consoling themselves or being protected from abuse during experiences involving emotional and physical abuse and pain. The researchers identified five types of schema modes (child modes, avoidant coping modes, parent modes, and over compensatory modes). Different PD has different characteristics of schema pattern. Current research attempts to study the construct validity of NPD inmates by using schema models [24]. Schema therapy with a good theoretical model is effective for NPD patients. 3.3.3. Other treatments In the past, the treatment of psychological disorders usually considered whether to use drug therapy or psychotherapy combined with drug therapy for intervention. For NPD, the effective treatment should be psychotherapy rather than medication. Due to the complexity of the long-term development of psychological disorders, medication can only be used to address other mood disorders caused by NPD. However, studies have found that lorazepam and Benzodiazepine as an adjunctive treatment for patients with "narcissistic rage" can reduce the stress associated with feelings of depression and anger with minimal side effects. However, Levy [25] considered that whether these patients met the criteria and characteristics of NPD was not clearly stated in this case. In addition to the classical theoretical treatment, some other treatment methods and measures combine with medication treatment in the treatment of NPD. Client-central-theory (CCT) as a traditional psychoanalytic psychotherapy skill, studies have shown that both CCT and CCT+ Medication can significantly improve patients' depression, self-esteem, and social adjustment. However, for CCT+, CCT can significantly improve patients' depression [26]. Therapist-centric techniques, which is a skill usually used in treatment and CCT, even though it focuses on the therapist, can also help patients feel understood during early TFP treatment without distortion of understanding during projection and therapist analysis [8], even if their focus is inconsistent. Still, the purpose is to encourage patients to put down their defense mechanisms and build better treatment alliances to prevent patient drop-outs. 4. DISCUSSION In general, there is still no direct evidence to prove the mechanism and cause of NPD. In addition to classical attachment theory, object relations theory and other theories that can explain narcissism (but do not correlate), there are also scholars to verify it. For example, some scholars have concluded that children's insecure attachment relationships can predict adult attachment relationships, and children's early interactions with their caregivers and how satisfied and satisfied their caregivers are can affect how adults perceive self-relationship with others some risky behaviors. The results of different studies all have one feature: early insecure attachment is significantly correlated with NPD, but different subjects may lead to consistency of results and lack of external validity. Other researchers have come up with different ideas about the effects of twin studies on NPD. Levy argues that even if the twins' results are significant, they cannot be ruled out as being influenced by their shared environment. In addition, Livesley found that the environmental factors of personality and personality disorders were not shared [27]. Even if people lived in the same environment, personality was inconsistent between people, so it could also be attributed to genetic factors. In addition to environmental genetics and theoretical explanations, we also find a new idea that social culture may be responsible for accelerating individuals' narcissism and that current self-values may be responsible for people's increasing narcissism. Existing psychotherapy mainly includes TFP and graphic therapy. TFP is a therapy based on BPD modification that helps patients explore and integrate internally divided selves and others. By helping them integrate and clean up identity reversals, they can better tolerate the realities of their relationships. A number of case studies have demonstrated the effectiveness of TFP. It is also applicable to patients with NPD/BPD comorbidities. In addition, studies have shown that graphic therapy can also treat NPD. It is a way to help patients better adapt to life by changing the way they respond to schema-induced emotions. Even so, more evidence-based and clinical trials are needed to prove the treatment is effective. However, little literature has proved that ST is effective in the treatment of NPD patients, and most of them are proved to be effective in the treatment of BPD as mentioned before，NPD has different subtypes and comorbidities, The main three subtypes including Grandiose/malignant narcissism, Fragile narcissism, High - functioning/exhibitionistic narcissism. Patients with different subtypes have their own personality characteristics and manifestations. To better treat patients with NPD, we must evaluate them before starting treatment. Because it helps people better deal with patients with different subtypes. Future studies 1608 Advances in Social Science, Education and Humanities Research, volume 615 should further explore the causes of NPD to reveal its pathogenesis. To develop a more effective treatment for NPD. 5. CONCLUSION Overall, this review summarizes the causes and treatment of NPD. Previous studies have shown that although no experimental study has found the direct cause of NPD, researchers have identified some possible related causes that can lead to the development of the disease, including environmental factors, genetic factors and so on. Parenting style, attachment between the patient and the caregiver can all contribute to the development of the disease. However, NPD will affect the life of patients, most directly affecting their interpersonal relationships, leading to negative emotions and other emotional disorders. The comorbidity rate of NPD is very high, so many characteristics of NPD will affect their daily social skills. There are a number of proven treatments that can help people improve their lives for a while. But at the same time, it feeds their narcissistic traits to some extent and exacerbates the psychological disorder. 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