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People exhibiting the Narcissistic Personality Disorder demonstrate excessive need for admiration and lack empathy. They exaggerate their self-importance while appearing over-confident and grandiose.  Their sense of superiority remains distorted and pervasive.  These individuals are unable to tolerate criticism or disagreement and demonstrate difficulty forming close personal relationships.

Narcissistic Personality Disorder

The Narcissistic Personality Disorder differs from the more common situation where people exhibit a variety of narcissistic traits.  The difference lies in degree with many cases straddling the border.  In those with the Narcissistic Personality Disorder (NPD) manifestations persist, prevent the individual from adapting and lead to significant functional impairment in multiple settings. This often lead to subjective distress.  NPD occurs less frequently than much less intrusive narcissistic traits.

Actually NPD was only recently recognized with original descriptions dating to the 1910s and mid-1920s. The term Narcissistic Personality Disorder first attached to the condition in the late 1960s.  Psychiatrists debate the exact status of the Narcissistic Personality Disorder with some arguing in favor of abandoning the condition as a diagnostic entity.  NPD remains in the current American Psychiatric Association’s Diagnostic and Statistical Manual as one of ten personality disorders.  In its International Classification of Diseases, the World Health Organization lists only eight personality disorders omitting NPD.

More information about the Narcissistic Personality Disorder

Diagnosis

No specific confirmatory laboratory or imaging techniques exist to firmly diagnose NPD. This means analysis relies on diagnostic interviews, subjective opinion of health care professionals and sometimes questionnaires.  Unfortunately this lack of standards translates into considerable variation from physician to physician in the ultimate label attached to any given individual. 

Frequency

Estimates suggest the condition may affect up to 5% of the general public with men moderately more often affected than women.  Other surveys indicate the range of NPD in general society may be as low as 0.5% or as high as 16% among those in a clinical setting.  Common traits of narcissism occur during childhood with a tendency toward megalomania in some. As a result the diagnosis of NPD is generally restricted to adults. 

Genetics

Genetic factors explain some of the tendency to NPD. The condition targets some families especially the twin sibling of an affected individual.  But as with so many conditions the nature versus nurture controversy deems early childhood environment a significant contributing factor.

Upbringing

Among the possible explanations for NPD are rejection by an unsympathetic mother, over-controlling parents and unwarranted excessive praise during early development.  Some suggest NPD stems from a learned behavior related to psychologically manipulative parents or others with whom the child interacts during the formative years.

Definition

Defining NPD appears fluid and continues to evolve with each new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual.  Each update modestly tweaks the meaning and leads to persistent dissatisfaction among clinical psychiatrists.  As a consequence a movement to eliminate NPD from the DSM almost succeeded immediately prior to the current edition.

Manifestations

Among the manifestations of NPD are a pervasive pattern of grandiosity, need for admiration, lack of empathy, failure to conform to social norms, potentially illegal actions and deceitfulness and repeated lying for pleasure or profit as well as the use of aliases.  Impulsivity, irritability and aggressiveness mark NPD.  These individuals are irresponsible, reckless without regard for safety and fail to honor financial or other commitments.  They lack remorse or attempt to rationalize their perverse behavior.

Other traits associated with NPD include boldness, extroversion, being thick skinned and attention seeking.  They are outspoken, domineering, antagonistic and egocentric.  They often believe they possess extraordinary charm or beauty and monopolize any conversation.  They tend to demonstrate great pride in accomplishments of their family and children yet demonstrate such small egos that others are banned for small or imagined slights.  They react with rage or contempt and belittle others in an attempt to burnish their own feelings of superiority.

People with NPD exaggerate their talents and achievements and are preoccupied with fantasies of unlimited power or intelligence.  They believe they are special and must only associate with others of high social, political or financial pedigree.  Among the other traits of NPD are a sense of entitlement, envy of others and arrogant behavior.  Relationships tend to be superficial and for self-gain rather than emotional attachment.

Vulnerable Narcissism

Recognizing the controversy among their members, the American Psychiatric Association modified the latest DSM definition with an alternative dimension away from the more traditional check list of traditional manifestations.  They currently recognize some with NPD may alternate between grandiose and deflated self-image.  Vulnerable narcissism appears under-recognized and may lead to feelings of defensiveness and hypersensitivity.  Some experience shame and humiliation or emptiness and feel vulnerable when success is not achievable.

Associated Psychiatric Conditions

In the absence of strict diagnostic criteria, symptoms define NPD.  Additionally a wide array of other conditions tend to congregate among those with NPD.  Among them are anxiety, major depression, bipolar disorder, mania and substance abuse especially of alcohol or cocaine.

NPD belongs in Cluster B of the personality disorders along with the antisocial personality disorder, borderline personality disorder and histrionic personality disorder.  Each of these Cluster B conditions shares a number of defining criteria and often coexists with NPD.   Shared features include overly emotional, unpredictable thinking or behavior and excessive dramatics.

Family Member Reactions

Family members do not escape the fraught relationship with these individuals.  Interactions are met with anxiety, foreboding, depression, anger, frustration, fear and a sense of bewilderment. 

Medical Setting

Diagnosis is generally established from clinical interviews rather than questionnaires.   Individuals rarely seek medical intervention for NPD itself.  Part of their pathology is a lack of self-awareness of their condition.  They often arrive in the medical setting seeking care for associated psychiatric comorbidities or as a result of family pressure.

Treatment

Unfortunately NPD lacks specific treatment.  The stable pervasive long-lasting personality disorder appears no more likely to change than eye color.  Medicines may improve some of the associated conditions.  A variety of psychotherapies may slowly alter the disorder but remain untested in appropriate circumstances.

Malignant Narcissism

An even more perverse condition known as Malignant Narcissism combines NPD with features of the antisocial personality disorder, sadism and paranoia.  The concept of Malignant Narcissism (MN) only arose in the mid-1960s with further refinement during the next several decades. 

MN tends to worsen with age as individuals become more isolated and demonstrate more manifestations of their underlying symptoms.  They tend to lose touch with reality and become cruel and sadistic.  Some consider this a separate disorder while others merely lump NPD with antisocial personality disorder as sufficient to fully describe the symptoms without the need for yet another ill defined condition.

Is Donald Trump a Narcissist?

The question exists regarding Donald Trump and whether he displays characteristics of NPD.  In her book: “Too Much and Never Enough: How My Family Created the World’s Most Dangerous Man” his psychologist niece Mary Trump discusses reasons to believe this diagnosis applies.  Dr. Bandy Lee a psychiatrist at the Yale University School of Medicine and here collaborators reach the same conclusion and worse in “The Dangerous Case of Donald Trump.” 

Dr. Henry Friedman, associate professor of psychiatry at Harvard Medical School wrote in the New York Times that Donald Trump is “so far beyond what could be called ordinary narcissism” that he “requires a category beyond narcissism.” 

Possible Examples

Trump claims to know more about ISIS, taxes, renewables, debt, banking, money and the establishment.  The number of Trump’s lies and mistruths is legion now exceeding 20,000 according to the Washington Post’s Fact Checker.  Among the lies are recurring themes relating to Barack Obama, crowd size, and health care.

Immediately before the 2018 election he claimed an impending 10% tax cut for the middle class when none was in the works.  He claims Mexico will pay for a border wall and that the economy is the best in history. He erroneously claims he has done “more for blacks” than any other President possibly with the exception of President Lincoln. 

He repeatedly spends taxpayer money visiting his properties and charges excessive rates to the government for room and board to Secret Service and others who must accompany his many visits.  Before election he claimed he would golf less than President Obama but instead has far eclipsed him.  There are issues of emollients, money for the FBI building, a government shut down and lack of prompt financial response to the millions in need of assistance due to the coronavirus pandemic.

Donald Trump frequently characterizes himself as a genius with a great mind who went to the very best schools.  Multiple times he claimed to have a “very good brain.”  He’s quoted as commenting that “I’m like really smart, a very stable genius.”  Of course he also refers to his “great and unmatched wisdom.”  According to Mary Trump’s book Donald’s sister labeled him as having “no principles.”  Maryanne Trump further comments of her brother Donald: “you can’t trust him.”

Still More Examples

And professing “my hair has to be perfect” evidently Trump directed his administration to ease the shower pressure standards meant to save water.  Of course he lied about paying women for sex and used the aliases John Baron, John Miller and David Dennison.

Other examples that at least support the diagnosis of NPD. They include his humiliating comments regarding ousted officials such as Rex Tillerson, Dan Coats, General John Kelly and General Jim Mattis.  And of course his repeated claims that:  “I alone can fix it.”

And then there’s his continued championing of hydroxychloroquine after studies conclusively demonstrate its lack of safety and effectiveness.  He refers to Dr. Deborah Birx as pathetic and believes he knows more than Dr. Anthony Fauci.  Donald Trump claims “we are doing an amazing job” in counteracting coronavirus and openly seems envious of press coverage of Dr. Fauci.

Does Trump = Narcissist?

Of course these are only a few of the many realms on which Donald Trump seems to qualify for the diagnosis of NPD.  Certainly from afar the diagnosis remains a major consideration.

The problem for America, assuming the diagnosis is indeed correct, remains how NPD colors so many of Trump’s decisions.  The public expects logical actions from the federal government. Decisions should be based on fact and on the interest of our institutions and allies.  Unfortunately in the case of the President we find the personal interests of Donald Trump seems to be at the core of his actions.

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