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definition - Narcissistic personality disorder

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Narcissistic personality disorder

                   
Narcissistic personality disorder
Classification and external resources

Narcissus by Caravaggio. Narcissus gazing at his own reflection.
ICD-10 F60.8
ICD-9 301.81
MeSH D010554

Narcissistic personality disorder (NPD) is a personality disorder[1] in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity. This condition affects one percent of the population.[2][3] First formulated in 1968, it was historically called megalomania, and it is closely linked to egocentrism.

Contents

  Symptoms

Symptoms of this disorder include, but are not limited to:

  • Reacts to criticism with anger, shame, or humiliation
  • May take advantage of others to reach their own goals
  • Tends to exaggerate their own importance, achievements, and talents
  • Imagines unrealistic fantasies of success, beauty, power, intelligence, or romance
  • Requires constant attention and positive reinforcement from others
  • Easily becomes jealous
  • Lacks empathy and disregards the feelings of others
  • Obsessed with oneself
  • Mainly pursues selfish goals
  • Trouble keeping healthy relationships
  • Is easily hurt and rejected
  • Sets unrealistic goals
  • Wants "the best" of everything
  • Appears as tough-minded or unemotional [4]


The symptoms of Narcissistic personality disorder can be similar to the traits of individuals with strong self-esteem and confidence; differentiation occurs when the underlying psychological structures of these traits are considered pathological. Narcissists have such an elevated sense of self-worth that they value themselves as inherently better than others. Yet, they have a fragile self-esteem and cannot handle criticism, and will often try to compensate for this inner fragility by belittling or disparaging others in an attempt to validate their own self-worth. It is this sadistic tendency that is characteristic of narcissism as opposed to other psychological conditions affecting level of self-worth. [5]

In children, inflated self-views and grandiose feelings, which are characteristics of narcissism, are part of the normal self-development. Children are typically unable to understand the difference between their actual and their ideal self, which causes an unrealistic perception of the self. After about age 8, views of the self, both positive and negative, begin to develop based on comparisons of peers, and become more realistic. Two factors that cause self-view to remain unrealistic are dysfunctional interactions with parents that can be either excessive attention or a lack thereof. The child will either compensate for lack of attention or act in terms of unrealistic self-perception.[6]

The Childhood Narcissism Scale (CNS) measurements concluded that narcissistic children seek to impress others and gain admiration but do not have any interest in creating sincere friendships. CNS researchers have measured that childhood narcissism has become more prevalent in Western society: any types of activities that focus on overly praising the individual, can raise narcissistic levels. More research is needed to find the reasons that promote or protect against narcissism.[7]

  Causes

The cause of this disorder is unknown, according to Groopman and Cooper. However, they list the following factors identified by various researchers as possibilities:[2]

  • An oversensitive temperament at birth
  • Excessive admiration that is never balanced with realistic feedback
  • Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood
  • Overindulgence and overvaluation by parents
  • Being praised for perceived exceptional looks or abilities by adults
  • Severe emotional abuse in childhood
  • Unpredictable or unreliable caregiving from parents
  • Valued by parents as a means to regulate their own self-esteem

Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood, they may intensify to the point where NPD is diagnosed.[8] Some psychotherapists believe that the etiology of the disorder is, in Freudian terms, the result of fixation to early childhood development.[9]

A 1994 study by Gabbard and Twemlow[10] reports that histories of incest, especially mother-son incest, are associated with NPD in some male patients.

  Theories

Pathological narcissism occurs in a spectrum of severity. In its more extreme forms, it is narcissistic personality disorder (NPD). NPD is considered to result from a person's belief that they are flawed in a way that makes them fundamentally unacceptable to others.[11] This belief is held below the person's conscious awareness; such a person would, if questioned, typically deny thinking such a thing. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognized their (perceived) defective nature, such people make strong attempts to control others’ views of them and behavior towards them.

Pathological narcissism can develop from an impairment in the quality of the person's relationship with their primary caregivers, usually their parents, in that the parents were unable to form a healthy and empathic attachment to them.[citation needed] This results in the child's perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.[12]

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others' needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen.[13]

Narcissistic individuals use various strategies to protect the self at the expense of others. They tend to devalue, derogate and blame others, and they respond to threatening feedback with anger and hostility.[14]

People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight criticism, real or imagined.[15] To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility. In cases where the narcissistic personality-disordered individual feels a lack of admiration, adulation, attention and affirmation, s/he may also manifest a desire to be feared and to be notorious (narcissistic supply).

Although individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements.[16] With narcissistic personality disorder, the individual's self-perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.

  Splitting

People who are diagnosed with narcissistic personality disorder use splitting as a central defense mechanism. According to psychoanalyst Kernberg, "the normal tension between actual self on the one hand, and ideal self and ideal object on the other, is eliminated by the building up of an inflated self concept within which the actual self and the ideal self and ideal object are confused. At the same time, the remnants of the unacceptable images are repressed and projected onto external objects, which are devalued."[17]

The merging of the "inflated self concept" and the "actual self" is seen in the inherent grandiosity of narcissistic personality disorder. Also inherent in this process are the defense mechanisms of devaluation, idealization and denial.[18] Other people are either manipulated as an extension of one's own self, who serve the sole role of giving "admiration and approval"[19] or they are seen as worthless (because they are unable to collude with the narcissist's grandiosity).[20]

  Relationship to shame

It has been suggested that narcissistic personality disorder may be related to defenses against shame.[21] Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes.[22] He saw the "oblivious" subtype as being grandiose, arrogant, and thick-skinned and the "hypervigilant" subtype as being easily hurt, oversensitive, and ashamed. In his view, the oblivious subtype presents for admiration, envy, and appreciation a powerful, grandiose self that is the antithesis of a weak internalized self, which hides in shame, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers. Dr. Jeffrey Young, who coined the term "Schema Therapy", a technique originally developed by psychiatrist Aaron T. Beck (1979), also links NPD and shame. He sees the so-called Defectiveness Schema as a core schema of NPD, along with the Emotional Deprivation and Entitlement Schemas.[23]

  Diagnosis

  DSM-IV-TR 301.81

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines narcissistic personality disorder (in Axis II Cluster B) as:[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. 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 favorable 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 recognize or identify with the feelings and needs of others
  8. Is often envious of others or believes others are envious of him or her
  9. Shows arrogant, haughty behaviors or attitudes

It is also a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

  Proposed removal from DSM-5

The Personality and Personality Disorders Work Group originally proposed[24] the elimination of NPD as a distinct disorder in DSM-5[25] as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains.

Some clinicians objected to this, characterizing the new diagnostic system as an "unwieldy conglomeration of disparate models that cannot happily coexist" and may have limited usefulness in clinical practice.[26]

In July 2011, the Work Group came back with a major revision to their original proposal. In this NPD was reinstated with dramatic changes to its definition. Note that the general move towards a dimensional (personality trait based) view of the Personality Disorders has been maintained despite the reintroduction of NPD.

  ICD-10

The World Health Organization's ICD-10 lists narcissistic personality disorder under (F60.8) Other specific personality disorders.[27]

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

  Millon's subtypes

Theodore Millon identified five subtypes of narcissist.[3][28] Any individual narcissist may exhibit none or one of the following:

  • Unprincipled narcissist – including antisocial features. A charlatan – is a fraudulent, exploitative, deceptive and unscrupulous individual.
  • Amorous narcissist – including histrionic features. The Don Juan or Casanova of our times – is erotic, exhibitionist.
  • Compensatory narcissist – including negativistic (passive-aggressive), avoidant features.
  • Elitist narcissist – variant of pure pattern. Corresponds to Wilhelm Reich's "phallic narcissistic" personality type.
  • Fanatic narcissist – including paranoid features. An individual whose self-esteem was severely arrested during childhood, who usually displays major paranoid tendencies, and who holds on to an illusion of omnipotence. These people are fighting delusions of insignificance and lost value, and trying to re-establish their self-esteem through grandiose fantasies and self-reinforcement. When unable to gain recognition or support from others, they take on the role of a heroic or worshipped person with a grandiose mission.

Alexander Lowen has also specified five major subtypes from phallic ("skirtchasing") to sociopathic (i.e., dissociative, capable of mayhem and murder) as outlined in his book, "Narcissism: Denial of the True Self".

Two types of narcissism: Those who have been diagnosed with narcissistic grandiosity express behavior "through interpersonally exploitative acts, lack of empathy, intense envy, aggression, and exhibitionism."[29] Another type is Narcissistic Vulnerability. It entails (on a conscious level) "helplessness, emptiness, low self-esteem, and shame, which can be expressed in the behavior as being socially avoidant in situations where their self-presentation is not possible, so they withdraw, or the approval they need/expect is not being met. [30]

  Treatment

Prominent clinical strategies are outlined by Heinz Kohut, Stephen M. Johnson and James F. Masterson, while Johns[12] discusses a continuum of severity and the kinds of therapy most effective in different cases. Schema Therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD.[31] It is unusual for people to seek therapy for NPD. Unconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes.[32][33] Pharmacotherapy is rarely effective.

Pattern change strategies, over a long period of time, are for the narcissist to work on increasing their ability to become more empathetic in everyday relationships. To help modify their sense of entitlement and self-centeredness schema is to help them identify how to utilize their unique talents and to help others rather than for their own personal gain. This is not going to change their self-perception of their "entitlement" feeling but more so help them empathize with others. Another type of treatment would be temperament change.[34]

Anger, rage, impulsivity and impatience can be worked on with skill training. Medication can also be an effective addition if needed. Anxiety disorders and somatoma dysfunctions are prevalent but the most common would be depression. Medication can be extremely beneficial when treating the disorder with regular therapy. Medications to help reduce impulsivity, depression, and anger (along with skilled training) will help the person create interpersonal relationships, be less impulsive, be less angry, and treat the depression/anxiety.[35]

Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted, but group therapy can also contradict itself as the patient may show "demandingness, egocentrism, social isolation and withdrawal, and socially deviant behavior." Relationship therapy stresses the importance of learning and applying four basic interpersonal skills: "effective expression, empathy, discussion and problem solving/conflict resolution." Marital/relationship therapy is most beneficial when both partners participate.[36]

  Correlative associations

  Eating disorders

The study of Narcissism and the Narcissistic Defenses in the Eating Disorders was concerned with the correlation between eating pathology and narcissism. Two types of narcissism were observed: core narcissism, having extremely positive self esteem with the delusions of the level and ability of achievement, and narcissistic defenses, defenses that are triggered when self esteem is threatened. Their self esteem is maintained by seeing themselves as misunderstood and a subject to intolerable demands.[37]

Two types of narcissistic defenses that were measured with eating pathology were "poisonous pedagogy" and "narcissistically abused". Poisonous pedagogy is one who places blame on others and is overly critical of others' inadequacies. The narcissistically abused are those who put others’ needs before theirs yet see themselves as being poorly treated ("poor me"). Two groups were measured: Clinical ( 83 women and one male with the mean age of 28.4) and Non Clinical ( 70 women mean age of 23.2). BMI of groups did not significantly vary. They filled out a questionnaire that was measured by eating characteristic and narcissism levels by the OMNI (O’Brien Multiphasic Narcissism Inventory) and the EDE-Q (Eating Disorder Examination Questionnaire). OMNI measures pathological narcissism of narcissistic personality, poisonous pedagogy, and narcissistically abused personality. EDE-Q measures the common eating disorders: restrain, eating concern, body shape concern, and body weight concern.[38]

The basic summaries of the questionnaire’s findings were the poisonous pedagogy defenses was related to restrictive mind-set; narcissistically abused defense related to restraint, eating concern, body shape concern, and body weight concern. The only main difference between the groups was the role of core narcissism in the clinical women’s levels of eating concerns. Further research is needed to better understand the relationship approaches in both groups.[39]

  Professional attainment

In 2005, Board and Fritzon published the results of a study in which they interviewed senior business managers, assessing them for the presence of personality disorder.[40] Comparing their findings to three samples of psychiatric patients, they found that their senior business managers were as likely to demonstrate narcissistic traits as the patient population, although were less physically aggressive.


Anecdotal evidence suggests that narcissists may be particularly common in the financial sector as they "are able to make quick, bold decisions without any thought for the consequences these might have on other people".[41]. One financier with experience of NPD claimed to know a recruitment consultant who actively sought to recruit narcissists.

  Epidemiology of NPD

Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.[2][42]

In 2009, Twenge and Campbell conducted studies suggesting that the incidence of NPD had more than doubled in the US in the prior 10 years, and that 1 in 16 of the population have experienced NPD.[43]

  History

The history of narcissism predates the classification of narcissistic personality disorder. The term "narcissistic personality structure" was introduced by Kernberg in 1967[44] and "narcissistic personality disorder" first proposed by Heinz Kohut in 1968.[45] Narcissism, the condition, was named after a mythological Greek youth named Narcissus who became infatuated with his own reflection in a lake. He eventually died there because he couldn't tear himself away from the admiration of his image.

  Cultural depictions

In the film To Die For, Nicole Kidman's character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she "was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder... had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder."[46]

  See also

Associated:

Case study:

  References

  1. ^ a b Narcissistic personality disorderDiagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000)
  2. ^ a b c "Narcissistic Personality Disorder". Personality Disorders – Narcissistic Personality Disorder. Armenian Medical Network. 2006. http://www.health.am/psy/narcissistic-personality-disorder/. Retrieved 2007-02-14. 
  3. ^ a b Millon, Theodore (1996). Disorders of Personality: DSM-IV-TM and Beyond. New York: John Wiley and Sons. p. 393. ISBN 0-471-01186-X. 
  4. ^ "Narcissistic personality disorder: Symptoms – MayoClinic.com." Mayo Clinic. N.p., n.d. Web. 2 Dec. 2011. <http://www.mayoclinic.com/health/narcissistic-personality-disorder/DS00652/DSECTION=sympto
  5. ^ Narcissistic personality disorder: Symptoms – MayoClinic.com." Mayo Clinic. N.p., n.d. Web. 2 Dec. 2011. <http://www.mayoclinic.com/health/narcissistic-personality-disorder/DS00652/DSECTION=symptoms
  6. ^ Development and Validation of the Childhood Narcissism Scale, SANDER THOMAES,1,2 HEDY STEGGE,1 BRAD J. BUSHMAN,3,4 TJEERT OLTHOF,1 AND JAAP DENISSEN. Department of Psychology, VU University, The Netherlands Department of Psychology, Utrecht University, The Netherlands Department of Psychology, University of Michigan Department of Communication Sciences, VU University, The Netherlands
  7. ^ Development and Validation of the Childhood Narcissism Scale, SANDER THOMAES,1,2 HEDY STEGGE,1 BRAD J. BUSHMAN,3,4 TJEERT OLTHOF,1 AND JAAP DENISSEN. Department of Psychology, VU University, The Netherlands Department of Psychology, Utrecht University, The Netherlands Department of Psychology, University of Michigan Department of Communication Sciences, VU University, The Netherlands
  8. ^ Cooper AM: Narcissism in normal development, in Character Pathology. Edited by Zales M. New York, Brunner/Mazel, 1984, pp. 39–56.
  9. ^ Joseph Fernando, MPSY, M.D., The Etiology of Narcissistic Personality Disorder, (1998). Psychoanalytic Study of the Child, 53:141–158.
  10. ^ Gabbard, Glen O., Stuart W. Twemlow. 1994. The Role of Mother-Son Incest in The Pathogenesis of Narcissistic Personality Disorder. Journal of the American Psychoanalytic Association, Vol. 42, No. 1, 171–189 (1994) doi:10.1177/000306519404200109.
  11. ^ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, pp. 19–20.
  12. ^ a b Stephen M. Johnson (1 May 1987). Humanizing the narcissistic style. W.W. Norton. p. 39. ISBN 978-0-393-70037-4. http://books.google.com/books?id=WxV2QgAACAAJ. Retrieved 31 March 2011. 
  13. ^ full list in DSM-IV-TR, p. 717.
  14. ^ Identifying and understanding the narcissistic personality Elsa F. Ronningstam. Oxfard University Press Inc.
  15. ^ American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994, p. 659.
  16. ^ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, p. 22.
  17. ^ Kernberg, O.F. (1970). Factors in the psychoanalytic treatment of narcissistic personalities. Journal of the American Psychoanalytic Association, 18:51–85, p. 56
  18. ^ Siegel, J.P. (2006). Dyadic splitting in partner relational disorders. Journal of Family Psychology, 20 (3), 418–422
  19. ^ Kernberg, O.F. (1970). Factors in the psychoanalytic treatment of narcissistic personalities. Journal of the American Psychoanalytic Association, 18:51–85, p. 52
  20. ^ Kernberg, O.F. (1970). Factors in the psychoanalytic treatment of narcissistic personalities. Journal of the American Psychoanalytic Association, 18:51–85
  21. ^ Wurmser L, Shame, the veiled companion of narcissism, in The Many Faces of Shame, edited by Nathanson DL. New York, Guilford, 1987, pp. 64–92.
  22. ^ Gabbard GO, subtypes of narcissistic personality disorder. Bull Menninger Clin 1989; 53:527–532.
  23. ^ Young, Klosko, Weishaar: Schema Therapy – A Practitioner's Guide, 2003, p. 375.
  24. ^ DSM-5: Proposed Revisions: Personality and Personality Disorders. American Psychiatric Association. 2010-02-13. http://www.dsm5.org/ProposedRevisions/Pages/PersonalityandPersonalityDisorders.aspx. 
  25. ^ Zanor, Charles (29 November 2010). "A Fate That Narcissists Will Hate: Being Ignored". The New York Times. http://www.nytimes.com/2010/11/30/health/views/30mind.html. Retrieved 30 November 2010. 
  26. ^ Shedler, Jonathan; Aaron Beck, Peter Fonagy, Glen O. Gabbard, John Gunderson, Otto Kernberg, Robert Michels, and Drew Westen (September 2010). "Personality Disorders in DSM-5". American Journal of Psychiatry 167 (9): 1026–1028. DOI:10.1176/appi.ajp.2010.10050746. PMID 20826853. http://ajp.psychiatryonline.org/cgi/pdf_extract/167/9/1026. Retrieved 30 November 2010. 
  27. ^ Narcissistic personality disorder – International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
  28. ^ Millon, Theodore – Personality Subtypes
  29. ^ Initial Construction and Validation of the Pathological Narcissism Inventory Aaron L. Pincus , Emily B. Ansell, Claudia A. Pimentel, Nicole M. Cain, Aidan G. C. Wright, Kenneth N. Levy
  30. ^ Initial Construction and Validation of the Pathological Narcissism Inventory Aaron L. Pincus , Emily B. Ansell, Claudia A. Pimentel, Nicole M. Cain, Aidan G. C. Wright, Kenneth N. Levy
  31. ^ Young, Klosko, Weishaar: Schema Therapy – A Practitioner's Guide, 2003, chapter 10, pp. 373–424.
  32. ^ Golomb, Elan PhD (1992). Trapped in the Mirror. New York: Morrow, p. 23.
  33. ^ Kohut, Heinz, (1971). The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders ISBN 978-0-8236-0145-5
  34. ^ Sperry, Lynn (1999) Narcissistic Personality Disorder, Cognitive Behavior Therapy of DSM-IV Personality Disorders: Highly Effective Interventions for the Most Common Personality Disorder. (131-138). Ann Arbor, MI: Edwards Brothers.
  35. ^ Sperry, Lynn (1999) Narcissistic Personality Disorder, Cognitive Behavior Therapy of DSM-IV Personality Disorders: Highly Effective Interventions for the Most Common Personality Disorder. (131-138). Ann Arbor, MI: Edwards Brothers.
  36. ^ Sperry, Lynn (1999) Narcissistic Personality Disorder, Cognitive Behavior Therapy of DSM-IV Personality Disorders: Highly Effective Interventions for the Most Common Personality Disorder. (131-138). Ann Arbor, MI: Edwards Brothers.
  37. ^ Narcissism and Narcissistic Defences in the Eating Disorders Glenn Waller, BA, MClinPsychol, DPhil, Jennie Sines, BSc3, Caroline Meyer, BSc, PhD, Anna Skelton, BSc3, Emma Foster, BSc
  38. ^ Narcissism and Narcissistic Defences in the Eating Disorders Glenn Waller, BA, MClinPsychol, DPhil, Jennie Sines, BSc3, Caroline Meyer, BSc, PhD, Anna Skelton, BSc3, Emma Foster, BSc
  39. ^ Narcissism and Narcissistic Defences in the Eating Disorders Glenn Waller, BA, MClinPsychol, DPhil, Jennie Sines, BSc3, Caroline Meyer, BSc, PhD, Anna Skelton, BSc3, Emma Foster, BSc
  40. ^ "Disorder personalities at work", Belinda Board and Katarina Fritzon, 2005, Psychology, Crime and Law, 11(1), pp.17-32. <http://dx.doi.org/10.1080/10683160310001634304>
  41. ^ "When narcissism becomes pathological", Adrian Tempany, Financial Times, 4 September 2010, accessed 23 June 2012. <http://www.ft.com/cms/s/2/5ff67be2-b636-11df-a784-00144feabdc0.html#axzz1wu6UVK53>
  42. ^ Megalomaniacs abound in politics/medicine/finance Business Day 2011/01/07
  43. ^ Twenge, Jean M. & Campbell, W. Keith The Narcissism Epidemic: Living in the Age of Entitlement (2009)
  44. ^ Kernberg O, Borderline Conditions and Pathological Narcissism, 1967
  45. ^ Kohut H The Psychoanalytic Treatment of Narcissistic Personality Disorders: Outline of a Systematic Approach, 1968
  46. ^ Hesse, Morten; Schliewe S, Thomsen RR (2005). "Rating of personality disorder features in popular movie characters". BMC Psychiatry (London: BioMed Central) 5: 45. DOI:10.1186/1471-244X-5-45. PMC 1325244. PMID 16336663. http://www.biomedcentral.com/1471-244X/5/45. 

Template:44. Pat Macdonald.2011.Narcissistic personality disorder. Practice nurse.41(1):16-18

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