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The Mental Illness So Stigmatized We Dare Not Speak its Name

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What's the mental illness so stigmatized that we dare not speak its name? Narcissistic personality disorder. It is a real condition that can be treated.

Narcissistic personality disorder, or NPD, sounds a lot more like an insult than a diagnosis. No clinician wants to insult their patients. Fewer people still want to think of themselves as suffering from something that is usually used to describe exes and awful bosses.

However, there is significant research on this diagnosis, and many people have suffered in this particular way.

First, let’s tackle some of the misconceptions: a personality disorder is not a “bad personality.” It does not make you a bad person, and it is something that is treatable with effective psychotherapy. Personality disorders describe long-standing patterns of behavior and thought, and these can cause problems with your interpersonal functioning and sense of self.

NPD has deep biological roots, with a heritability of 0.71. This means that 71 percent of the factors that contribute to this disorder are determined by your genetics. NPD is more “inborn” than major depressive disorder, bipolar disorder, anxiety disorders, and most other psychiatric illnesses.

What are the problems that individuals suffering with NPD have? Beyond, of course, being the topic of every click-bait article on psychology in your Facebook feed? The symptoms tend to be related to a sense of self linked to success, and challenges in interpersonal functioning.

Have you seen any of the Superman movies? He has “grandiose” ideas about his ability to save the world. And in Superman’s case, he’s not wrong; he is a remarkable hero. But no one else is vulnerable to kryptonite. And in every movie, the kryptonite comes out, and our all-powerful hero is brought to his knees! And if Superman weren’t able to dress up as Clark and go low profile from time to time, he’d be a pretty poor friend. “Did he tell you about flying around the world backwards? Yeah, he can’t seem to shut up about it...”

Individuals with NPD tend to have “grandiose” ideas. Of course, grandiose ideas aren’t inherently bad, and almost any revolutionary idea is highly “unrealistic”. The iPhone was not a realistic device until it was one. Thinking people would pay hundreds or even thousands of dollars for a phone —that’s madness. Until it became what we do every day.

Almost all big ideas sound unrealistic at first, and NPD individuals can have more of them—and be more willing to pursue them. When this becomes a disorder, however, someone can be so tied to the success of their projects, or the appearance of success, that they can have a hard time imagining what value they hold independent of the success of a project. Furthermore, if you start to understand yourself only as valuable if you are successful, it’s only the next success that lets you feel good. Failure becomes your kryptonite – able to bring you to your knees and guaranteed to show up every time. Big-thinking individuals who understand their self-worth as coming from a number of sources – family, friends, internal values, and success – are more able to tolerate a “failure.”

As in all personality disorders, interpersonal functioning, or how you handle intimacy and empathy in your life, can be impaired. If the thrill of the chase immediately gives way to boredom and a fear of deep connection, you’re going to have a lot of relationships that aren’t very fulfilling for either partner. And if you prioritize being successful over having relationships built on mutual care and understanding, those relationships are not going to go well, either – just like they wouldn’t if Superman was never able to be Clark Kent.

Many people with a psychiatric condition are likely to have another one, and so many individuals with NPD might experience a severe major depressive episode, for example. This is often what brings patients into treatment. You can imagine how a psychiatrist who only recognizes or feels comfortable diagnosing the major depressive disorder will prescribe treatment that only addresses that problem. For individuals with NPD, this dancing around the issue rarely works out. Many of them can’t tolerate general treatment very well at all, which leads to a 60 percent dropout rate.

This is one of the reasons why psychiatry is such a complicated medical specialty; we have to look at problems from multiple angles to be able to create comprehensive treatment plans which often require both medications (or other biological interventions like transcranial magnetic stimulation) as well as effective psychotherapy.

That sometimes means explaining diagnoses that have names made up a long time ago and don’t paint a full picture.

I would argue that an incomplete diagnosis is not an accurate diagnosis and that individuals with NPD can get significant benefits out of effective evidence-based psychotherapies combined with biological treatments. This can include medication for disorders like depression, anxiety, ADHD, or any other condition we have proven treatments for.

So it’s important to get the medications or other biological treatments right – but that’s only part of the psychiatrist’s job. Pills never taken because you don’t feel the psychiatrist understands you don’t work as well as those that come with a dose of Trust. Even if they’re not doing psychotherapy themselves, psychiatrists are the quarterback for the mental health team. Working with people with real problems means sometimes your patients might be a bit difficult for you, because their problems are difficult for them too.

So my advice to anyone seeking treatment is: Before embarking on a treatment course, after your clinician has done a thorough evaluation, it’s your right to ask for an explanation of what they think is going on and what the evidence is for different treatment options.

And maybe those conversations will go a little bit better once we change the name of Narcissistic personality disorder to Superman Syndrome. Until then, helping a person who is suffering feel more understood will remain my goal with all my patients.

Owen Muir, MD, is the Medical Director of and a clinical assistant professor of psychiatry at the Baylor College of Medicine. He is also an Anna Freud National Center for Children And Families (AFNCCF) official Supervisor for Mentalization-Based Treatment psychotherapy. His conflicts of interest include compensated consultation to Genomind, research support from Brainsway, USA and AFNCCF, and serving on the medical advisory board of Limitless Ventures. 

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