12 Am J Psychiatry 139:1, Janrmry 1982 Am J Psychiatry 139:1, January 1982 SALMAN AKHTAR AND J. ANDERSON THOMSON, JR. 13 Overview: Narcissistic Personality Disorder sistic neuroses," "psychoses," "dementia precox," scious envy in these patients. Tartakoff (22) wrote of and "schizophrenia." Waelder (9) considered narcis- the Nobel Prize complex among people who are intel- sistic personality a muted variant of schizophrenia. In lectually gifted and uniformly preoccupied with the BY SALMAN AKHTAR, M.D., AND J. ANDERSON THOMSON, JR., M.D. "On Narcissism" Freud (8) avoided character typolo- pursuit of applause, wealth, power, or social prestige. gy but pointed out that some people "compel our The term "narcissistic personality disorder" was interest by the narcissistic consistency with which introduced in the literature by Kohut in 1968 (23). they manage to keep away from their ego anything that Since then Kernberg and Kohut have been the major would diminish it." In 1931 Freud (13) wrote of the theoreticians examining the concept of narcissistic "narcissistic character type," personality disorder. The authors trace the evolutior~of narcissistic personality away from it, he died of languor. Havelock Ellis (4) (A more detailed historical account of the origin of disorder as a nosological entity in rr critical slrrlJeyof the first invoked this myth to illustrate a psychological the narcissistic personality disorder was provided by state in reporting a case of male autoeroticism. In The subject's main interest is directed to self-preserva- literature, considering and comparing djfering theoreticnl tion; he is independent and not open to intimidation. His Rothstein in a publication that appeared after the viewpoints regarding the genesis of this disorder. They commenting on Ellis' work, Nacke (5) first used the ego has a large amount of aggressiveness at its disposal, submission of this paper [24].) review its various descriptions, including the one in DSM- term "narcissmus." The term "narcissistic" was first which also manifests itself in readiness for activity. In his 111, and develop a composite pictrrw of the syndrome. The used by Freud in a 1910 footnote to "Three Essays on erotic life loving is preferred above being loved. People disorder consists of cltaracteristic deficits in six broad the Theory of Sexuality" (6). Otto Rank (7) wrote the belonging to this type impress others as being "personal- areas offrrnctioning: I) self-concept, 2) interpersonal first psychoanalytic paper on narcissism in 191 1, and ities"; they are especially suited to act as a support for relationships, 3) social adaptation, 4) ethics, standards, Freud's paper "On Narcissism" was published in 1914 others, to take on the role of leaders and to give a fresh Kernberg's description of "narcissistic personality" and ideals, 5) love and sexuality, and 6) cognitive style. (8). stimulus to cultural development or to damage the estab- (16) is derived from clinical psychoanalysis. Although The authors identifj,guidelines for distingriishir~gthe lished state of affairs. narcissistic personality from other per:~onalitydisorders crs In a 1925 paper that foreshadowed the work of more most of his writings on pathological narcissism (25,26) well as areas needing continued research. recent authors, Waelder (9) reported in detail on an are theoretical, he does offer explicit descriptions of individual with a "narcissistic personality." Waelder Annie Reich (14) emphasized that "narcissistic pa- clinical characteristics and bases the diagnosis on characterized such individuals as displaying conde- thology cannot be viewed as restricted to psychosis" readily observable behavior. Kernberg portrays pa- he diagnosis of narcissistic personality disorder scending superiority, intense preoccupation with their and pointed out the "compensatory narcissistic self- tients with this condition as having excessive self- T has been used with increasing frequency in recent self-respect, and marked lack of empathy and concern inflation" in certain nonpsychotic individuals. These absorption, intense ambition, grandiose fantasies, years; DSM-III lists it as a distinct character disorder. for others while maintaining an adequate external individuals, according to Reich, have "exaggerated, overdependence on acclaim, and an unremitting need Yet the concept remains poorly defined and controver- adaptation to reality. Their lack of empathy is often unrealistic-i.e., infantile-inner yardsticks" and con- to search for brilliance, power, and beauty. He stress- sial. It depends largely on data derived from clinical most apparent in their sexuality. Intercourse is a stantly seek to be the object of admiring attention "as es the pathological nature of their inner world, regard- psychoanalysis and lacks phenomenological documen- purely physical pleasure, the partner being less a a means to undo feelings of inferiority ." less of their superficially adaptive behavior. This pa- tation from extensive patient samples. In this paper we person than a means to an end. Waelder also pointed In 1961 Nemiah (15) described individuals with a thology is manifest in an inability to love; a lack of attempt a critical survey of the literature relevant to out the narcissistic motives that underlie even the "narcissistic character disorder" as displaying great empathy; chronic feelings of boredom, emptiness, and narcissistic personality disorder with the goal of devel- morality of these individuals. Unlike the usual super- ambition, highly unrealistic goals, intolerance of fail- uncertainty about identity; and exploitation of others. oping a composite picture of the syndrome. Similar ego dictate, "1 must not do or think this, for it is ures and imperfections in themselves, and an almost Kernberg also emphasizes the "presence of chronic efforts to clarify another controversial diagnosis, the immoral; my parents have forbidden it," narcissistic insatiable craving for admiration. Such individuals, intense envy, and defenses against such envy, particu- borderline personality (1-3), have been useful in iden- morality prompts something like, "This may not be, according to Nemiah, do very little in life because they larly devaluation, omnipotent control, and narcissistic tifying diagnostic criteria and in defining areas for for it would humiliate me; it does not accord with my want to; their actions are constantly influenced by withdrawal" (25, p. 264). These defenses appear in continued research. lofty and noble personality." Waelder indicated that what they think will make others like them. their contempt for, anxious attachment to, or avoid- these individuals often displayed a "narcissistic mode Nemiah postulated that if the parents set unrealisti- ance of secretly admired or envied others. There is of thought," which included "libidinization of think- cally high standards for the child and if the child also a tendency toward sexual promiscuity, homosex- ing" (thinking for thinking's sake), preference of con- HISTORY cannot live up to those standards, the parents treat the uality, perversions, and substance abuse and a pecu- cepts over facts, and an overvaluation of their mental child with harsh criticism. The child internalizes these liarly corruptible conscience, a readiness to shift val- In Greek mythology Narcissus fell in love with his processes. parental attitudes, and as an adult he demands too ues quickly to gain favor. own reflection in still water; unable to tear himself sism,,Following was used these with early various papers, meanings. the term Pulver ..narcis- much of himself and becomes very ambitious. He also According to Kernberg, individuals with a narcissis- criticizes himself and reacts to even an ordinary set- tic personality possess a capacity for consistent work - and van der Waals (I I), who catalogued the various back with a dismal sense of inadequacy. Such an and may even become socially quite successful, yet Received Nov. 16, 1979; revised Aug. 18, 1980; accepted Oct. 15, of narcissism from 191 1 to the 1960s- pointed individual becomes "a prisoner of his aspirations, his their work and productivity are in the service of 1980. out that it was first used to denote a sexual perversion. needs, and his harsh self-criticism." exhibitionism, and these individuals lack genuine, in- From the Department of Psychiatry and Human Behavior, Jeffer- son Medical College; Dr. Thomson is in private practice in Char- Later, the wordys connotations were expanded and In 1967 Kernberg (16) presented a coherent clinical depth professional interests. Kernberg calls this ten- lottesville, Va. Address reprint requests to Dr. Akhtar. Jefferson changed t' an stage of infant develop- description of the "narcissistic pesonality structure." dency "pseudosublimatory" (25, p. 229) in order to Medical College, Edison ~lh~.,13th floor, 9th and Sansom ~tredGI ment, placement of psychic enerav (the libidinal ca- In a later paper Kernberg (17) cited several early distinguish it from mature forms of productivity. Philadelphia, PA 19107. thexis of the self), a type of interp&sdnal relationship, authors who had contributed to the concept. Ernest Kernberg holds that the narcissistic individual as a The ruthon thank Dn. Andre Derde~n,Paul J. Fink. Joseph Mooney, and Jeffrey Dekret for critical comments on earlier drafts and, most recently, a synonym for self-esteem. ln this Jones (18) had described patients with a God complex, child was left emotionally hungry by a chronically overview we use Moore and Fine's definition of nar- of