Narcissistic personality disorder

Background

• A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy

Clinical Features

• Five (or more) of the following criteria, beginning by early adulthood and present in a variety of contexts:
  • Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  • Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  • 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).
  • Requires excessive admiration.
  • Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
  • Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  • Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  • Is often envious of others or believes that others are envious of him or her.
  • Shows arrogant, haughty behaviors or attitudes.

Differential Diagnosis

• Other personality disorders
• Mania or hypomania
• Substance use disorders

Evaluation

• A clinical diagnosis; however if entertaining other organic causes may initiate workup below

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)

Management

• Set clear boundaries and expectations, be fact-based and up front about what you can and cannot do
• If patient making unreasonable demands/entitlement, circle back to emphasize the patient does deserve excellent medical care
• Tolerate emotions but not outbursts
• Referral for outpatient psychiatric treatment, as psychotherapy is the primary treatment.

Disposition

• Discharge