skills in a safe, nonthreatening environment can help
clients to gain confidence in their ability to interact so-
cially. The nurse must be specific in describing and
modeling social skills including establishing eye con-
tact, active listening, and respecting personal space. It
also helps to outline topics of discussion appropriate
for casual acquaintances, closer friends or family, and
the nurse only.
Clients may be quite sensitive to discussing self-
esteem and may respond with exaggerated emotions.
It is important to explore personal strengths and as-
sets and give specific feedback about positive charac-
teristics. Encouraging clients to use assertive com-
munication, such as “I” statements, may promote
self-esteem and help them to get their needs met
more appropriately. The nurse must convey genuine
confidence in the client’s abilities.
NARCISSISTIC PERSONALITY
DISORDER
Clinical Picture
Narcissistic personality disorderis character-
ized by a pervasive pattern of grandiosity (in fantasy
or behavior), need for admiration, and lack of empa-
thy. It occurs in 1% to 2% of the general population
and 2% to 16% of the clinical population. Fifty per-
cent to 75% of people with this diagnosis are men.
Narcissistic traits are common in adolescence and do
not necessarily indicate that a personality disorder
will develop in adulthood. Individual psychotherapy
is the most effective treatment, and hospitalization
is rare unless comorbid conditions exist for which the
client requires inpatient treatment (APA, 2000).
Clients may display an arrogant or haughty at-
titude. They lack the ability to recognize or to em-
pathize with the feelings of others. They may express
envy and begrudge others any recognition or mater-
ial success because they believe it rightfully should
be theirs. Clients tend to disparage, belittle, or dis-
count the feelings of others. They may express their
grandiosity overtly, or they quietly may expect to be
recognized for their perceived greatness. They often
are preoccupied with fantasies of unlimited success,
power, brilliance, beauty, or ideal love. These fan-
tasies reinforce their sense of superiority. Clients may
ruminate about long-overdue admiration and privi-
lege and compare themselves favorably with famous
or privileged people.
Thought-processing is intact, but insight is lim-
ited or poor. Clients believe themselves to be superior
and special and are unlikely to consider that their be-
havior has any relation to their problems: they view
their problems as the fault of others.
Underlying self-esteem is almost always fragile
and vulnerable. These clients are hypersensitive to
16 PERSONALITYDISORDERS 395
criticism and need constant attention and admiration.
They often display a sense of entitlement (unrealistic
expectation of special treatment or automatic compli-
ance with wishes). They may believe that only special
or privileged people can appreciate their unique qual-
ities or are worthy of their friendship. They expect
special treatment from others and often are puzzled
or even angry when they do not receive it. They often
form and exploit relationships to elevate their own
status. Clients assume total concern from others
about their welfare. They discuss their own concerns
in lengthy detail with no regard for the needs and feel-
ings of others and often become impatient or con-
temptuous of those who discuss their own needs and
concerns.
At work, these clients may experience some suc-
cess because they are ambitious and confident. Diffi-
culties are common, however, because they have trou-
ble working with others (whom they consider to be
inferior) and have limited ability to accept criticism or
feedback. They also are likely to believe that they are
underpaid and underappreciated or should have a
higher position of authority even though they are not
qualified.Nursing Interventions
Clients with narcissistic personality disorder can
present one of the greatest challenges to the nurse.Narcissistic personality