The Cracked Mirror: Features of

Narcissistic Personality Disorder in Children

Karen Kernberg Bardenstein, PhD

T
he notion of character disor-
der in children remains highly
controversial given unanswered
questions regarding personality forma-
tion. According to the Diagnostic and
Statistical Manual of Mental Disorders,
fourth edition,1 personality is defined as
enduring patterns of perceiving, relat-
ing to and thinking about the environ-
ment and oneself when they are mal-
adaptive and inflexible, they constitute
Personality Disorders.1 Currently, such
disorders are generally recognized by
adolescence or earlier. DSM-IV con-
tinues, however, by emphasizing cor-
responding diagnoses given to children
and adolescents, such as Conduct Dis-
order, as an earlier equivalent to Anti-
social Personality Disorder. Narcissistic
Personality Disorder (NPD) has no such
equivalent despite the acknowledgment
that it develops earlier than 18 years. The
ambivalence and ambiguity regarding
personality disorder in children are fur-
ther highlighted by the suggestion that
one can apply the diagnosis of personality
Trisha Gupta / Pennsylvania College of Art & Design

Karen Kernberg Bardenstein, PhD, is with Case

Western Reserve University, Cleveland, OH.
Address correspondence to: Karen Kern-
berg Bardenstein, PhD, 12429 Cedar Road,
Suite 18, Cleveland Heights, OH 44106; e-mail
kkbard@earthlink.net
Dr. Bardenstein has disclosed no relevant
financial relationships.

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 disorder to children if the traits are stable failure. They can lose at board games or Paulina Kernberg2,10 pioneered the
for at least 1 year and are not limited to a suffer the loss of a championship without application of NPD criteria and dynam-
particular developmental stage. becoming devastated or enraged. They ics as developed by Otto Kernberg11 to
do not take such temporary setbacks as children and added additional descriptive
NORMAL AND PATHOLOGICAL an assault to their self worth, in contrast characteristics. The narcissistic child has
NARCISSISM IN CHILDREN to the narcissistic child. Researchers have a grandiose sense of self as evidenced by
P. Kernberg2 contrasts normal narcis- difficulty tolerating anything in which he
sism from pathological NPD traits in chil- is not immediately successful. Failure
dren in the following ways. The normal to maintain efforts in academic work or
childs need for admiration is satisfied by activities involving learning new skills is
the age-appropriate attention that he re- a common feature. The inflated sense of
ceives. He is able to express gratitude for self impairs the development of a normal
and can reciprocate what others give him. conscience (or superego) since any ac-
Such children genuinely value and love knowledgment of ones flaws or failure
the significant people in their lives. Nor- to meet expectations is unbearable. Such
mal children do have fantasies of being children cannot experience guilt nor con-
powerful, famous, and highly successful. cern about the affect of their behavior on
They imagine themselves as president, a others. A 10-year-old patient remarked
famous actress or athlete, or even a hero when asked about his reaction causing a
with superpowers. The distinguishing concussion in his fellow teammate, Well,
feature of such wishes from pathological he just happened to be in the wrong place
narcissism, however, is the awareness that Normal children do have at the wrong time and got hit in the head
the wish is an aspiration and that others when I kicked the ball. The narcissistic
have the ability to be special as well. The
fantasies of being powerful, child justifies personal deficits, irrespon-
narcissistic child is convinced that he is famous, and highly successful. sible behavior or defeats through blaming
already endowed with unique and special others, evasively responding or outright
abilities and becomes envious if anyone lying. P. Kernberg noted that her narcis-
else becomes successful. One 4-year-old documented that narcissism and high sistic child patients developed both anti-
adopted girl was enraged that newborn self-esteem are independent constructs social traits and paranoid anxiety due to
twin baby sisters arrived, and she com- in child development and that narcissism this impairment in ego functioning.2,10
manded all the attention. When a fellow (in contrast with high self-esteem) in Kernberg observed that the sense of
classmate was praised for a drawing, this children correlates with other pathologi- entitlement, stemming from their sense
girl grabbed the drawing and ripped it up. cal behavior.4-6 of superiority, leads to exploitation of
Narcissistic children are in need of con- The literature supporting the presence others. An 11-year-old narcissistic pa-
stant admiration and assurance that they of narcissistic pathology in youth con- tient asserted that she wanted to grow up
are uniquely special. tinues to expand. Bleiberg7-9 articulated and be rich and have slaves. In contrast
Normal childrens needs are realistic narcissistic pathology in children, based to the normal child, the narcissistic child
and can be fulfilled. They show genu- on his clinical experience. He integrated feels entitled to what is received and the
ine attachment to friends and family theory and research about constitutional need to be grateful or reciprocate is com-
and trust significant adults in their lives. factors, attachment disorders, and trau- promised. The constant need to fuel the
Their capacity to maintain good self-es- ma. He contends that narcissistic chil- brittle sense of self and protect it from
teem, empathy, and consideration of oth- dren have a fundamental deficit in their external assaults results in extreme dis-
ers sets them apart from their narcissis- capacity for reflective functioning. This trust of others and rage when challenged
tic counterparts. Self-esteem refers to a capacity refers to the ability to interpret or criticized. These children often crave
satisfaction with ones self and how one accurately and respond adaptively to the material goods and quickly tire of and de-
lives ones life.3 It involves an evaluation world. Impairment interferes with the ca- value what they have already been given.
of how one sees and feels about the self. pacity to intuit others intentions and em- One 9-year old girl demanded that she
Well-adjusted children are able to accept pathetically grasp the feelings, thoughts, get presents and attention on her mothers
themselves, flaws and all, and can be re- and motivations that underlie others be- birthday. Like their adult counterparts,
silient in the face of disappointment or havior as well as ones own. these children exhibit intense envy of

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 others, devaluation, lack of empathy, berg interprets such behaviors as defens- bergs child patients announced that if he
and the inability to express gratitude or es against sadistic scenarios of primitive had not been adopted by his current par-
concern for others. A 13-year-old patient aggression, potential failure to perform ents, another set of parents would have
remarked that one apologizes in order to well with games, and exposure of any adopted him because he knew that there
maintain ones image and not let them deficits to the therapist. She notes that as were so many parents in line that would
think that you enjoy hurting people. He treatment progresses, sadistic fantasies of have been eager to have him. Adoptive
also defined the word obey, as listen- destroying rivals, being invulnerable and parents may also overcompensate for
ing to the whims of others. Another boy controlling and devaluing others (includ- their sense of damage at not being able
of 14 years attempted to write a letter of ing the therapist) begin to appear. to produce a biological child by overin-
apology for misbehavior to his mother dulging the adoptive child.
but quickly shifted to demanding that she ORIGINS OF NARCISSISTIC Children of the wealthy, or who have
lavishly redecorate his room. PATHOLOGY IN CHILDREN been overindulged, may be raised in an
Kernberg summarizes the childhood P. Kernberg10 described the possible environment where entitlement and con-
context in which narcissistic pathology etiology of pathological narcissism in trol of others is accepted and reinforced.
becomes evident. Peer relationships are children. From her clinical experience, Wealthy parents may also be invested in
compromised by the lack of empathy, the she identified certain circumstances that protecting the child from disappointment
need to be exploitative, devaluing, and increase the risk of narcissistic pathol- and accommodate to his wishes. These
manipulative. The quality of the friend- ogy: the child of narcissistic parents, the children may expect to have the best
ships is superficial. One young patient adopted child, the child of successful and internalize the devaluation of more
boasted that he has 1,000 friends but parents (particularly if the child lacks common lifestyles. The authors child
could not name anyone who knew him similar ability), the overindulged or reported that a fellow camper at an over-
well or whom he trusted. These children wealthy child, and the child of divorce. night summer camp complained that the
often become bossy and coercive with Narcissistic parents may over-idealize bathrooms were not made with marble
friends. Their arrogance interferes with their children and insulate them from floors and walls and that he would not
the ability to take turns, comply with disappointment or criticism. The chil- return to camp again. Deferential treat-
their friends wishes, or follow agreed- dren can easily develop the idea that ment of the child because of his connec-
upon game rules. they are, in fact, superior to others and tions can further fuel grandiosity.
Academic performance also suffers above criticism and failure. One couple, Children of successful parents may
because narcissistic children do not enjoy convinced that their 5-year-old was a have the expectation that they should
their learning experiences. Achievement genius, removed him from consecutive naturally be as talented without effort
serves the purpose of eliciting admiration schools they deemed incompetent and because they born from brilliance. Meet-
rather than acquiring knowledge for its mediocre because he was not receiv- ing such expectations is particularly dif-
own intrinsic value. If admiration wanes, ing teachers praise. They dismissed ficult if the child has less ability or has
the child becomes easily bored. Despite the schools concerns about the childs any deficits that affect success. Narcis-
innate intelligence in some narcissistic aggressive behavior as irrelevant and sistic pathology serves as a compensa-
children, they lose motivation to apply justified his poor adjustment as bore- tion for a sense of inadequacy that is
themselves in new subjects and skills and dom. When they received a report that too painful to acknowledge. The son of
get poor grades because of to lack of ef- the child tested as having average intel- a famous basketball player failed to be
fort. Kernberg also noted their inability to ligence, they complained to the head of accepted in his school basketball team
maintain eye contact as a defense against the psychiatric hospital about the incom- and responded with severe tantrums and
potential critical scrutiny and tuning petence of the evaluator. devaluation of the coach.
out of the unwelcome demands or ex- Children who are adopted can be sus- Children of divorce are particularly
pectations of others. They are so haughty ceptible because they have to address the susceptible if the parents convey that they
that no one can tell them what to do, and initial rejection of why their biological are prized possessions that are vied for.
their capacity to learn from others feed- parents did not keep them. Adoptive par- Each parent in an attempt to carry favor
back is curtailed. ents may compensate for this injury by with the child may be at risk for not pro-
Additional pathology is evident in the emphasizing how they are more special viding critical feedback and refusing to
narcissistic childs play. The child initially than biological children because they indulge the child with material goods or
professes boredom, dissatisfaction with were chosen, especially if biological sib- excessive privileges. In turn, some chil-
the toys, or devaluation of games. Kern- lings are part of the family. One of Kern- dren of divorce develop a sense of self-

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 importance, entitlement, and devaluation Some studies have utilized structured Psychological testing has only been
of the parent who does not offer immedi- interviews to systematically identify nar- recently applied to the study of narcis-
ate gratification or flexible limits. cissistic features in children. Eppright et sism in children. Abrams34 reports a sin-
Parent-child interactions continue to al21 interviewed incarcerated adolescents gle case study using the Thematic Ap-
be studied with respect to their contri- with the Diagnostic Interview for Chil- perception Test (TAT) and the Childrens
bution to narcissistic pathology and are dren and Adolescents-Revised and the Apperception Test (CAT) to assess an 8-
critical aspects of intervention with nar- Structured Clinical Interview for Mental year-old boy and describes his dynamic
cissistic children.2,12 Disorders-III-Revised, for Personality issues. The TAT and the CAT, however,
Disorders, to establish diagnoses. They lack the rigorous empirical validity and
ASSESSMENT OF NARCISSISTIC observed that after antisocial personality reliability required to systematically
PATHOLOGY IN CHILDREN AND disorder, narcissistic personality disor- study personality disorder, despite their
ADOLESCENTS der was one of the most frequent diag- rich clinical utility.
Egan and Kernberg,13 Ferreira,14 noses. Myers et al22 similarly conducted Although research examining char-
Rinsley,15 Cohen,16 Beren,17 Bernstein,18 structured diagnostic interviews and uti- acter or personality disorder in adults
and Imbesi19 wrote about narcissistic lized the Revised Psychopathy Checklist has become common in the Rorschach
traits in children from the psychoanalytic (PCL-R) to evaluate comorbid personal- literature, a notable absence exists re-
perspective as well. They proposed theo- ity disorders in psychiatrically hospital- garding characteristics of children with
retical explanations for the distinctive ized adolescents and reported significant personality disorders. The Rorschachs
characteristics of the disorder includ- relationships between psychopathy scores ability to methodically and validly as-
ing grandiosity, negative and aggressive and narcissistic personality disorder. sess narcissistic personality disorder has
transference, attachment difficulties, Recent reports are documenting the va- been established by Hilsenroth and col-
boundary disturbances between self, and lidity and stability of personality disorder leagues,35 utilizing independently diag-
other and primitive defenses such as split- in children and adolescents using behav- nosed patients based on DSM-IV crite-
ting and devaluation. These publications ioral checklists and interviews.17,20,23,24 ria1 for Clusters A, B, and C personality
are primarily based on clinical observa- The Narcissistic Personality Inventory disorders. (Previous publications report-
tions of child patients in treatment. Blei- developed by Raskin and Hall25 has been ing the Rorschachs ability to differenti-
berg9 integrated his previous work with applied to children and adolescents.12,26 ate NPD from other personality disorders
additional clinical material and treatment Ang27 has recently reported on the Nar- were not based on DSM-IV criteria.)
considerations but did not address psy- cissistic Personality Questionnaire for They demonstrated that the Rorschach
chological testing of such children. Children-Revised (NPQC-R), which has variables of reflection (one image is mir-
Guile20 assessed the three differ- adequate reliability and validity to serve rored by another), pairs (two related or
ent systems for diagnosing narcissism as a measure of superiority and exploi- identical items are seen), personalization
in children based on DSM diagnostic tation. Thomaes28 introduced the Child- (the response is justified not be aspects of
criteria (P. Kernbergs for children,2 hood Narcissism Scale, which also valid- the inkblot but by personal experience),
Bleibergs for adolescents,8 and DSM- ly and reliably assesses grandiose sense idealization (aggrandizing attributes of
IV criteria for pre-adolescents1) and of self, inflated sense of superiority and the percept), and the Egocentricity Index
reported a high concordance rate. He entitlement, and exploitative interperson- (a ratio of reflection and pair responses
concluded that NPD could be identi- al attitudes. Guile24 reported adequate to total number of responses) effective-
fied among pre-adolescents. With the reliability for the Diagnostic Interview ly differentiated the NPD group from a
increasing ability to consistently iden- for Narcissism Adapted for Pre-Ado- non-clinical sample and from Cluster A,
tify narcissistic features, the research lescents: Parent Version (P-DIN), based Cluster C, and other Cluster B personal-
on narcissistic personality in children, on Gundersons Diagnostic Interview.29 ity disorders. They noted two variables
especially using psychological instru- These instruments are providing further that were robustly significant across sta-
ments and structured interviews, has understanding about how narcissism tistical analyses: reflection responses and
expanded as a result. Kernberg, Wein- interacts with aggression, delinquency, idealization. The Egocentricity Index and
er and Bardenstein2 reported psycho- shame, and interpersonal adjustment in pair responses differentiated NPD from
logical test findings that were char- young populations.5,6,26,30-33 Crawford33 some groups but not consistently across
acteristic of children with personality reported high stability of pathological all groups. The authors found significant
disorder in general, as well as narcis- narcissistic behaviors in children from correlations between Rorschach criteria
sistic personality disorder. early adolescence into adulthood. and DSM-IV criteria for NPD.

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 LEXAPRO (escitalopram oxalate) TABLETS/ORAL SOLUTION The Rorschach is clearly a compelling instrument with
(5% and 4%); Fatigue (5% and 2%). Psychiatric Disorders: Insomnia (9% and 4%); Somnolence (6% and 2%); Appetite Decreased (3% and 1%); Libido
Decreased (3% and 1%). Respiratory System Disorders: Rhinitis (5% and 4%); Sinusitis (3% and 2%). Urogenital: Ejaculation Disorder1,2 (9% and <1%);
which to assess patterns of perceiving, relating to, and think-
Impotence2 (3% and <1%); Anorgasmia3 (2% and <1%).*Events reported by at least 2% of patients treated with Lexapro are reported, except for the following
events which had an incidence on placebo Lexapro: headache, upper respiratory tract infection, back pain, pharyngitis, inflicted injury, anxiety. 1Primarily ejacu-
ing about the environment but has yet to be actively utilized
latory delay. 2Denominator used was for males only (N=225 Lexapro; N=188 placebo). 3Denominator used was for females only (N=490 Lexapro; N=404 placebo).
Generalized Anxiety Disorder Table 3 enumerates the incidence, rounded to the nearest percent of treatment-emergent adverse events that occurred among 429 to address the issue of whether children exhibit personality
GAD patients who received Lexapro 10 to 20 mg/day in placebo-controlled trials. Events included are those occurring in 2% or more of patients treated with Lexapro
and for which the incidence in patients treated with Lexapro was greater than the incidence in placebo-treated patients. The most commonly observed adverse disorder and if such disorders truly persist over time. Although
events in Lexapro patients (incidence of approximately 5% or greater and approximately twice the incidence in placebo patients) were nausea, ejaculation disorder
(primarily ejaculatory delay), insomnia, fatigue, decreased libido, and anorgasmia (see TABLE 3). TABLE 3: Treatment-Emergent Adverse Events: Incidence in
Placebo-Controlled Clinical Trials for Generalized Anxiety Disorder* (Percentage of Patients Reporting Event) Body System/Adverse Event [Lexapro (N=429)
numerous Rorschach indices and features have been proposed
and Placebo (N=427)]: Autonomic Nervous System Disorders: Dry Mouth (9% and 5%); Sweating Increased (4% and 1%). Central & Peripheral Nervous
System Disorders: Headache (24% and 17%); Paresthesia (2% and 1%). Gastrointestinal Disorders: Nausea (18% and 8%); Diarrhea (8% and 6%); Constipation
as indicative or characteristic of adult NPD, such as the re-
(5% and 4%); Indigestion (3% and 2%); Vomiting (3% and 1%); Abdominal Pain (2% and 1%); Flatulence (2% and 1%); Toothache (2% and 0%). General:
Fatigue (8% and 2%); Influenza-like symptoms (5% and 4%). Musculoskeletal: Neck/Shoulder Pain (3% and 1%). Psychiatric Disorders: Somnolence (13% and flection response,36 most examine the content of the response
7%); Insomnia (12% and 6%); Libido Decreased (7% and 2%); Dreaming Abnormal (3% and 2%); Appetite Decreased (3% and 1%); Lethargy (3% and 1%);
Yawning (2% and 1%). Urogenital: Ejaculation Disorder1,2 (14% and 2%); Anorgasmia3 (6% and <1%); Menstrual Disorder (2% and 1%). *Events reported by (as opposed to the coding of the response). Kwawer37 notes
at least 2% of patients treated with Lexapro are reported, except for the following events which had an incidence on placebo Lexapro: inflicted injury, dizziness,
back pain, upper respiratory tract infection, rhinitis, pharyngitis. 1Primarily ejaculatory delay. 2Denominator used was for males only (N=182 Lexapro; N=195
placebo). 3Denominator used was for females only (N=247 Lexapro; N=232 placebo). Dose Dependency of Adverse Events The potential dose dependency of
that narcissistic mirroring in responses involving reflec-
common adverse events (defined as an incidence rate of 5% in either the 10 mg or 20 mg Lexapro groups) was examined on the basis of the combined
incidence of adverse events in two fixed-dose trials. The overall incidence rates of adverse events in 10 mg Lexapro-treated patients (66%) was similar to that of
tion, twin imagery or shadows is associated with narcissistic
the placebo-treated patients (61%), while the incidence rate in 20 mg/day Lexapro-treated patients was greater (86%). Table 4 shows common adverse events
that occurred in the 20 mg/day Lexapro group with an incidence that was approximately twice that of the 10 mg/day Lexapro group and approximately twice that traits. Lerner and Lerner38 and Cooper, Perry, and Arnow39 in-
of the placebo group. TABLE 4: Incidence of Common Adverse Events* in Patients with Major Depressive Disorder Receiving Placebo (N=311), 10 mg/day
Lexapro (N=310), 20 mg/day Lexapro (N=125): Insomnia (4%, 7%, 14%); Diarrhea (5%, 6%, 14%); Dry Mouth (3%, 4%, 9%); Somnolence (1%, 4%, 9%); fer narcissistic defenses, devaluation, and idealization in the
Dizziness (2%, 4%, 7%); Sweating Increased (<1%, 3%, 8%); Constipation (1%, 3%, 6%); Fatigue (2%, 2%, 6%); Indigestion (1%, 2%, 6%).*Adverse events
with an incidence rate of at least 5% in either of the Lexapro groups and with an incidence rate in the 20 mg/day Lexapro group that was approximately twice
that of the 10 mg/day Lexapro group and the placebo group. Male and Female Sexual Dysfunction with SSRIs Although changes in sexual desire, sexual
content of the responses as well. Berg40 examines grandiosity
performance, and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of pharmacologic treatment. In
particular, some evidence suggests that SSRIs can cause such untoward sexual experiences. Reliable estimates of the incidence and severity of untoward experi- in the content. Wagner and Hoover41 report exhibitionism as
ences involving sexual desire, performance, and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss
them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling are likely to underestimate their actual indicative of the narcissistic protocol. The exploratory nature
incidence. Table 5 shows the incidence rates of sexual side effects in patients with major depressive disorder and GAD in placebo-controlled trials. TABLE 5:
Incidence of Sexual Side Effects in Placebo-Controlled Clinical Trials [In Males Only: Adverse Event: Lexapro (N=407) and Placebo (N=383)]: Ejaculation of Rorschach assessment of NPD in children required a pilot
Disorder (primarily ejaculatory delay) (12% and 1%); Libido Decreased (6% and 2%); Impotence (2% and <1%). [In Females Only: Lexapro (N=737) and Placebo
(N=636)]: Libido Decreased (3% and 1%); Anorgasmia (3% and <1%) There are no adequately designed studies examining sexual dysfunction with escitalopram
treatment. Priapism has been reported with all SSRIs. While it is difficult to know the precise risk of sexual dysfunction associated with the use of SSRIs, physi-
study to examine what structural features would be generated
cians should routinely inquire about such possible side effects. Vital Sign Changes Lexapro and placebo groups were compared with respect to (1) mean change
from baseline in vital signs (pulse, systolic blood pressure, and diastolic blood pressure) and (2) the incidence of patients meeting criteria for potentially clinically by children and adolescents who had narcissistic clinical pre-
significant changes from baseline in these variables. These analyses did not reveal any clinically important changes in vital signs associated with Lexapro treat-
ment. In addition, a comparison of supine and standing vital sign measures in subjects receiving Lexapro indicated that Lexapro treatment is not associated with sentations. The current study was developed to test whether
orthostatic changes. Weight Changes Patients treated with Lexapro in controlled trials did not differ from placebo-treated patients with regard to clinically impor-
tant change in body weight. Laboratory Changes Lexapro and placebo groups were compared with respect to (1) mean change from baseline in various serum
chemistry, hematology, and urinalysis variables, and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in
previously identified features in NPD adults would be simi-
these variables. These analyses revealed no clinically important changes in laboratory test parameters associated with Lexapro treatment. ECG Changes
Electrocardiograms from Lexapro (N=625), racemic citalopram (N=351), and placebo (N=527) groups were compared with respect to (1) mean change from
larly present and whether other features would distinctly
baseline in various ECG parameters and (2) the incidence of patients meeting criteria for potentially clinically significant changes from baseline in these variables.
These analyses revealed (1) a decrease in heart rate of 2.2 bpm for Lexapro and 2.7 bpm for racemic citalopram, compared to an increase of 0.3 bpm for characterize these younger patients.
placebo and (2) an increase in QTc interval of 3.9 msec for Lexapro and 3.7 msec for racemic citalopram, compared to 0.5 msec for placebo. Neither Lexapro nor
racemic citalopram were associated with the development of clinically significant ECG abnormalities. Other Events Observed During the Premarketing Evaluation The particular questions addressed in the study include
of Lexapro Following is a list of WHO terms that reflect treatment-emergent adverse events, as defined in the introduction to the ADVERSE REACTIONS section,
reported by the 1428 patients treated with Lexapro for periods of up to one year in double-blind or open-label clinical trials during its premarketing evaluation.
All reported events are included except those already listed in Tables 2 & 3, those occurring in only one patient, event terms that are so general as to be uninfor-
whether any structural features would emerge consistent
mative, and those that are unlikely to be drug related. It is important to emphasize that, although the events reported occurred during treatment with Lexapro, they
were not necessarily caused by it. Events are further categorized by body system and listed in order of decreasing frequency according to the following definitions:
with theoretical explanations, whether chronicity of the fea-
frequent adverse events are those occurring on one or more occasions in at least 1/100 patients; infrequent adverse events are those occurring in less than 1/100
patients but at least 1/1000 patients. Cardiovascular - Frequent: palpitation, hypertension. Infrequent: bradycardia, tachycardia, ECG abnormal, flushing, varicose tures would be evident (which would support the notion of
vein. Central and Peripheral Nervous System Disorders - Frequent: light-headed feeling, migraine. Infrequent: tremor, vertigo, restless legs, shaking, twitching,
dysequilibrium, tics, carpal tunnel syndrome, muscle contractions involuntary, sluggishness, coordination abnormal, faintness, hyperreflexia, muscular tone an enduring constellation of traits), and whether the children
increased. Gastrointestinal Disorders - Frequent: heartburn, abdominal cramp, gastroenteritis. Infrequent: gastroesophageal reflux, bloating, abdominal discom-
fort, dyspepsia, increased stool frequency, belching, gastritis, hemorrhoids, gagging, polyposis gastric, swallowing difficult. General - Frequent: allergy, pain in limb,
fever, hot flushes, chest pain. Infrequent: edema of extremities, chills, tightness of chest, leg pain, asthenia, syncope, malaise, anaphylaxis, fall. Hemic and
and adolescents of the sample would share a distinct con-
Lymphatic Disorders - Infrequent: bruise, anemia, nosebleed, hematoma, lymphadenopathy cervical. Metabolic and Nutritional Disorders - Frequent: increased
weight. Infrequent: decreased weight, hyperglycemia, thirst, bilirubin increased, hepatic enzymes increased, gout, hypercholesterolemia. Musculoskeletal System
stellation of traits that could be contrasted with other child
Disorders - Frequent: arthralgia, myalgia. Infrequent: jaw stiffness, muscle cramp, muscle stiffness, arthritis, muscle weakness, back discomfort, arthropathy, jaw
pain, joint stiffness. Psychiatric Disorders - Frequent: appetite increased, lethargy, irritability, concentration impaired. Infrequent: jitteriness, panic reaction, patient populations.
agitation, apathy, forgetfulness, depression aggravated, nervousness, restlessness aggravated, suicide attempt, amnesia, anxiety attack, bruxism, carbohydrate
craving, confusion, depersonalization, disorientation, emotional lability, feeling unreal, tremulousness nervous, crying abnormal, depression, excitability, auditory
hallucination, suicidal tendency. Reproductive Disorders/Female* - Frequent: menstrual cramps, menstrual disorder. Infrequent: menorrhagia, breast neoplasm,
pelvic inflammation, premenstrual syndrome, spotting between menses. *% based on female subjects only: N=905 Respiratory System Disorders - Frequent:
bronchitis, sinus congestion, coughing, nasal congestion, sinus headache. Infrequent: asthma, breath shortness, laryngitis, pneumonia, tracheitis. Skin and
RORSCHACH FEATURES OF NPD CHILDREN
Appendages Disorders - Frequent: rash. Infrequent: pruritus, acne, alopecia, eczema, dermatitis, dry skin, folliculitis, lipoma, furunculosis, dry lips, skin nodule.
Special Senses - Frequent: vision blurred, tinnitus. Infrequent: taste alteration, earache, conjunctivitis, vision abnormal, dry eyes, eye irritation, visual disturbance,
The initial study included the Rorschachs of 36 chil-
eye infection, pupils dilated, metallic taste. Urinary System Disorders - Frequent: urinary frequency, urinary tract infection. Infrequent: urinary urgency, kidney stone,
dysuria, blood in urine. Events Reported Subsequent to the Marketing of Escitalopram - Although no causal relationship to escitalopram treatment has been dren,42 ranging in age from 5 to 17 years, with a mean
found, the following adverse events have been reported to have occurred in patients and to be temporally associated with escitalopram treatment during post
marketing spontaneous and clinical trial experience and were not observed during the premarketing evaluation of escitalopram: Blood and Lymphatic System age of 11.8 years. The sample was divided approximately
Disorders: hemolytic anemia, leukopenia, thrombocytopenia. Cardiac Disorders: atrial fibrillation, cardiac failure, myocardial infarction, torsade de pointes, ventric-
ular arrhythmia, ventricular tachycardia. Endocrine Disorders: diabetes mellitus, hyperprolactinemia, SIADH. Eye Disorders: diplopia, glaucoma. Gastrointestinal
Disorders: gastrointestinal hemorrhage, pancreatitis, rectal hemorrhage. General Disorders and Administration Site Conditions: abnormal gait. Hepatobiliary
equally among female and male patients, with the major-
Disorders: fulminant hepatitis, hepatic failure, hepatic necrosis, hepatitis. Immune System Disorders: allergic reaction. Investigations: electrocardiogram QT
prolongation, INR increased, prothrombin decreased. Metabolism and Nutrition Disorders: hypoglycemia, hypokalemia. Musculoskeletal and Connective Tissue ity coming from middle to upper class backgrounds. The
Disorders: rhabdomyolysis. Nervous System Disorders: akathisia, choreoathetosis, dysarthria, dyskinesia, dystonia, extrapyramidal disorders, grand mal seizures
(or convulsions), hypoaesthesia, myoclonus, neuroleptic malignant syndrome, nystagmus, seizures, serotonin syndrome, tardive dyskinesia. Pregnancy, patient group was mostly white, (89%) with two black and
Puerperium and Perinatal Conditions: spontaneous abortion. Psychiatric Disorders: acute psychosis, aggression, anger, delirium, delusion, nightmare, paranoia,
visual hallucinations. Renal and Urinary Disorders: acute renal failure. Reproductive System and Breast Disorders: priapism. Respiratory, Thoracic and Mediastinal three Asian patients. All the children were evaluated in an
Disorders: pulmonary embolism. Skin and Subcutaneous Tissue Disorders: angioedema, ecchymosis, erythema multiforme, photosensitivity reaction, Stevens
Johnson Syndrome, toxic epidermal necrolysis, urticaria. Vascular Disorders: deep vein thrombosis, hypotension, orthostatic hypotension, phlebitis thrombosis. outpatient setting over a period of 5 years and presented
Forest Pharmaceuticals, Inc. Subsidiary of Forest Laboratories, Inc. St. Louis, MO 63045 USA Licensed from H. Lundbeck A/S Rev. 04/08 2008 Forest
Laboratories, Inc. behaviorally as NPDs as defined by DSM-IV criteria, in-
cluding a pervasive pattern of grandiosity, lack of empathy,
and hypersensitivity to criticism.
The childhood equivalents included: temper tantrums
when criticized or made demands of; antisocial behavior
such as lying, stealing, or physical aggressiveness with oth-
ers; devaluation of others; envy of others status, material
wealth, or skills; grandiose self perceptions not founded in
reality; suspiciousness of others motives; denial or lack of

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 SIDEBAR. ity to distort reality, engage in peculiar or
thought-disordered ideation, and a less-
DSM-IV Criteria for Narcissistic Personality Disorder ened ability to see conventional reality,
1. Grandiose sense of self-importance. as indicated by a positive Schizophrenia
2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Index. This finding also suggests that
3. Belief that one is special, unique, and can only be understood by or should associate with these children have faulty or distorted
other special or high-status people.
reasoning that further impairs their func-
4. Requiring excessive admiration.
tioning. The Hypervigilance Index (HVI)
5. Sense of entitlement, unreasonable expectations of especially favorable treatment, or auto-
suggests that they invest significant en-
matic compliance with expectations.
ergy in protecting the self against the
6. Interpersonal exploitation.
perceived malevolence of the outside
7. Lack of empathy.
world. When combined with poor reality
8. Being envious of others and believing others are envious in turn.
testing, hypervigilance becomes para-
9. Arrogant, haughty behaviors and attitudes.
noia. They are interpersonally guarded,
remain suspicious of others motives, and
responsibility for ones actions; and a tress caused by their maladaptive behav- zealously maintain personal space. Their
lack of remorse and concern for oth- ior. The DSM-IV criteria are summarized relationships are likely to be distant and
ers. These behaviors are included in the in the Sidebar. superficial. The HVI constellation is ex-
Hare Psychopathy scale43 for the differ- The Rorschach protocols were scored tremely rare in non-patient children and
ential diagnosis of NPDs with antiso- by two raters using the Exner Compre- adolescents yet characterized the NPD
cial features. One child had retorted to hensive System 44 with acceptable re- children older than 7 years. Three of the
his art teacher after being reprimanded, liability (91%). The second rater was four age groups also were positive on the
Id rather clean the toilets in the bath- blinded to the diagnoses of the patients. Coping Deficit Index (CDI), a measure of
room than do your project. Another The Rorschachs were then scored for general coping capacity, particularly in
child had threatened to sue his school structural features and reviewed for the interpersonal realm. A positive CDI
for harassment because he lost credit those that occurred in more than half the is associated with interpersonal ineptness
when he failed to turn in an assignment. protocols and were also significant (> 1 and a chaotic history of relationships. The
A first grader told his teacher that she standard deviation) from the non-patient Depression Index was also elevated in the
was obtuse, and he would prefer to normative data published by Exner44 for NPD population, indicative of frequent
count bricks in the hall than to stay in the comparable age. Although Exner experiences of dysphoric affect, low self-
class with her. A second grader refused generally discourages such a practice, esteem, and psychological pain that was
to do her worksheets and explained to he allows for reports that are highly dis- not consistently evident in the presenting
her teacher that she did not have to do crepant from the expected range. The symptoms of these patients.
such boring work in summer camp or results were divided into smaller groups These constellations are not only
Sunday school, so she did not have to based on age to also reveal possible de- rare in the non-patient comparison
do it in regular school. velopmental indications that would be group but also represent premature,
These children were characterized by otherwise lost by combining latency age crystallized, developmental formations
previous resistance to treatment interven- children with older adolescents. that are stable over time and unlikely to
tions, oppositional and defiant behavior, The Rorschach findings were clus- disappear with continued maturation.
lack of motivation to pursue activities or tered along basic aspects of personality The impact on affect and cognitive
school when success was not immediately functioning including: 1) constellations processes is also profound as the results
forthcoming, expectations that others are of clinically related traits; 2) the expe- suggest. The elevated space responses
there to gratify needs without a need for rience and expression of emotions; 3) are associated with an alienated, opposi-
reciprocity or gratitude, a constant need cognitive functions; 4) interpersonal tional stance toward others that can lead
to be the center of attention, and a lack of perceptions, and 5) self-perception. The to clashes with the environment. Anger
investment in friends or family, resulting explanations of the terms will appear in and resentment are easily triggered,
in superficial relationships. They exter- the discussion of the results. and the personal investment in being a
nalized blame for their behavior to avoid These young narcissistic patients tend nonconformist further distances these
punishment or justify poor work. All of to be positive on several of the Exner children from others. These children are
the patients were indifferent to the dis- constellations. They exhibited a capac- very uncomfortable and avoidant around

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 emotionally charged situations. They try The children turn to their own ideation the interpersonal variables reveals that,
to remove themselves from affective ex- as their best resource to solve problems like most other patient populations, the
changes with others, as indicated by the or address demands. However, their sus- absence of texture responses frequently
low Affectivity Ratio scores. They strive ceptibility to simplifying and distorting found in this group, suggests a deficit in
to restrict and inhibit emotional expres- information seriously compromises the the ability to form attachments to oth-
sion in a manner that is not only atypical efficiency of their problem-solving style. ers and a resignation to not having ones
developmental for children and adoles- needs for nurturing met. The relative
cents but also detrimental to learning absence of aggressive and cooperative
from emotional exchanges with peers. movement is also significant because
In contrast with the non-patient group, these groups both share an interactive
the overall acknowledgment of feelings and mutual engagement, either positive
is suppressed in the Rorschach protocols or negative, that NPD children do not ex-
as shown by the lower Weighted Sum C hibit. The NPD children exist on the pe-
scores. The elevation in Morbid scores riphery of human involvement, observ-
in the NPD group may provide a clue to ing but not truly connecting with others.
the overall affective restriction. Morbid The last variable, the overall number of
responses are associated with feelings of full human responses, confirms the rela-
damage, pessimism, and inadequacy that tive lack of interest and identification
may prove intolerable to NPD children with other people. Others are perceived
who are valiantly battling to maintain as extensions of the self or need-grati-
their inflated but flawed sense of self. The NPD children exist on fiers or frustraters. People are objects to
be used, envied, or devalued.
FURTHER VARIABLES
the periphery of human The findings in the self-perception
The cognitive processes also appear involvement ... variables are also consistent with the
to succumb to the need to protect the theoretical understanding of NPD. These
self. These childrens Lambda scores They are likely to generate unexpected patients exist with an inflated sense (as
are relatively high. Lambda represents a and often inappropriate solutions to the seen by their reflection responses) that
cognitive operation of reducing complex demands that they experience. exceed the non-patients profile. Ironi-
or ambiguous detail or information to The two Ideation variables confirm cally, even the self-aggrandizement does
a simplistic, black and white picture. this problem. The NPD group engages not elevate their insidious feelings of in-
This just the facts, Maam, approach in fantasy to an excess to avoid dealing adequacy (Egocentricity ratio) that they
to life eliminates problematic nuances with unpleasant situations, hoping that, try to keep from their own awareness.
that may blur the situation. NPD chil- eventually, they can escape any respon- The presence of reflection responses also
dren need to see problems in ways that sibility and someone else will clean includes other operations such as denial
suit their psychological needs. However, up the mess. This maladaptive Snow and externalization of blame in an effort
the simplification of facts, consequently, White syndrome, a term used to de- to preserve the need for a flawless self.
leaves them vulnerable to missing im- scribe Mp > Ma scores, occurred two to The unusual amount of Form Dimen-
portant (and possibly distressing) de- four times more often in the NPD group sion (FD) responses in these children is
tails. The increased X-percentage con- than in the non-patient controls. The an unexpected finding. The term refers
firms that NPD children regularly distort second variable, M-, also occurred more to using contours to indicate depth. In
information and are unable or unwilling often in the NPD group. M- involves the adults, FD correlates with an ability to
to see things in conventional ways, was use of human movement with distorted objectively look at oneself but in these
observed in the lower Popular scores. form and is empirically associated with children, the presence of FD may have a
They engage in a problem solving style, circumscribed peculiar ideation about distinct meaning. It may indicate a preco-
and pervasively so, that is unexpected people that can become delusional. cious awareness of the self as others see
for children across the age range. This Not surprisingly, the interpersonal one (or how one would wish to be seen by
Superintroversive problem solving realm is affected. The HVI score already others) that is a precursor to the reflection
style involves delaying any reaction un- suggests that the NPD group will keep response. This self-consciousness, ironi-
til alternatives are examined methodical- their distance from others, who are al- cally, emerges instead of the capacity for
ly, without integrating emotional cues. ways suspect. Further examination of self-reflection or introspection, a person-

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 ality trait that is rare in the child and ado- ers malevolence (aggression externalized are consistent with theory about narcis-
lescent NPD group. FD appears entwined onto others); and sadistic or aggressive sism and with the assumption that per-
with the HVI index as others are moni- pleasure in the defeat of others, without re- sonality disorder exists in children. The
tored to determine how the NPD child is morse or concern. These constructs were findings indicate the narcissistic chil-
being perceived. Stegge and Bushman5 organized into the categories of food re- dren and adolescents are presenting with
found that the self esteem of narcissistic sponses (Fd) which correlate with depen- pervasive personality pathology. They
children is highly dependent on external dency, preparedness (content involving exhibit distortion of reality, constric-
evaluations: Narcissists gain and lose tion of affect, a hypervigilant wariness
worth according to how others view them of others motives, depressive features
In contrast, normal, healthy forms of not apparent in the clinical presentation,
self esteem are stable and relatively inde- inflated sense of self in the presence of
pendent of the appraisals of others. As a sense of inferiority and comparatively
the sample has grown, the elevated FD less interest in others, and less involve-
has consistently appeared in the NPD ment in close relationships. They rely on
childrens Rorschach responses, with- themselves as their own best resources
out evidence of objective self-evaluation and engage little with others to solve
implied by adult studies.45 This need to problems. Their personality traits tend
monitor others reactions to ones image to stable, despite their maladaptive na-
is consistent with theory of NPD. ture, and they are not likely to experi-
The structural features outlined in this ence any need to engage in treatment to
study have a clinical counterpart in the change the nature of their adjustment.
content of these Rorschach protocols. The cruel, antisocial tendency Therapy is likely to trigger the paranoid
The responses were classified according and narcissistic traits as their behavior
to theory and other research findings. associated with NPD is evident is examined and interpreted. These fea-
The theory-based categories that were tures are not only consistent with clinical
significantly present in these childrens
in these childrens responses. descriptions of these patients outlined at
responses included grandiosity, exhibi- the start of this chapter but also suggest
tionism, and the defenses of devaluation radar, antennae, binoculars, weaponry), the chronicity and intractability of the
and idealization. Grandiose responses and aggressive or aggressive/morbid re- personality constellation that has been
included percepts in which status and sponses. As noted previously, cooperative erected to compensate for the cracked
admiration were emphasized: a preach- or mutual relationships between subjects image of the self.
er lifting his hands as he speaks to the was unusual in the protocols. Interactions
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