Adverse childhood experiences leading to narcissistic personality disorder: a case report

Abstract

Background

Narcissistic personality disorder (NPD) is associated with a complex interplay of genetic, neurobiological, and environmental factors. In this case report, we discuss the association between adverse childhood experiences (ACEs) and the development of NPD in adulthood.

Case presentation

Here, we report a clinical case of NPD to illustrate how ACEs, particularly physical and emotional neglect, combined with early life parental overvaluation, can impair emotional regulation and self-worth, contributing to the development of narcissistic traits. We analyse, in light of existing literature, how ACEs are associated with a wide spectrum of personality disorders, how parental overvaluation is linked to grandiose narcissism, and how childhood neglect and abuse are associated with vulnerable narcissism.

Conclusion

ACEs are the primary risk factor for the development of NPD in adulthood. Dysfunctional household environments and parenting practices compound the association between ACEs and pathological narcissism. It is important to address childhood trauma for the prevention and treatment of NPD. Further research is necessary to clarify how individual factors influence the relationship between ACEs and pathological narcissism.

Background

Narcissistic Personality Disorder (NPD) is a severe psychological condition characterised by an inflated sense of self-importance, a constant need for admiration, and a lack of empathy for others [1]. Narcissistic personalities can vary widely from an overvalued, entitled self-image characterized by aggressive, exploitative, and exhibitionistic behaviours (grandiose narcissism) to anxious, defensive, hypersensitive, resentful, and socially reticent behavioural patterns (vulnerable narcissism) [2]. However, the current criteria for diagnosing NPD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) arguably overemphasize grandiose narcissism at the expense of recognizing vulnerable narcissism (Table 1) [1]. In general, NPD has received increasing attention owing to its social consequences, such as violence, and antisocial tendencies. The global burden of NPD varies widely, with the prevalence rates ranging from 0 to 6.2% (Average of 0.8% [3]), across communities and population groups, and is likely underestimated due to the focus on the grandiose aspects of NPD [1]. The prevalence of NPD is particularly higher in males, those with a family history of NPD, and those with underlying mental health conditions [1, 4].

Table 1.

Definition of narcissistic personality disorder according to American Psychiatric Association’s Diagnostic and Statistical Manual of Mental disorders, Fifth Edition (DSM-5) [1]

Narcissistic personality disorder is defined as comprising a pervasive pattern of grandiosity (in fantasy or behaviour), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of the following 9 criteria:

1. A grandiose sense of self-importance  2. A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love  3. A belief 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  4. A need for excessive admiration  5. A sense of entitlement  6. Interpersonally exploitive behaviour  7. A lack of empathy  8. Envy of others or a belief that others are envious of him or her  9. A demonstration of arrogant and haughty behaviours or attitudes

From a biopsychosocial perspective, a gene–environment interaction as well as accumulation of psychosocial risk factors rather than a single risk factor contributes to the development of pathological narcissism. Among the psychosocial risk factors, experiencing early childhood trauma, or excessive exposure to criticism or overpraise during childhood are found to be relevant for NPD [5]. However, the underlying mechanisms of how early life adversities and experiences lead to the development of narcissistic personality traits are unclear, and the implications of this knowledge for the prevention or mitigation of risks at the population level have not been well discussed.

Adverse Childhood Experiences (ACEs) are the traumatic experiences before the age of 18, which basically include 10 different spectrums: physical, emotional, and sexual abuse, physical and emotional neglect, parental separation, domestic violence, parents having mental illnesses, parental substance abuse or having an incarcerated parent. Individuals who encounter four or more ACEs during childhood have a higher chance of developing severe mental health outcomes later in life, including post-traumatic stress disorder (PTSD), anxiety, depression, problematic drug use, and self-harm tendencies [6]. Four or more ACEs have been found to impact an individual’s emotional development, coping mechanisms, and development of various adverse personality traits, including borderline personality disorder, antisocial personality disorder, and schizoid personality disorder during childhood and later in life [7].

Association of ACEs and NPD

Multiple ACEs are associated with impaired brain development, leading to structural and functional abnormalities, impaired emotional regulation, interpersonal behaviours, and sense of self-worth [8]. Specific ACEs types, including physical neglect, and physical and sexual abuse, as well as parenting malpractices (e.g., overvaluation or neglect) are found to have a direct effect on the development of these narcissistic traits [9]. However, there are contrasting views about which factors are more relevant across the wide spectrum of narcissistic personalities.

Social-developmental theories consider parenting behaviours are particularly significant for the development of grandiose narcissism (exhibitionistic narcissism) [10, 11]. Inconsistency in parenting practices, including alternating between excessive pampering to severe criticism, can create confusion, loss of identity and insecurities in a child’s self-perception. Childhood abuse or neglect, on the other hand, is associated with a shameful and inferior sense of self, powerlessness, and submissiveness, which is more consistent with the nature of vulnerable narcissism (fragile narcissism) [2, 12, 13].

A recent meta-analysis has confirmed that a combination of ACEs is significantly associated with both vulnerable and grandiose narcissism [2]. However, it reported a stronger association between ACEs and vulnerable narcissism compared to grandiose narcissism, with narcissistic traits being more common among those who experienced neglect than among those who experienced physical abuse. Dysfunctional household environments characterized by poverty, illiteracy, high levels of conflict, instability, or violence, and underlying mental health conditions can compound the association between ACEs and pathological narcissism [1, 13, 14]. Individuals who have experienced physical abuse, or witnessed their mothers being treated violently, or grown up in a dysfunctional household may learn and internalize similar behaviours in adulthood [13]. The mediating effect of age, sex, and other socio-demographic characteristics (e.g., poverty, living with disability, having incarcerated parents or parents with mental illness) on the association between ACEs and pathological narcissism remains unclear [2].

In light of available evidence, we discuss underlying mechanisms of how ACEs lead to the development of narcissistic traits. Additionally, a clinical case study of a patient with a history of ACEs and a possible diagnosis of NPD during life progression is presented and discussed.

Case presentation

A 75-year-old retired Vietnamese man presented with his daughter. The patient and his wife have resided at the daughter’s family home for the past decade. The daughter described that her father had always been ‘narcissistic’ but was getting worse with age. “He is constantly trying to lecture me on how to raise my children and continually puts me down stating that I am a failure as a wife and as a mother.” The daughter stated that the patient contributed nothing financially, spends over eight hours daily in front of the computer, and only comes out when called for meals. The patient has no friends, and was becoming more isolated, delusional with grandiosity, and unbearable to live with. She stated “he considers himself to be a very special person, believing his wisdom and enlightenment now exceeds that of the Buddha. He is cruel to others and constantly belittles family and friends he deems far inferior to himself.”

The patient was born into one of the wealthiest families in former Saigon as a son of businessman. Until the age of 10, his family lived in a grand mansion with multiple maids, personal servants, gardeners, and chauffeured limousines. The father was described as a workaholic, leaving the mother to manage the household, and devoted only two hours per week to his children. The mother considered herself (and her children) to be ‘special’, with gifted insight and ability to foretell the future. The patient was oldest of three brothers and two sisters. He describes his childhood as peaceful until the commencement of war.

At the age of 10, he was sent to live with his uncle while the rest of his family sought refuge in the jungle for political reasons. He stated his uncle provided for his basic needs but offered no love and that he had no friends. After school he spent most his days roaming through the near-by forest. He did not return to the family home until approximately five years later. Upon his return he felt like a stranger in his own home and was not close to his siblings. He wished to go overseas to study music, but this was discouraged by his father who planned for him to take over the family business. At the age of 21 he married his wife who was 19 years old. They lived in the family mansion, and both worked in management at the factory. Two years later their daughter was born but the patient described his marriage as strained and loveless after the birth of his first child. When war broke out his father requested that he leave the country with his wife and two-year-old daughter. He was very reluctant to leave but joined his wife and daughter (on the boat) at the very last minute to leave for Indonesia where they lived in a refugee camp for approximately six months. They were accepted as refugees to the USA and became citizens.

In the USA the patient was unable to work for several years due to depression (not diagnosed or treated). After 10 years in the USA, the patient immigrated to Australia with his family to be closer to his siblings and subsequently worked as a jeweller with an Australian company. He later returned to Vietnam to set up a jewellery factory and lived there until his retirement at the age 65. He stated he lived like a king during that time and enjoyed the company of many young women. Since the age 65, he has been residing in the home of his daughter in Australia and received a small pension.

The patient had no major physical health concerns and no history of hospitalization and mental illnesses in past ten years. He had no history of head injury or epilepsy. He is followed for mild, chronic medical condition but nothing acute. He is a non-smoker, non-diabetic and an occasional drinker.

The patient appeared alert and with normal cognition. He was orientated by person, place, and time. The patient looked elderly, but well-groomed and modestly dressed. He appeared somewhat agitated that he had to attend the appointment and was largely uncooperative. The patient spoke clearly but wanted to say as little as possible. Responses to questioning were limited. He appeared arrogant and annoyed by the comments of his daughter and upon questioning. He was also somewhat perplexed and suspicious during the interview. The patient had delusions of grandeur. He considered himself to be a ‘high-class’ individual, wealthy, handsome, and a gifted singer. “I can’t sing Karaoke with my friends because I set the standard too high which will be embarrassing for them.” He stated that his wisdom and insight were beyond that of the Buddha. The patient believed that he receives divine messages from God when he meditates. He stated he was not interested or concerned about the feeling of others he lived with. “I only think of myself and how I can enjoy my remaining years. It is my daughter’s duty to take care of me and it is my wife’s responsibility to provide for all my essential needs in this life and the next.”

A provisional diagnosis of narcissistic personality disorder was made as the patient fulfills all nine of the DSM-5 criteria (Table 1). The patient was referred to a psychiatrist for further assessment and psychoanalytic therapy but refused to go. “What is the point in going when I know more than the psychiatrist”.

Discussion and conclusions

The aetiology of narcissism is based largely on genetic susceptibility and biopsychosocial parameters. The patient was born into an elite Vietnamese family and was told at a very young age by his mother that he was special and destined for greatness (parental overvaluation). However, at the age of 10 he was sent to live with his uncle for five years with only the bare necessities of life provided. The patient stated that during this time he felt unloved, isolated, and alone, and even felt like a stranger in the family home. Later, the patient suffered a major depression in his life. What is the evidence that these biopsychosocial parameters coupled with inherent genetic influences lead to the development of NPD in our patient?

Several studies have examined the role of genetics in the development of NPD [15, 16]. Hypersensitivity, aggression, low anxiety, and affect regulation have a genetic basis and are linked to the development of NPD [17]. More recently, Luo and colleagues examined over 300 twins in China and found that two dimensions of narcissism, intrapersonal grandiosity, and interpersonal entitlement, had an heritability of 23% and 35% respectively [18]. These two traits were evident in our patient. Thus, he may have been genetically susceptible to developing NPD from the onset.

According to Million biopsychosocial theory, narcissism is the result of parents overvaluing their child’s self-worth with uncontrolled praise, attention, and compliments [19, 20]. “As a consequence of teaching a child that he or she is better than others, or that he or she is qualified for special treatment regardless of effort, behaviour, or performance, permissive parenting leads to narcissism.” The theorists Adler and Brummelman also believed narcissism arose from parents who excessively pampered, complimented and entitled their children [19, 20]. Our patient was told by his mother at a very young age that he was special, destined for greatness and that this was his karma.

ACEs play a role in the aetiology of grandiose narcissism [5, 13]. According to Howell (2003), grandiose self-states, as the result of ACEs, serve as a defence mechanism [21]. Such self-states enable children to satisfy their needs for safety and shelter independent of their environment [13]. It also allows children to disassociate from their abusive reality [13]. “The long-term manifestations of this defence mechanism are self-centeredness, dominating behaviours and a sense of grandiosity” [13, 21]. After the age of 10, our patient experienced intense emotional neglect. Arguably, this had profound effects on his psychological development and perhaps was the major cause of his grandiose narcissism.

Narcissism is not only linked with ACEs but also associated with post-traumatic symptoms later in life [22]. According to Montoro and colleagues, post-traumatic symptoms were positively related to entitlement and negatively to vanity and self-sufficiency [22]. Narcissism was also found to be a hinderance with regards to migration and integration into a new society [23]. Narcissistic patients are resistant to external integration, including learning a new language and taking an active part in the community [23]. Our patient was forced to flee Vietnam due to war with his young family and start a new life in the USA. Arguably, this traumatic event had a profound effect on our patient’s emotional well-being and led to his poor integration and inability to work initially due to a major depressive episode lasting for 2–3 years. According to Kealy and colleagues, narcissistic vulnerability contributes to persistent and intrusive negative feelings which in turn contribute to depression [24]. Depressive temperament has also been linked to narcissistic oversensitivity due to a lack of admiration of others [25]. In Vietnam, the patient was among the ruling elite but in the USA, he was on the bottom of the social ladder. This abrupt change in social status and feelings of shame had a significant impact on both his NPD and episodes of depression [26]. It was simply too much for his innate narcissistic defences and masked ‘implicit’ self-esteem to cope with [27].

Our patient predominantly exhibited grandiose traits, including delusions of grandeur and a sense of superiority over others. There were no clear indications of vulnerable traits, such as hypersensitivity to criticism or feelings of inadequacy, nor did he appear to oscillate between grandiosity and vulnerability. However, given that such oscillation can occur in narcissistic individuals, this may not have been fully captured due to the lack of formal psychometric testing. Therefore, a key limitation of this case report is that, while clinical observations were made, incorporating psychometric tools, such as the Pathological Narcissism Inventory (PNI), would have allowed for a more objective evaluation of both grandiose and vulnerable traits [28].

The patient’s expectations of being cared for by his daughter may also reflect filial piety, a deeply rooted value in many Asian societies that emphasizes respect, care, and duty toward one’s parents and elders. Distinguishing between culturally appropriate expressions of self-importance (normal or adaptive narcissism) and pathological narcissism can be complex, as the divide between these forms may be influenced by several factors, including childhood experiences [29]. However, in our patient, the extreme grandiosity, lack of empathy, and disregard for others’ feelings appear to extend beyond adaptive narcissism, contributing to significant dysfunction in his interpersonal relationships [30].

It is evident that genetic susceptibility and biopsychosocial factors, including childhood neglect, parental overvaluation, and household dysfunction, have contributed to the grandiose narcissism apparent in our patient, who refuses to seek further treatment or support. The toll on his family has been enormous and there is no doubt they have suffered from anxiety and depression [31]. The patient has been able to cope in society due to the unconditional love and support of his family, despite his disorder. However, his refusal to seek treatment, stating, ‘I know more than any psychiatrist,’ has impacted their quality of life. But Asian culture is strong and respect for the elderly is unconditional.

Abbreviations

ACEs

Adverse childhood experiences

BMI

Body mass index

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

NPD

Narcissistic personality disorder

PNI

Pathological Narcissism Inventory

PTSD

Post-traumatic stress disorder

Author contributions

AGR conceived the idea and wrote the first draft of the manuscript. SG, AEA, SM, FHA, MMH, KYA, UKM, ST critically revised the manuscript. AGR, ST and SG conducted the literature review and extracted the data. All authors approve the final version.

Funding

The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors for this work.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for the publication of his personal or clinical details, along with any identifying images, in this study.

Competing interests

The authors declare no competing interests.