The other day I was asked a question by a friend of mine about the age of onset for NPD. I was pretty sure I knew the answer and trotted out the information about the characteristics as defined in the DSM and that it often begins to emerge in late teens but it essentially becomes noticeable from the 20’s onwards and as a person ages they tend to show less extreme grandiose behaviours. Her response to my “off pat” answer was surprising and sent me back to all my favourite textbooks in total insecurity of my knowledge. She described the case of her brother-in-law:
“Sam was a research scientist in a university geology department and had been highly successful, particularly in his teaching which he loved, and by all accounts was loved back by his students. He is a little on the short side so has a bit of a “small man complex” in that in a social gathering or event, he liked to perform in front of others and you always noticed Sam. His voice was on the loud side too. This is probably what made him such a good lecturer in that they were always a performance, whether he was talking about his passion for quaternary sub-fossils or his love of breeding and rescuing injured raptors on his farm near the city.
He had by all accounts some risk factors for a personality disorder in that his mother had been cold, distant and resentful at having to give up her life to become a mother and let her children know about it always until her death. He had also been shipped off to boarding school and was the family black sheep having chosen a career as an academic rather than becoming a surgeon like his father, and younger siblings. The fact that he had an international reputation, meant nothing. This if anything spurred him on.
Sam was happily married with 4 children who were half grown when he suffered a trauma. A student who had failed her dissertation, made an accusation that he had sexually assaulted her. He was suspended and eventually cleared, turned out she had done the same thing at school to a teacher who had befriended her. But the rumours spread around the university and he felt he couldn’t work there anymore. He left to work for an environmental archaeology consultancy.
Shortly afterwards he started drinking heavily and when drunk berated his wife, family and anyone. He became louder and more attention seeking and this thoroughly nice guy as was, appeared to fit the diagnostic criteria for NPD except for the age of onset. His condition became dysfunctional and he could no longer work and went into a spiral of decline, loosing wife, family and home. He is now living with his parents where he rages against the world and writes angry, unpublishable articles on his former specialism”
Sam of course is not his real name.
I must admit, the story sent me scurrying to any source I could find, and there weren’t many. No whilst no one definitively states that NPD cannot develop later in life, there is a dearth of evidence to support it. The dominance of medical model may be in part to blame for this. In clinical terms, only young people have been studied in any great depth and the diagnostic criteria are focussed this age group.
There is an old proverb which suggests that if you look for something then you will find it and nothing else. The implication is that no one has looked for late onset personality disorders and NPD. My guess it could be out there but hidden somewhere else. We have so many adults now labelled with a variety of long term mental health conditions that perhaps some people with say, PTSD, major depressive illness etc. could equally well fit the diagnostic criteria for a form of late onset NPD.
One academic review article exists which supports my hunch Oltman and Balsis(1) attest that:
“In comparison to the literatures concerned with most forms of mental disorder, relatively little attention has been paid to the trajectory of personality disorders. This is especially true about middle adulthood and later life. A few longitudinal studies have made substantial contributions to our understanding of personality disorders, but they have focused largely on the period of the lifespan ranging from childhood through adolescence and young adulthood”
The conclusion of their article advocates a need to study the course of personality disorders in middle age and older populations to gain better insight. If, however, the clinicians who are applying the label have pre-conceived notions about the age of onset then finding that sample is going to be as difficult as finding “Hen’s teeth”. In the less academic and clinical environment of the internet it is possible to find posts by many people, like my friend’s sister who had a relationship with a person who has late onset personality disorder. They alone are questioning the diagnostic processes and criteria when their lives are being ruined by proxy. This happens when a person they once knew and loved, turns into someone they no longer recognise – a boastful, egotistical, manipulative user who may or may not have a self-sabotaging streak.
From my reading of these anguished posts, most of the partners appear to have had a predisposition to a personality disorder which may be NPD, including an abusive childhood followed by some sort of psychic trauma which has caused the full emergence.
Unlike their diagnosed counterparts, they are not taken seriously in mental health treatment because they don’t fit the criteria and are given inappropriate treatment such as CBT and then left to flounder with completely the wrong label of “recidivist” or “alcoholic”. How many families are ruined in the process? Something must be done.
Endnote: Sam’s eldest daughter is now in her 20’s. She had a traumatic relationship…. with a narcissist!
- Thomas F. Oltmanns and Steve Balsis (2011) Personality Disorders in Later Life: Questions about the Measurement, Course, and Impact of Disorders Annu Rev Clin Psychol. Apr 27; 7: 321–349.