Narcissistic Personality Disorder

Narcissistic personality disorder is a pervasive pattern of exaggerated self-regard, grandiosity, entitlement, and need for acclaim that often emerges from deep-rooted insecurity. Underdiagnosed and poorly understood, narcissistic personality disorder leads to significant impairment, especially in relationships, and can contribute to substance abuse.

What is narcissistic personality disorder?

Narcissistic personality disorder (NPD) is a mental health condition in which individuals have an exaggerated sense of their importance and talents, excessive need for attention and admiration, lack of empathy, and exploitative behavior toward others. They may have grandiose fantasies about their intelligence, beauty, and success, and dismiss and belittle those they think inferior. They turn any situation into an opportunity to flaunt—and reinforce—their superiority.

NPD may affect between 0.8 and 6.2% of the population.[1] 

NPD is a personality disorder, a long-term and inflexible maladaptive pattern of behavior, thinking, and inner experience, present across many contexts, from romantic relationships to work, and deviating from social norms. Often these patterns have been developed as a coping strategy.[2] For some people with NPD, excessive confidence may actually be a compensatory adaptation to mask and overcome low self-esteem and deep vulnerability to criticism.[3]

That contrast between outer arrogance and inner insecurity has led to the elaboration of the two most widely accepted subtypes of narcissistic personality disorder: grandiose or overt narcissism and vulnerable or covert narcissism. Recent research suggests that these subtypes aren’t binary but often co-exist in the same person.[4]

Other subtypes have also been proposed by psychologists.

Grandiose or overt narcissist

The definition of NPD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is thought to most closely describe people in the grandiose subtype. These individuals have a sense of superiority which leads to high self-esteem, self-confidence, entitlement, interpersonal dominance and exploitation, immodesty, exhibitionism, need for admiration, and aggression.[5]

Vulnerable or covert narcissist

People in the vulnerable subtype have low self-esteem and are introverted, defensive, fragile, hypersensitive to criticism, and socially withdrawn, while still harboring a sense of entitlement and egocentricity. They may be very fragile and require lots of affirming attention. This subtype is more associated with maladaptive attachment styles, childhood abuse and neglect, and negative emotions.[5]

Vulnerable narcissists are most commonly women.[6]

High-functioning or exhibitionist narcissist

People in this subtype may be outgoing, energetic, articulate, and even charming, characteristics that propel them to success. However, they’re also grandiose, competitive, attention-seeking, sexually provocative, and unable to relate to others.[7][8]

Malignant narcissist

A subtype postulated by the psychoanalyst Erich Fromm, a malignant narcissist has traits of NPD and antisocial personality disorder, as well as paranoia and sadism. These individuals’ inflated self-regard has a dark side. They’re highly manipulative and aggressive and feel no remorse. As long as they get their way, they don’t care who they harm, especially people they believe are inferior. They lash out and humiliate others when they feel slighted and blame those people for their own bad behavior.[9]

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Symptoms of narcissistic personality disorder

According to the DMS-5, people with narcissistic personality disorder:

  • Have a grandiose sense of self-importance

  • Are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

  • Believe they are “special” and unique and can only be understood by, or should associate with, other special or high-status people

  • Require excessive admiration

  • Have a sense of entitlement, with unreasonable expectations of favorable treatment or automatic compliance with their wishes

  • Are exploitative of others, taking advantage of them to achieve their own ends

  • Lack of empathy (meaning they don’t recognize, take into account, or relate to the feelings and needs of others)

  • Are envious of others or believe others are envious of them

  • Appear arrogant or haughty[10]

How is narcissistic personality disorder diagnosed?

Narcissistic personality disorder is underdiagnosed because narcissists often lack insight into their condition. They're unable to admit they have a problem, instead ascribing blame for their difficulties on others.[11] This is despite NPD causing a lifetime of difficulties, especially with interpersonal relationships. Often NPD is better identified by the people in the narcissist's life, who push them to get treatment.

Narcissistic personality disorder can be diagnosed by a credentialed mental health professional such as a psychologist or psychiatrist. They will conduct a thorough psychological evaluation, charting your long-term patterns of thinking, feeling, behavior, and relationships. 

They may ask questions such as:

  • How do you feel when others criticize or reject you?

  • How would you describe your closest relationships? If you don’t have any, why do you think that is?

  • How would you describe your childhood, including your relationship with your parents?

  • How do you feel when someone expresses sadness or fear to you?[12]

They may have you complete questionnaires such as:

Under the DSM-5, someone can be diagnosed with NPD if they have long-term impairments in identity, self-direction, empathy, or intimacy, and display five of the nine characteristics listed above.

What causes narcissistic personality disorder?

There is no specific cause for narcissistic personality disorder. Rather risk factors spanning environmental, genetic, and neurobiological factors have been identified.

Environmental risk factors

Most environmental risk factors involve the circumstances of childhood, when an individual’s personality and relationship patterns are being formed. 

  • Dysfunctional emotional attachment with the primary caregiver in childhood. Grandiose narcissism has been linked to avoidant attachment, while vulnerable narcissism is linked to anxious attachment.[14]

  • Oversensitive temperament

  • Overindulgence or overvaluation by parents

  • Overprotective parenting or over-involved “helicopter” parenting

  • Excessive praise for good behavior in childhood or excessive criticism for bad behavior

  • Praise from adults for exceptional looks or talents

  • Childhood trauma such as psychological, physical, or sexual abuse

  • Unpredictable or unreliable caregiving

  • Use by parents to regulate their own self-esteem

  • Learning manipulative behaviors from parents[15]

  • Being raised in an individualistic as opposed to collectivist culture[16]

Genetics

Research, including twin studies, suggests that the heritability of NPD is around 40%. This means around 40% of the difference between individuals developing NPD comes down to genetics.[17]

The genes behind narcissism may have been selected for and persist in the populations because they confer a survival or reproductive advantage. Narcissism, with its related qualities of attractiveness and sexual coerciveness, has been theorized to enable short-term mating, meaning the genes are passed down to future generations. Pride and dominance may lead narcissists to attain high social status, making them more likely to survive.[18]

Neurobiology

Common structural abnormalities have been identified in the brains of people with NPD, including a lower volume of gray matter in areas associated with empathy.[19]

What treatment options are there for narcissistic personality disorder?

There is no standardized treatment for narcissistic personality disorder and a dearth of empirical studies about the efficacy of various treatments.[20]

Psychotherapy

Psychotherapy, including cognitive behavioral and psychodynamic modalities, is the primary treatment for NPD. However, people with NPD are often reluctant to participate in talk therapy because they frequently reject the diagnosis and are hypersensitive to criticism and averse to feeling vulnerable.

Cognitive behavioral therapy (CBT) teaches individuals to change the way they think, solve problems, abandon unhealthy coping mechanisms, and develop new ones. For NPD, this can mean teaching them to identify and ditch grandiosity, control impulses, and treat others better.

Types of CBT used for NPD include:

  • Schema-focused therapy: an approach combining psychotherapy and CBT and helping patients identify needs that weren’t met during childhood and led to the development of maladaptive schema, or patterns of thought and behavior. The therapist helps the patient confront these negative schemas and develop healthy ways to meet those unmet needs as adults.

  • Dialectical behavioral therapy: an approach developed for individuals with borderline personality disorder but that has also been deployed for NPD. DBT teaches emotional regulation, distress tolerance, and interpersonal effectiveness. In patients with NPD who seek validation to reduce their feelings of shame and self-criticism, it can help them abandon this coping mechanism and sit with those uncomfortable feelings.[21]

  • Meta-cognitive interpersonal therapy: tackles the perfectionism seen in many cases of NPD. MIT helps patients dismantle narcissistic processes by thinking autobiographically, improving access to their inner states, and identifying dysfunctional patterns. They then learn better patterns of thinking, feeling, and behaving and develop a sense of agency and autonomy.[22]

Psychodynamic approaches draw on psychoanalysis to help the patient understand how their feelings and behaviors are shaped by their unconscious and childhood. Psychodynamic modalities that may be used for NPD include:

  • Transference-focused psychotherapy: challenges the patient’s grandiose defenses and explores their sensitivity to shame and humiliation. 

  • Mentalization-based treatment: teaches the patient to reflect on their own and others’ states of mind and connect these to their actions and behaviors.

Medication

There’s no evidence that any specific medication is helpful for NPD. However, people with NPD have higher than average rates of other mental disorders, including depression and bipolar disorder, which are responsive to medication such as antidepressants and mood stabilizers.

Narcissistic personality disorder and substance abuse

Narcissistic personality disorder is commonly co-morbid with substance use disorder, especially alcohol and cocaine addictions. One study found that 64.2% of respondents with a diagnosis of NPD in their lifetimes had a substance use disorder sometime in their lifetimes. 8.8% of people with lifetime substance use disorder had narcissistic personality disorder.[23]

The link between narcissism and substance abuse is complex. The conditions may share underlying drivers such as childhood abuse and trauma and therefore emerge independently in the same people. 

Additionally, drug intoxication, especially with stimulants, can create grandiosity and exaggerated self-confidence—in short, can make them seem like narcissists. The DSM-5 definition of NPD says that substance abuse needs to be ruled out as a cause of narcissistic symptoms.

The high rates of substance abuse among narcissists seem to contradict the traditional idea that it’s low self-esteem that underlies addiction, as people use drugs to soothe their feelings of insecurity or to express their self-loathing. But it makes sense if you understand the narcissist's exaggerated self-regard as unstable and excessively dependent on external reinforcement. Narcissistic traits such as grandiosity are a means of regulating this self-esteem. Drug consumption may work similarly, a recent review argues. Among narcissists who lack social success and are highly sensitive to failure or criticism, substance intoxication can give them a feeling of power, control, triumph, and even superiority that they don’t get elsewhere.[24]

Narcissist features such as feelings of invulnerability and lack of empathy toward others may also lead people to continue to use drugs despite harm to themselves and others. 

Getting help for narcissistic personality disorder

Treatment for narcissistic personality disorder will start with locating a therapist with experience with personality disorders, especially NPD. 

Where does the term "narcissist" come from?

The term narcissism or narcissist comes from the greek myth of Narcissus. Narcissus was a hunter famed for his beauty who rejected all romantic advances as he deemed no one worthy. Narcissus became so besotted with himself that he eventually fell in love with his own reflection on the surface of a pool of water, where he stayed transfixed with himself until he died. 

It is not hard to see the leap from this parable to the early examination of what would come to be known as narcissistic personality disorder. The term was first used in the field of psychoanalysis by Sigmund Freud in the 1920s.[25]