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.
- Narcissistic personality disorder (NPD) is a long-term mental health condition characterized by grandiosity, entitlement, a need for admiration, and difficulties with empathy and relationships.
- NPD has no single known cause. Genetic, neurobiological, and environmental factors, including childhood experiences, may contribute to its development.
- Treatment for narcissistic personality disorder primarily involves psychotherapy, which may help address unhealthy thought patterns, behaviors, relationships, and coping strategies. NPD also commonly occurs alongside substance use disorders, making appropriate professional support important.
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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, an excessive need for attention and admiration, a 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 are inferior. They turn any situation into an opportunity to flaunt—and reinforce—their perceived 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 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 are not binary but often coexist 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 that 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]
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]
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 to 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:
- Pathological narcissism inventory (PNI)
- Five-Factor Narcissism Inventory (FFNI)
- Millon clinical multiaxial inventory III (MCMI-III)
- International personality disorder examination (IPDE) [13]
Under the DSM-5, someone can be diagnosed with NPD if they display five of the nine characteristics listed above or, under the alternative model, if they have long-term impairments in identity, self-direction, empathy, or intimacy.
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]
- Temperamental emotional reactivity, rejection sensitivity, impulsivity, or unstable self-esteem may increase vulnerability to narcissistic traits.
- 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.
- Childhood trauma such as psychological, physical, or sexual abuse.
- Being treated by parents primarily as a source of status, achievement, admiration, or emotional validation may interfere with the development of an autonomous and stable sense of self.
- Learning manipulative behaviors from parents. [15]
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]
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.
Psychodynamic approaches draw on psychoanalysis to help the patient understand how their feelings and behaviors are shaped by their unconscious and childhood.
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 health issues, 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 comorbid with substance use disorder, especially alcohol and cocaine addictions.
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.
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.
The term was coined in 1899 by Paul Näcke, and first used in the field of psychoanalysis by Sigmund Freud in 1914. [25]
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