Narcissistic Personality Disorder (NPD) is a mental health condition that affects how an individual behaves, thinks and feels in relation to themselves and others.
While people usually use the term “narcissist” in order to describe somebody who is self-absorbed, the clinical diagnosis of NPD is far more complex. It is characterized by a persistent need to impress others or feel important, which can be strong enough for an individual to engage in harmful behaviors.
Development of NPD depends on a combination of factors such as environment, genetics and upbringing. Research suggests that when it comes to the U.S. population, NPD is more common in men (7.7%) than women (4.8%). It usually manifests in early adulthood, leading to significant impairment in social and occupational functioning.
DSM-5 criteria
According to DSM-5 criteria, Narcissistic Personality Disorder is defined as a pervasive pattern of grandiosity, either in fantasy or behavior, along with the constant need for admiration and a lack of empathy, beginning in early adulthood and present in various areas of life.
This pattern is indicated by at least five of the following:
- A grandiose sense of self-importance (ex. exaggerating talents or achievements).
- Preoccupation with fantasies of unlimited success, wealth, power, beauty, and brilliance.
- Belief that they are special or unique, and therefore should only engage with other special or high-status people or institutions.
- A need for excessive admiration.
- A sense of entitlement (ex. unreasonable expectations of favorable treatment by others).
- Interpersonally exploitative behavior – taking advantage of others in order to achieve their own goals.
- Lack of empathy – unwillingness to recognize the feelings and needs of others.
- Envy of others or belief that others are envious of them.
- Arrogant behaviors or attitudes.
In order for a diagnosis to be established, these traits must cause clinically significant distress and impairment in social, personal, and occupational functioning, and cannot be better explained by another mental disorder.
Symptoms and presentations
While the DSM-5 criteria emphasize overt narcissistic traits, clinical presentations can vary. Two types of NPD traits are often discussed in research and clinical practice:
- Overt (Grandiose) narcissism – narcissistic traits such as arrogance, confidence, and a tendency to assert control over others are usually displayed openly. Individuals may often seek admiration and recognition, express their achievements (exaggerated or real), and react strongly to criticism. For example, they may seek out compliments and become upset if they are ignored. They also tend to view their relationships in a more transactional manner. The most damaging traits are often a lack of empathy and an inability to see other people’s perspectives.
- Covert (Vulnerable) narcissism – in contrast to overt narcissism, this form is less openly displayed. Individuals may appear shy or withdrawn, while still having deep-seated fantasies of superiority and entitlement. They may struggle with feelings of inadequacy and oscillate between self-doubt and self-importance. The need for admiration can show in a more subtle form, for example saying “I’m not as good as you” while waiting to be contradicted. Their lack of empathy can manifest as defensiveness or subtle invalidation (ex. “You are overreacting”). Covert narcissism is often overlooked because it doesn’t present with overt arrogance.
Treatment methods
Treating Narcissistic Personality Disorder can be challenging due to the nature of the condition itself. Individuals may not recognize they need help, or they may not recognize the impact their behavior has on their life and the people around them.
Psychotherapy is the cornerstone of NPD treatment. There are a few different therapeutic approaches, such as:
Psychodynamic Therapy – focuses on increasing self-awareness, understanding the roots of maladaptive patterns, and improving an individual’s ability to connect and relate to others in healthier ways. It focuses on exploring early childhood experiences and attachment dynamics.
Dialectical Behavioral Therapy (DBT) – originally developed for Borderline Personality Disorder (BPD), but has been adapted in the treatment of other personality disorders, including NPD. DBT focuses on building practical skills in four main areas:
- Mindfulness – increasing awareness of narcissistic traits.
- Distress tolerance – strategies which help the patient cope with emotional pain without resorting to grandiosity or withdrawal.
- Emotion regulation.
- Interpersonal effectiveness – practicing balanced communication.
Cognitive Behavioral Therapy (CBT) – targets distorted thought patterns and the behaviors that reinforce them. It helps individuals challenge their unrealistic beliefs about entitlement and superiority, while developing a more realistic representation of their achievements. CBT also helps with building an individual’s ability to accept constructive criticism.
Group Therapy – not the first choice in treatment due to potential interpersonal conflicts, however it can offer a safe space for individuals with NPD to receive feedback and see how others interact. Group leaders need to carefully manage these therapy sessions in order to prevent competitive or dominating behaviors from derailing the process.
When it comes to pharmacotherapy, there is no specific medication used for NPD. Antidepressants, anti-anxiety medication or mood stabilizers can be prescribed to address co-occurring symptoms such as depression, anxiety, or mood instability.
It is important to note that progress in NPD treatment is only possible if the individual is willing to actively participate in therapy, engage in self-reflection, and remain committed regardless of difficulties. Progress is measured in shifts toward more flexible thinking, increased empathy, and improved relationship satisfaction.
