Narcissistic Personality Disorder

However, with the right treatment, including therapy and support, symptoms and behaviors associated with this disorder can be managed effectively. Relationships can also improve, as individuals with NPD learn to develop greater self-awareness, empathy, and healthier communication patterns.

Key Takeaways

• While narcissistic traits exist on a spectrum, NPD is a rare diagnosable mental health condition, and is typically functionally impairing.

• Narcissists may manipulate and exploit others in order to feel admired and in control. However, while the behaviors of people with NPD may overlap with various forms of abuse, NPD and abuse are defined differently.

• Many people with NPD are incapable of acknowledging the problem and rarely seek help unless pressured by others. Unfortunately, therapy outcomes are poor due to early termination of sessions and difficulty working collaboratively with the therapist. However, although challenging, with willingness therapy can help to manage and improve symptoms.

Understanding Narcissistic Personality Disorder

The term “narcissism” has gained popularity in recent years, often used by influencers in reference to toxic relationships. However, although the trait of narcissism can manifest in different degrees throughout the population, there is a difference between being narcissistic and having NPD, which is a clinically diagnosable mental health condition.^[1]

Narcissism exists on a spectrum, and small doses of narcissism are actually healthy (providing confidence for forming new relationships, being adventurous, and taking calculated risks). While it is not uncommon for people who are incredibly self-centred to be referred to as narcissists, NPD is more complex and can have severe consequences.

When it comes to diagnosing NPD, the Diagnostic and Statistical Manual for Mental Disorders (now in its fifth edition, referred to as the DSM-5) has created a set of criteria that outlines symptoms that are rarely seen in the general population. These symptoms highlight narcissistic abnormalities only seen in around 8% of men and 5% of women in the US.^[1]

While certain celebrities or politicians may instantly come to mind, members of the public who have NPD only meet the diagnostic criteria once they experience difficulty with occupational, social, relational, and everyday functioning. Unfortunately, it is not common for people with narcissistic personality disorder to recognize their illness, and treatment is currently limited.^[1]

Different Types of Narcissistic Personality Disorder

Although the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5) does not officially categorize NPD into subtypes, some research indicates that the disorder may present in different forms:^[3]

• Grandiose subtype: Typically characterized by attention-seeking behavior, entitlement, arrogance, exploitation of others, a lack of empathy, and an initially charming demeanor.

• Vulnerable subtype: Marked by shyness, extreme sensitivity to criticism, and persistent envy. Despite their insecurity, these individuals may privately hold grandiose self-views.

• High-functioning subtype: Individuals may function well, appearing confident, ambitious, and socially skilled (often exhibiting competitiveness, grandiosity, and sexual provocativeness).

Despite their differences, both grandiose and vulnerable subtypes tend to be deeply self-absorbed.^[3]

How Narcissistic Personality Disorder Affects Others

Extreme narcissism can understandably cause significant strain in friendships, family dynamics, romantic partnerships, and professional relationships. When it comes to individuals with NPD, maintaining any type of relationship can be emotionally draining and confusing for loved ones.

People with narcissistic personality disorder may use manipulation or exploitation, eroding the self-esteem of others and even distorting loved ones’ perceptions of reality (gaslighting). These behaviors stem from an unhealthy drive to control and feel admired.

While these types of behaviors are also seen in abusive relationships, according to the National Domestic Violence Hotline, NPD is a subconscious personality disorder, whereas abuse is a conscious choice.^[4]

While individuals with narcissistic personality disorder (NPD) may engage in abusive behavior, narcissism and abuse are not the cause of one another. Instead, they are distinct issues that can overlap but do not inherently create each other.^[4]

Confronting a person with NPD directly often leads nowhere, with the more effective approach being to set firm boundaries and create emotional distance. While you can’t always change how you feel about someone, you can choose how to respond to them.

In some cases, ending the relationship (whether with a partner, relative, or a superior at work) may be necessary. Taking time to reflect on the person’s behavior can also help prevent similar experiences in the future.

Romantic Relationships with Narcissists

A person with NPD’s hunger for admiration and validation (especially from romantic interests) often leads them to show their charismatic and charming side, qualities that can spark an intense initial connection. People are often drawn to narcissists because they seem confident and self-assured, even though that confidence may not be as deep-rooted as it appears.

However, while narcissists may display charm and passion early in a relationship, their interest is usually rooted in personal gain. For many individuals with NPD, relationships are purely transactional - and any attention and sexual intimacy involved is simply an attempt to acquire an ego boost or a sense of conquest.

As soon as the relationship begins to require emotional depth or sustained commitment, a person with NPD’s interest often fades. Additionally, as the relationship progresses, a lack of empathy can make it difficult for the individual with the disorder to truly consider their partner's emotions or build a meaningful long-term partnership.

People with NPD may attempt to impose rigid expectations, control their partner, or even isolate them from friends and family - patterns that can become emotionally harmful over time. NPD is not a common condition, and many people act selfishly or inconsiderately at times, but in people with this clinical disorder, there is a consistent lack of empathy.

Causes of Narcissistic Personality Disorder

As with many mental health conditions, there is limited research on what causes narcissistic personality disorder, but some studies suggest that it can be strongly influenced by the following factors:^[1]

Genetic Influences

Several studies examining the genetic basis of behavior have shown that NPD has a strong hereditary component. This means that individuals with a family history of these disorders may be more likely to develop similar traits or conditions themselves.^[1]

Medical Factors

Some medical conditions that damage the brain (such as head injuries, strokes, brain tumors, epilepsy, and more) can lead to personality changes or contribute to personality disorders, including NPD.^[1]

Normal Development of Narcissism

Narcissistic traits are a natural part of childhood development. These traits usually show up around age 8, increase during adolescence, and tend to fade in adulthood. However, people who show abnormally narcissistic traits early in life often continue to be narcissistic in adulthood.^[1]

Defense Mechanisms and Psychological Factors

Psychologist Wilhelm Reich has suggested that people may develop mental “armor” to protect themselves from inner conflict and anxiety. Narcissistic individuals often rely on protective strategies like fantasy, defensiveness, and seeing people as either all good or all bad.^[1]

Impact of Childhood Experiences

Both negative and overly positive childhood experiences can potentially contribute to NPD. Rejection or emotional neglect may lead to narcissism, but so can excessive praise or being told one is unusually special.^[1]

The Role of Temperament and Life Experience

Personality is shaped by a mix of inherited traits (known as temperament) and life experiences. While temperament is something individuals are born with, it can be shaped by things like trauma, upbringing, and environment over time.^[1]

Is it Preventable?

While the exact causes of narcissistic personality disorder remain inconclusive, a mounting body of evidence indicates that the nature of an infant’s bond with their primary caregiver significantly influences their social, emotional, and cognitive development. These factors are thought to affect mental health and have been linked to nearly all psychiatric conditions.^[5]

Given the connection between childhood experiences and mental wellness, working to build secure attachments in infants and children may help lower the risk of NPD in future generations. A secure attachment style is believed to develop when caregivers consistently respond to a child's distress with comfort and encouragement.^[5]

Narcissistic Personality Disorder Symptoms

According to the DSM-5, narcissistic personality disorder involves a consistent pattern of inflated self-importance (in thoughts or behavior), a pervasive desire for admiration, and a lack of empathy for others. This pattern usually begins in early adulthood and affects various life areas. It is diagnosed when 5 or more of the following traits are present:^[6]

• A deep-rooted belief of being more important than others (grandiosity), often exaggerating achievements and expecting to be seen as superior without corresponding accomplishments.

• Obsessed with fantasies of unlimited power, beauty, success, intelligence, or their personal concept of perfect love.

• Thinks they are special or different and should only associate with other high-status or exceptional people, believing they are the only people capable of understanding them.

• Craves excessive praise and admiration.

• Feels entitled to special treatment or expects others to automatically meet their demands or expectations.

• Takes advantage of and exploits others to achieve personal goals.

• Lacks empathy and struggles to identify, understand, or care about other people’s feelings or needs.

• Often experiences jealousy or believes that others are jealous of them.

• Acts in a smug, arrogant, or condescending way.

Do Narcissists Seek a Diagnosis?

The very nature of narcissism is egocentric, meaning that individuals with NPD are often overly focused on themselves and tend to view the world primarily from their own perspective. Egocentric individuals often struggle to see things from other viewpoints and may assume that their thoughts, feelings, or needs are the most important.^[1]

As a result of this, many narcissists do not believe they have a mental health condition, so they do not commonly seek help. If the individual does pursue treatment, it’s usually for a different issue such as depression or substance use. In the event that a person with NPD does pursue therapy for the condition, it is generally after being urged by a loved one.^[1][7]

This usually happens after their harmful behaviors have caused strain on others, rather than because they feel distress themselves.^[1]

Diagnosing Narcissistic Personality Disorder

If an individual with NPD consults a mental health professional, it is likely that the provider will ask about symptoms (including how intense they are and how long they’ve lasted). The practitioner may also conduct a psychiatric interview to better understand the person with NPD’s personality, coping mechanisms, and relationships with others.^[7]

The Narcissistic Personality Inventory (NPI) is the most commonly used tool for assessing narcissistic traits. Diagnosing narcissistic personality disorder can be difficult, as it frequently occurs alongside other mental health conditions that blur the lines between other disorders and NPD. These include:^[7][8]

• Depression

• Anxiety

• Substance use disorders

• Bipolar disorder

• Other personality disorders, such as borderline, histrionic, antisocial, or schizotypal personality disorders

Risks and Complications

Individuals with narcissistic personality disorder often face a wide range of physical and mental health challenges, along with significant social difficulties. Contributing factors may include a tendency to feel shame, self-directed anger, helplessness, impulsivity, and an inflated sense of self-admiration.^[2]

Studies have indicated that individuals with NPD have been shown to have higher mortality rates from cardiovascular disease than people without personality disorders. Narcissistic personality disorder has also been associated with gastrointestinal issues. Furthermore, people with NPD commonly use a variety of health care services more than those without the disorder, indicating a link between the mental health condition and physical wellness.^[2]

NPD is strongly linked to suicide risk and has been identified as a significant predictor of multiple suicide attempts. This includes suicide attempts using highly lethal methods (eg. firearms, or jumping from great heights) often triggered by events such as getting fired or personal crises related to finances, health, or relationships.^[2]

From a behavioral perspective, people who have been diagnosed with narcissistic personality disorder are more likely to have a history of criminal convictions, interpersonal violence, causing harm to others, to have served time in prison, and general impairment in their ability to function in social roles.^[2]

Treatment for NPD

As a result of many people with narcissistic personality disorder only seeking treatment to appease their loved ones, it is important for therapists to assess the individual’s specific goals for treatment. Since NPD rarely goes away on its own (or even with therapy) the aim is often to reduce conflict in relationships and improve overall functioning.^[1]

However, research points to the fact that key traits of narcissistic personality disorder are linked to poor therapy outcomes. These may include slow progress in changing behaviors, a tendency for clients to end therapy early, and difficulties in forming a positive, collaborative relationship with the therapist, due to dramatic, erratic, or emotionally volatile behavior.^[2]

Treatment for narcissistic personality disorder typically involves therapy aimed at addressing the behaviors and thought patterns that cause difficulties in relationships and daily life. There are many forms of therapy that can benefit individuals with NPD, provided the person is willing to commit to treatment and is motivated to change.

Therapy for NPD often begins by helping individuals overcome any resistance to treatment and identifying narcissistic symptoms that are affecting their lives and how they impact others. Over time, the focus shifts to replacing grandiose thoughts with more realistic ones and practicing healthier patterns of behavior.

Therapy

• Cognitive behavioral therapy (CBT): CBT focuses on identifying and replacing unhealthy thought patterns and related behaviors with more constructive alternatives. Through practice, people with NPD work on new skills with their therapist, often completing assignments to reinforce these skills between sessions.^[9]

• Dialectical behavior therapy (DBT): DBT (a form of CBT) centers on emotion regulation, mindfulness, distress tolerance, and relationship skills. This form of therapy aims to equip NPD individuals with the ability to manage their emotions and improve relationships.^[10]

• Psychoeducation: Psychoeducation helps individuals with narcissistic personality disorder improve their understanding of emotional experiences and thought patterns. This increased self-awareness not only supports greater control over emotions, but can also increase motivation for treatment by clarifying its purpose and benefits.^[10]

• Gestalt therapy: In Gestalt therapy, the emphasis is on present situations rather than the past. This form of therapy encourages self-reflection surrounding current experiences and how these relate to past events. The goal is to improve self-awareness and develop the ability to take responsibility for one's actions.^[11]

• Mentalization-based therapy (MBT): MBT is designed to improve one’s ability to self-reflect on one’s thoughts and emotions, and those of others. It also encourages individuals with NPD to consider the intent behind others' behaviors with an open mind and to pause before reacting.^[12]

• Transference-focused psychotherapy (TFP): This approach involves transforming an NPD individual’s emotions involving others by directing them toward the therapist, which encourages greater insight into one's thoughts and feelings. This can make it easier to process and understand complex emotions.^[13]

Living With NPD

Living with untreated narcissistic personality disorder is a daily battle against an overinflated sense of self-importance. Individuals with NPD may exaggerate their achievements, expect others to recognize them as superior, and desire excessive admiration, often leading to disappointment, subsequent overreactions, and isolation.

Unfortunately, people living with the disorder struggle to feel empathy toward others and may exploit or manipulate others, making it challenging to form meaningful, reciprocal relationships. Individuals with NPD may even experience jealousy or resentment toward those they perceive as rivals or threats to their sense of superiority.

Additionally, people living with NPD may develop an obsession with fantasies of unlimited power, beauty, or success, driving them to constantly seek validation through external means. If left untreated, the symptoms of NPD can intensify over time, increasing loneliness, frustration, and dissatisfaction.

However, although it is rare for NPD individuals to seek out and engage in treatment, if they are willing to actively participate in treatment, there is hope for improvement. With the right therapeutic support, people with NPD can develop healthier ways of interacting with others and enhance self-awareness, leading to improved relationships and life satisfaction.

Final Thoughts

Narcissistic personality disorder (NPD) is a complex and often misunderstood condition that deeply affects both the individual with NPD and those around them. Symptoms of the disorder include a strong need for admiration, a sense of superiority, fantasies of unlimited success, and a deep lack of empathy.

Unfortunately, therapy has not been found to decrease NPD symptoms, however, it may help individuals with the condition to build a sense of self and navigate relationship difficulties. At the end of the day, prioritizing one’s own well-being by setting firm boundaries is crucial when dealing with a loved one who has NPD.