Narcissists are often described as being self-absorbed, vain, or overly confident. Most of us will display some level of narcissism from time to time. The difference between what might be considered “normal” narcissism and narcissistic personality disorder (NPD) is that the symptoms of NPD are far more significant are unlikely to change over time and cause significant distress in their personal, social, and/or occupational lives.

Narcissistic personality disorder is a serious mental health condition affecting approximately 5% of adults in the United States. 

Symptoms of NPD can develop in the later teen years, but for some, do not show up until early adulthood. Most professionals will not diagnose a personality disorder until the patient is a legal adult.

Symptoms of Narcissistic Personality Disorder

Narcissistic personality disorder is considered a Cluster B personality disorder in the DSM-V (Diagnostic and Statistical Manuel of Mental Disorders, 5^th edition). The predominant traits shared among the personality disorders making up Cluster B are emotional dysregulation and difficulty in relating to others. 

Those with narcissistic personality disorder experience a pervasive and inflated sense of self-importance and superiority. This leads to an unhealthy fixation on the self. This self-fixation is reflected in thoughts, feelings, and actions and leads to significant impairment in all areas life.

General Symptoms

• Inflated sense of self-importance and superiority
• Desire for admiration
• Sense of entitlement 
• Arrogance
• Fantasies about achieving high levels of power and success
• Wanting to only associate with “high-status” individuals
• Frequent thoughts of being more important, powerful, successful, or attractive than others

Symptoms in Relationships

Individuals with narcissistic personality disorder have great difficulty in forming and sustaining relationships.

Those with NPD experience impairment in relationships of all kinds– with romantic partners, family members, business colleagues, and friends. The tendency toward interpersonal exploitation, or the willingness to take advantage of others, is the most significant symptom of NPD leading to relationship problems.

Other features of narcissistic personality disorder that contribute to impaired relationships include:

• Diminished capacity for empathy
• Willingness to take advantage of others (especially to achieve personal goals)
• Difficulty listening to others
• Tendency to monopolize conversations
• Strong desire/need for control in relationships (often leading to manipulative behaviors)
• Lack of awareness or consideration of others – individuals with NPD are usually apathetic toward the emotional, mental, or psychological needs of others.  
• Prone to envy for those perceived as having a higher status
• Distant or “cold” demeanor
• Indifference regarding the negative effects of their behaviors on others
• Inclination to insult or blame others
• Quick to end relationships over small or imagined issues 

Other Associated Symptoms

Individuals with narcissistic personality disorder are inclined to exaggerate personal accomplishments, skills, or talents. This exaggeration fuels the already heightened sense of superiority. this inflated sense of superiority can come across as unshakeable, indestructible confidence. Yet, those with NPD have a surprisingly difficult time receiving criticism.

Any criticism is typically met with expressions of anger disproportionate to the nature of the criticism. This is because at their core, those with NPD are actually quite insecure and suffer from deep-seated self-esteem issues. These self-esteem issues not only lead to anger expressions, but also defensiveness.

Many with NPD use the following defense mechanisms as a way to “protect” their fragile ego.

• Idealization – attributing excessive and exaggerated positive qualities to self  
• Devaluation – attributing excessive and exaggerated negative qualities to others
• Denial – rejecting a reality (despite what, at times, could be irrefutable evidence) as untrue due to the discomfort associated with accepting the reality.

Because of this fragile ego, those with NPD are more prone to feelings of shame, guilt, or worthlessness, often over minor incidents of day-to-day life. While the personal insecurities of someone with NPD may occasionally show through, the inflated self-concept (shown to the outside world) remains primarily stable.  

As with any mental health disorder, the spectrum of symptoms associated with NPD vary in prevalence and intensity depending on the individual. In more severe presentations of narcissistic personality disorder, individuals may experience paranoia, aggression, or even sociopathy. 

Symptomatology of Narcissistic Subtypes

Although not recognized by the DSM-5, some in the psychology world describe different subtypes of narcissistic personality disorder – grandiose narcissism, vulnerable narcissism, high-functioning narcissism, and malignant narcissism.

Grandiose narcissism, also called overt narcissism, is characterized by grandiose traits such as arrogance and egotism.

Covert narcissism, occassionally called vulnerablenarcissism, is characterized by more covert traits like hypersensitivity and defensiveness.

Individuals with high-functioning narcissism have similar behaviors to those with grandiose narcissism yet seem to function better in society. High-functioning narcissists are usually able to “hide” their personality disorder to the outside world and use their narcissistic traits to achieve success.

Malignant narcissism presents the most severe set of symptoms. Individuals with malignant narcissism are those most likely to experience aggression and paranoia, and unfortunately, have the least desire for change. 

Comorbidity

Narcissistic personality disorder has a high rate of comorbidity with other mental health disorders. Individuals with NPD commonly experience bouts of depression, many of which meet clinical criteria for a diagnosis of a depressive disorder. NPD is also associated with the occurrence of substance use disorders and bipolar disorder.  

Causes of Narcissistic Personality Disorder

The symptoms of narcissistic personality disorder are significant. They manifest in a way that can cause other people to view those with NPD as bad, evil, or even immoral. Yet it is important to remember individuals with NPD did not choose to have this disorder. And while the exact cause of NPD is unknown, as with all mental health issues, narcissistic personality disorder develops as a result of a combination of factors.

• Childhood trauma – emotional, physical, or sexual abuse
• Genetics – evidence shows a person is more likely to develop NPD if a family member has a history of NPD.
• Early childhood relationships with parents – unpredictable or inconsistent care or overindulgence or excessive praise from parents/guardians
• Hypersensitivity in childhood (to noises, light, etc.)

Studies are continually being conducted in an attempt to better define the exact cause(s) of narcissistic personality disorder. In 2013, researchers from the Humboldt University of Berlin in Germany found that people with narcissistic personality disorder have less gray matter in the region of the brain linked to empathy (the left anterior insula).

In a 2020 study out of University of Chicago, Royce Lee, MD, a psychiatrist and personality disorder specialist, found that NPD has a strong biological component. The study identified a link between increased oxidative stress in the blood and traits associated with narcissism.

Oxidative stress refers to an imbalance in antioxidants and free radicals in the body. The study also found a connection between NPD and interpersonal hypersensitivity. Interpersonal hypersensitivity is a genetic trait affecting areas of the brain (such as the amygdala) associated with attachment and emotion regulation. 

Treatment of Narcissistic Personality Disorder

The evolving research on potential causes of narcissistic personality disorder help to inform and clarify effective treatment modalities. And while treatment is essential to the management of symptoms, NPD is rarely the primary reason narcissists enter into any kind of mental health treatment.

Individuals with narcissistic personality disorder are usually prompted to get help due to some sort of challenging life experience, or because they are seeking relief from another mental health issue (i.e. – depression, anxiety). This is because narcissists tend to have poor insight regarding the symptoms of their NPD. This poor insight means difficulty recognizing how their thoughts or behaviors are problematic and have contributed to their problems.

Seeking treatment at all, for any issue or concern, can be difficult for narcissists due to the inherent low self-esteem and fear of criticism.   

There is not one particular standardized treatment for NPD, but ongoing psychotherapy is generally considered the basis. Several approaches to psychotherapy have shown promising outcomes. 

Psychodynamic Therapy

Psychodynamic therapy for narcissistic personality disorder encourages people to explore past experiences and relationships and identify the impact these have had on their lives and beliefs about themselves.

Psychodynamic therapy also helps individuals with NPD examine the unconscious beliefs and assumptions that may support their narcissistic attitudes and behaviors. Through identifying patterns in thought and belief, individuals gain increased awareness and insight. This insight can then be used to spur change.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) concentrates on the connection between thought and behavior. CBT can help individuals with NPD identify distorted or destructive thoughts that lead to unhealthy behaviors. Through challenging and changing the unhelpful thoughts, narcissists can start to break negative cycles.  

Schema Focused Therapy

Schema focused therapy combines elements of cognitive-behavioral, gestalt, and psychodynamic therapy. The theory behind this approach is that schemas (patterns of thought or behavior) are a result of unmet emotional needs. These schemas are then reinforced throughout one’s life by various challenges, trauma, abuse, or other difficult experiences.

The primary goal of schema-focused therapy is to recognize the unmet need(s) and find ways to get those needs met in a healthy way.