What Is Narcissistic Personality Disorder?

A narcissist is often described by others as selfish, arrogant, and manipulative. However, behind this mask of self-confidence lies a person unsure of their own self-worth. Everyone can show occasional narcissistic behaviour; however, true narcissists tend to need and seek too much attention and lack the ability to understand or care about the feelings of others.

It is important to understand that whilst narcissism can be a trait, it could also be part of a larger personality disorder. Narcissistic Personality Disorder (NPD) is at the highest end of the narcissistic spectrum and is a prevalent, psychosocially disabling personality disorder that happens to be one of the least studied.¹ Those who suffer from NPD are in love with an idealised or inflated image of themselves, allowing them to avoid feelings of deep insecurity. But devoting such vast amounts of time to fantasies and delusional thinking is what brings about the dysfunctional attitudes and behaviours associated with the disorder.

This article will thoroughly explain and give an overview of the causes, symptoms and management of narcissistic personality disorder, and discuss its variable presentation

Overview

Narcissistic personality disorder is a mental health condition that gives people an unreasonably high sense of their own importance. It can cause problems in many areas of life such as work, family, love life, school, and financial matters. When those with the disorder aren’t given special treatment, they often become very unhappy and disappointed. 

Symptoms of narcissistic personality disorder and their severity can vary, and may sometimes  overlap with other mental health disorders like bipolar disorder, which can make diagnosing NPD difficult. The main treatment for NPD focuses on talk therapy with a mental health professional which aims to help patients learn healthy ways to connect with others.

It is common for children to show narcissistic tendencies, but this does not mean they will go on to develop the disorder. The mental health disorder usually begins in teens or early adulthood and affects more men than women.²

Causes of narcissistic personality disorder

It is unknown what the exact cause of narcissistic personality disorder is, but the cause is likely complex. It may result from a combination of factors:²

• Genetics - dependent on family history, you may inherit certain characteristics that make developing NPD more likely
• Environmental - early relationships with parents, friends, and family. Any childhood trauma such as physical, verbal, or sexual abuse
• Neurobiology - the way in which the brain is connected to behaviour and thinking

Signs and symptoms of narcissistic personality disorder

Mental health professionals will diagnose NPD when you have at least five of the following symptoms:^{2, 3}

• An extremely high sense of self-importance
• Feelings of superiority and only wanting to be associated with people of high-status
• Constant thoughts about being more successful, attractive, powerful, smart or loved than others
• A need for constant or excessive admiration
• The willingness to manipulate, exploit or take advantage of others in order to achieve their own goals
• A lack of empathy towards others
• A sense of entitlement
• Arrogant, snobby behaviour
• Are envious of others and expect others to be envious of them
• A need to have the best of everything - for example, house, car, or job 

As well as the symptoms listed above, with narcissistic personality disorder you may have trouble handling anything viewed as criticism. Therefore, you can:

• Feel depressed or moody if you feel as though you are falling short of perfection
• Avoid situations in which you might fail
• Find it difficult to manage your feeling and emotions
• Become angry or impatient when not receiving special treatment or recognition
• Have serious problems interacting with others
• Try to belittle other people to make themselves appear superior or react with rage
• Have inner feelings of insecurity, humiliation and fear of being exposed as a failure²

There is a chance of differential diagnosis when it comes to narcissistic personality disorder due to its common coexistence and shared symptoms with other mental disorders:

Histrionic personality disorder is also characterised by the need to always be the centre of attention, but individuals with histrionic personality disorder have the ability to rely on, support and love others. They are therefore less dismissive of others and more emotionally expressive compared to those with NPD.¹

Borderline personality disorder (BPD) and NPD can sometimes be further distinguished by the impulsivity and self-destructiveness associated with BPD. Identity disturbance refers to the relative instability of the sense of self, which is a diagnostic criterion for BPD.¹

Antisocial personality disorder and NPD share the traits of exploitation, superficiality, and lack of empathy, but even at the more severe end of the spectrum, individuals with narcissistic personality disorder do not demonstrate the total breakdown of moral functioning and absence of any capacity for loyalty that typifies antisocial personality disorder.¹

Subtypes of narcissistic personality disorder

Typical presentations of narcissistic personality disorder are: the grandiose, “overt,” subtype; the vulnerable, “covert,” subtype; and less well covered in current diagnostic criteria, the healthier, “high-functioning” subtype.¹ Each of these different presentations of pathological narcissism has shared symptoms but those who suffer from the different types may come across as very different people.

The grandiose

These individuals have the potential to be socially charming despite lacking any real empathy and being oblivious to the needs of others. As a child, they were most likely treated as though they were superior or above others. These expectations can follow them as they become adults.

Those with grandiose narcissism are aggressive, dominant, and very self-confident with little observable anxiety.¹

The vulnerable

Individuals suffering from the vulnerable subtype are thin-skinned and often feel offended or anxious when others don't make them feel as if they are special. The behaviour usually stems from a childhood of abuse or neglect. Their feelings of inadequacy are quenched and protected by their narcissistic characteristics and behaviours.

Those with vulnerable narcissism are fragile, manifestly distressed, and hypersensitive.¹

The high-functioning

These individuals use their narcissistic traits to succeed. They have a high level of functioning, which at first glance means they may not appear to have a personality disorder. This can lead to the narcissistic personality disorder being overlooked on diagnostic assessment.

Those with high-functioning narcissism are grandiose, attention-seeking, and competitive.¹

Management and treatment for narcissistic personality disorder

The primary treatment for narcissistic personality disorder is long-term talk therapy, also known as psychotherapy. There are now also extensive online therapy resources available. If you have co-occurring mental health conditions such as depression, medication can also be included in your treatment plan. 

Psychotherapy

Treatment for narcissistic personality disorder is centred around psychotherapy. It has the ability to help you gain a greater insight into your problems by helping you to:

• Relate to others in a more positive and rewarding way to encourage closer relationships
• Understand the root causes of your emotions, addressing any feelings of distrust and dislike towards others or yourself, aiding the development of healthy self-esteem
• Have a more realistic expectation of others

Therapy can be provided on an ongoing basis to help you achieve and maintain your goals, or in times of crisis or stress on a short term basis.² 

Medicines

There aren't any specific medicines used to treat narcissistic personality disorder. However, if you are experiencing symptoms of anxiety, depression, or other mental health conditions, anti-anxiety or antidepressant medication may be helpful.²

FAQs

How is narcissistic personality disorder diagnosed?

For NPD, diagnosis is usually based on:

• Your symptoms and how they impact and affect your life
• A physical exam to ensure a bodily issue isn’t causing your symptoms
• A thorough psychological evaluation which could include filling out questionnaires
• Guidelines in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association²

Can narcissistic personality disorder be prevented?

Due to the cause being unknown, there is no way to prevent the personality disorder. It may help to get treatment for childhood mental illnesses as soon as they are noticed. The inheritance of genes is one of a combination of factors that contribute to the development of narcissistic personality disorder, meaning the condition could be unavoidable for some. 

Who is at risk of narcissistic personality disorder?

Despite narcissistic personality disorder's causes being unknown, researchers believe that neglectful and overprotective parenting could potentially impact those children born with a tendency to develop the mood disorder. Genetics may also play a part, so if a parent or sibling has it, you may be more likely to develop the disorder too. 

How common is narcissistic personality disorder?

It is believed by experts that 5% of people have narcissistic personality disorder. NPD is just one of 10 personality disorders that negatively affect the way you feel, think and behave about others and yourself. 

The prevalence of narcissistic personality disorder is higher in certain demographics, including:⁴

• 2–6% of those seeking help from mental health clinics
• 6% of forensic analysts
• 20% of people in the military
• 17% of first-year medical students 

When should I see a doctor?

It can be difficult for narcissists to realise or accept they need treatment due to what they perceive as being an insult to their already low self-esteem. They're more likely to receive treatment for mental health conditions other than narcissistic personality disorder, or for symptoms of depression or drug and alcohol misuse. 

If you’re feeling overwhelmed by sadness or recognise aspects of your personality that are common to narcissistic personality disorder, consider reaching out to a mental health provider. Receiving the correct treatment as early as possible will help make life more enjoyable.

Summary

Narcissistic personality disorder should not be seen as a flaw, as it is a serious mental health condition. NPD has variable presentations, with three main subtypes: grandiose, vulnerable and high-functioning. People who suffer from NPD do and say things that make it difficult for them to form functioning relationships with others. This usually doesn't tend to be on purpose - in fact, it's stimulated by deep-seated insecurity and the need for people to think that you’re worthy. With treatment, you can work on learning ways to boost your self-esteem, get along better with others, and maintain healthy relationships.