Narcissistic Personality Disorder: Signs, Causes, and Treatment

Narcissistic personality disorder (NPD) is a chronic pattern of inner experience and behavior characterized by self-centeredness, lack of empathy, and an exaggerated sense of self-importance.

It is one of several types of personality disorders recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which many mental health professionals use to diagnose this and other disorders.

The disorder causes significant impairments in personality in terms of functioning and is accompanied by several other pathological personality traits. As with other personality disorders, this condition negatively impacts life in various areas, including social, family, and work relationships.

Symptoms of Narcissistic Personality Disorder

Five common signs of narcissism include an inflated sense of self, a constant need for attention, self-centeredness, lack of empathy, and preoccupation with power and success. Some of the symptoms associated with NPD include:

• Belief that one is unique or special and should only associate with other people of the same status
• Constant need for attention, affirmation, and praise
• Exaggerated sense of one's own abilities and achievements
• Exploiting other people for personal gain
• Feeling envious of others, or believing that others are envious of them
• Lack of empathy for others
• Persistent fantasies about attaining success and power
• Preoccupation with power or success
• Sense of entitlement and expectation of special treatment

Narcissism vs. NPD

Narcissism is a term commonly used to describe those who seem more concerned with themselves than with others. But not all people with these traits have a personality disorder. While narcissistic traits may be common at times, such as during adolescence, this does not necessarily mean people will go on to develop NPD.

Diagnosis of Narcissistic Personality Disorder

An official diagnosis can only be made by a qualified mental health professional and requires that the individual show impairments in personality functioning in various domains, including a grandiose sense of self-importance and interpersonal difficulties with attention-seeking, empathy, and intimacy.

Various questionnaires and personality tests may be used to help get greater insight into a person's symptoms. Tests commonly used to diagnose narcissistic personality disorder include the International Personality Disorder Examination (IPDE) and the Narcissistic Personality Inventory (NPI).

Impairments in personality function and expression of personality traits must also be stable over time and across different situations; must not be typical for the individual's culture, environment, or stage of development; and must not be due to the direct influence of substance use or a general medical condition.

Prevalence of NPD

The National Institute of Mental Health suggests that approximately 9.1% of U.S. adults experience at least one type of personality disorder during any given year. Older estimates had suggested that as many as 6.2% of American adults experienced narcissistic personality disorder specifically, yet more recent figures suggest that prevalence rates may be lower than previously believed.

Estimates suggest that between 0.5% and 5% of adults in the U.S. have narcissistic personality disorder. NPD is more common among men than women.

Narcissistic personality disorder is thought to be less common than other personality disorders such as borderline personality disorder, antisocial personality disorder, and histrionic personality disorder.

Causes of Narcissistic Personality Disorder

While the exact cause is unknown, researchers have identified some factors that may contribute to the disorder. Some early life experiences are thought to contribute to narcissistic personality disorder, including:

• Abuse or trauma
• Excessive praise
• Lack of an authentically validating environment
• Parental overindulgence
• Unreliable parenting

Genetics and biology are also thought to play a considerable role, although the exact causes are likely complex and varied.

Types of Narcissistic Personality Disorder

While the DSM-5 does not differentiate between different variations of the condition, there is evidence that the expression of symptoms can vary considerably. Some researchers have suggested that there are at least two distinguishable subtypes of NPD:

• Grandiose, overt narcissism is characterized by boldness, arrogance, and grandiose personality traits. People with this type of NPD are more likely to lack empathy, behave aggressively, exploit others, and engage in exhibitionist behaviors.

• Vulnerable, covert narcissism is characterized by hypersensitivity and defensiveness. People with this type of NPD may seek approval, but socially withdraw if it is not given. They may also experience low self-esteem.

Other proposed subtypes including hypervigilant and high-functioning narcissism. People with the hypervigilant type are described as who experience shame, excessive sensitivity, and easily hurt feelings. Those with the high-functioning type are described as appearing mostly normal with issues centered on lack of empathy, a sense of entitlement, and self-centeredness.

Treatment for Narcissistic Personality Disorder

It is important to note that people with this disorder rarely seek out treatment. Individuals often begin therapy at the urging of family members or to treat symptoms that result from the disorder such as depression.

Therapy can be especially challenging for people with NPD, because they are often unwilling to acknowledge the disorder. This difficulty in treatment is often compounded by the fact that insurance companies tend to pay for short-term treatments that focus only on symptom reduction, not on underlying personality problems.

There are treatments that can help people gain greater insights into their behaviors, establish a more coherent sense of self, and better manage their behaviors. These include:

• Individual psychodynamic psychotherapy can be effectively used to treat narcissistic personality disorder, although the process can be potentially difficult and lengthy.  

• Cognitive behavioral therapy (CBT) is often effective to help individuals change destructive thought and behavior patterns.   The goal of treatment is to alter distorted thoughts and create a more realistic self-image.

• Psychotropic medications are generally ineffective for long-term change but are sometimes used to treat symptoms of anxiety or depression.

Coping With Narcissistic Personality Disorder

People who have relationships with a person who has narcissistic personality disorder may struggle to deal with their loved one's actions. People with NPD do not have a coherent sense of self, so they often engage in harmful or exploitive behaviors that are designed to garner attention, esteem, or love from others.

If someone you know has NPD, there are some things that you can do that may make it easier to understand and cope with their behaviors.

• Learn to recognize narcissistic behaviors. People with NPD may engage in abusive actions such as gaslighting that are meant to manipulate other people's feelings and actions. Knowing how to recognize these behaviors is the first step toward dealing with them more effectively.

• Set clear boundaries. Don't allow the other person to direct angry, abusive, or extreme behaviors toward you. Set limits and be willing to enforce them, even if it means ending the relationship.

• Talk to others. Sometimes, it can be difficult to recognize behaviors that are abusive when they have become normalized within your relationship. Having friends, family members, or a therapist to help you understand the dynamics of your relationship can help you better learn to identify when the person with NPD has crossed a line.

• Encourage your loved one to seek treatment for their condition. Recognize, however, that many people with NPD never seek treatment. If the other person refuses to get help, consider talking to a doctor or mental health professional yourself. A therapist can help you work to rebuild self-esteem that has been damaged by the relationship.