Narcissistic Personality Disorder

In order to understand narcissistic personality disorder, the concept of personality is important. As with a normal personality, a person with narcissistic personality disorder (NPD) has a pervasive way of thinking, feeling, and interacting with other people that tends to be fairly established and fixed by the time the individual reaches adulthood. A narcissist is someone who has therefore established a long-standing pattern of being fixated on him- or herself that permeates their thoughts, feelings, actions, and relationships.

The word narcissism comes from the story of Narcissus, a hunter in Greek mythology well known for his beauty and for being completely in love with himself. His all-consuming self-love resulted in his eventual death, caused by his becoming so attracted to his own reflection in a pool that he was unable to stop staring at his image.

People with narcissism tend to interact with others and the world in general by distorting things such that they alternate between feeling omnipotent or devalued. Children of narcissistic parents often feel like they are never good enough. Narcissistic personality disorder has an average occurrence rate of about 1% of the population and occurs as often as in 6% of adults. Some research indicates that the incidence of NPD more than doubled from 1999 to 2009.

Medical professionals diagnose NPD more often in men than in women. It is also more often found in people who are involved with the court system compared to the public. An antisocial personality disorder is an illness that commonly co-occurs with a narcissistic personality disorder.

As with most mental health disorders, narcissistic personality disorder does not have one single definitive cause. Rather, people with this illness tend to have biological, psychological, and environmental risk factors that contribute to its development.

• Biologically, narcissists have a tendency to have a smaller part of the brain that is related to having empathy for others.
• Psychologically, individuals with narcissism tend to have trouble having opposing self-images of excessive admiration and devaluing in their minds and in their relationships. They are excessively emotionally sensitive.

Early psychoanalytic theory on the emotional motivations for the development of NPD focused on the relationship between mothers and sons. Specifically, medical professionals believed that men develop this disorder as the result of having an excessively close relationship with their mother that is contingent upon always doing what she wants, with a resulting paranoid fear of retaliation by their father and humiliation or abandonment by their mother. Since those early theories, the social risk factors for developing NPD have been expanded to include excessive admiration or neglect by either parent.

In addition to receiving excessive, unrealistic admiration, praise, overindulgence, or excessive criticism for misbehavior during childhood, theories about other social risk factors of narcissistic personality disorder include emotional abuse, unpredictable parental care, and parent-child interactions, as well as learning manipulation from caregivers.

In order to be assessed with the diagnosis of narcissistic personality disorder, an individual must demonstrate a pervasive pattern of significantly inflated self-esteem (grandiosity), a need to be admired, and a lack of empathy for others that begins by early adulthood and is present in a number of different aspects of their life. According to the DSM-5/DSM-V (the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), the diagnostic reference that is written and endorsed by the American Psychiatric Association, specific symptoms and signs of this illness have remained consistent from the previous edition (DSM-IV-Text Revision) and include the following:

• An excessive sense of self-importance, with an expectation of being seen as superior for no reason
• Preoccupation with self-aggrandizing fantasies: unlimited success, power, brilliance, beauty, or love
• The excessive belief that he or she is special or unique and therefore should only associate with other high-status people
• A need for excessive admiration
• A sense of entitlement to receiving especially favorable treatment or compliance with their wishes
• A tendency to take advantage of others to achieve their own ends
• Lacking empathy for the needs and feelings of people
• Frequently envious of others or thinking others are envious of him or her
• Exhibits haughty, arrogant thoughts or behaviors

Mental health professionals describe individuals who have some symptoms of narcissistic personality disorder but not enough for the full-blown diagnosis as having narcissistic personality traits.

The most common traits of the disorder are people with grandiose ideas about themselves that simultaneously:

• mask their low self-esteem
• present an elevated/inflated version of themselves
• are self-centered
• believe they are better than others and treat others with contempt (without respect)
• lack empathy
• crave attention and admiration

All narcissists, men and women, share common traits. However, there are some differences between the behaviors of both sexes concerning the disorder, such as:

• Male narcissists tend to be online trolls more than female narcissists.
• Male narcissists tend to purposely put down/disrespect women in a relationship/marriage or at work, making them feel less powerful.
• Male narcissists are more likely to dominate using manipulation or mind games.
• However, female narcissists are more likely to use their sexual charm to dominate and get what they want.

1. Extreme sensitivity to criticism

Feelings of insecurity are typical of NPD. In a covert narcissist, this manifests as extreme sensitivity to criticism.

Of course, sensitivity to criticism isn't unique to NPD, since few people enjoy being criticized. However the way someone responds to both real and perceived criticism can shed light on whether this sensitivity is extreme.

Someone with covert narcissism might act as if they are above the criticism. Internally, however, they may feel empty, humiliated or angry, and their dismissive, sarcastic remarks are an attempt at hiding these feelings.

2. Passive-aggressive behavior

A covert narcissist may use passive-aggressive behavior to convey frustration or make themselves look superior. Passive-aggressive behavior may involve:

• Sabotaging other people's work or relationships
• Mocking others
• Giving others the silent treatment
• Making others feel bad
• Procrastinating on tasks they think are beneath them

3. Tendency to put themselves down

People with NPD crave admiration and rely on others to build self-esteem. Covert narcissists are no different, but instead of boasting about themselves, they tend to put themselves down with an underlying goal of earning compliments.

4. Shy or withdrawn nature

Covert narcissism is more strongly linked to introversion than other types of narcissism. People with this type of NPD are deeply insecure and afraid of other people seeing their failures. They may therefore avoid situations or relationships that lack clear benefits.

5. Grandiose fantasies

A covert narcissist usually spends more time thinking about their abilities and achievements than talking about them. They may have an "I'll show you" attitude and often withdraw into a fantasy world of unlimited success or brilliance where they are superior to others.

6. Feelings of depression and anxiety

People with covert narcissism have a higher risk o depression and anxiety than other types of narcissists. Because of a deep fear of failure and frustration over unrealized perfectionistic ideals, they may struggle with feeling empty or even suicidal.

7. Tendency to hold grudges

Covert narcissists tend to hold grudges for a long time. If they feel they are being treated unfairly, they may say nothing at the moment but wait to take revenge in some way. Along with a desire for revenge, these grudges can lead to feelings of bitterness and resentment.

8. Envy

People with NPD are often envious of others who possess things they feel they should have. While a covert narcissist may not openly discuss their feelings of envy, they may show bitterness and resentment over not getting what they want.

9. Feelings of inadequacy

When covert narcissists can't meet their own high standards, they often feel inadequate. This can result in feelings of shame, anger or powerlessness.

10. Fake empathy

Covert narcissists have the ability to seem empathetic and compassionate, but it's usually self-serving and just for show. They may try to be helpful or generous but with the goal of winning approval and admiration.

Many providers of health care may help make the diagnosis of narcissistic personality disorder, including pediatricians, primary care providers, licensed mental health therapists, psychiatrists, psychologists, psychiatric nurses, physician assistants, and social workers. As part of this examination, the sufferer will likely undergo a full physical examination and laboratory tests in an attempt to rule out any medical condition that may contribute to the symptoms described.

• The person with NPD may be asked a series of questions from a standardized questionnaire or self-test to help assess the presence of the illness.
• Given the low level of insight that narcissistic individuals have regarding their symptoms, there is a lower tendency for them to self-report symptoms. Therefore, mental health professionals may seek information from family members as part of the assessment of people with NPD.
• A medical professional will conduct a thorough exploration of any history or presence of mental health symptoms such that narcissistic personality disorder can be distinguished from other personality traits or disorders like histrionic personality disorder, borderline personality disorder, or antisocial personality disorder.
• The mental health professional will also explore whether other forms of mental illness are present since narcissism is often also associated with depression or perfectionism.
• In addition to demonstrating a pattern of grandiose thoughts or behaviors, self-absorption, need for admiration, and lack of empathy for others characterized by at least five of the previously described symptoms, other diagnostic criteria for narcissistic personality disorder include
  • the sufferer's pattern of such behaviors being pervasive throughout the person's life,
  • as well as stable,
  • longstanding symptoms that are not better explained by another mental illness,
  • the effects of a substance, or
  • a medical condition.

• The primary treatment for narcissistic personality disorder is talk therapy (psychotherapy) rather than medication.
• However, medication may be appropriate to address some co-occurring mental health symptoms like depression, irritability, or anxiety.

Psychotherapy tends to focus on how the person with the disorder interacts with the therapist during therapy,

• examining and changing the individual's grandiose sense of self and excessively vulnerable thinking,
• teaching the sufferer ways to regulate their emotions, and
• correcting self-centered behaviors to more healthy self-confidence and prosocial ways of interacting with others.

Some studies indicate that limited reparenting of the person with NPD by the therapist may help decrease the symptoms of the disorder. That approach, referred to as schema-focused therapy, involves accessing the aspects of the person consistent with a vulnerable child than helping the person emotionally mature to think and behave like a mature adult.

Providing family members of people with pathological narcissism with therapy that teaches them about the illness of their loved one as well as ways to improve their communication and problem-solving skills helps decrease symptoms in their narcissistic loved one.

Compared to people without mental illness, people with narcissistic personality disorder are at higher risk of becoming depressed, anxious, and socially isolated. They tend to have problematic relationships, as well.

They are also more prone to developing cardiovascular illnesses, abusing substances, becoming aggressive, and having suicidal thoughts on a long-term basis.

How well or poorly people with narcissistic personality disorder progress over time seems to be influenced by how severe the disorder is at the time that treatment starts, the state of the individual's current personal relationships, whether or not the sufferer has a history of being abused as a child, as well as whether or not the person receives appropriate treatment.

Simultaneously suffering from other mental health problems, like major depression, obsessive-compulsive disorder, or another personality disorder, is associated with a lower likelihood of symptoms of NPD being alleviated with treatment. One of the major obstacles to treatment and therefore to a good prognosis for narcissistic individuals is the perception by these individuals that their problems are caused by others rather than by their own self-centered tendencies.

Societal interventions like prevention of child abuse, domestic violence, and substance abuse in families can help decrease the occurrence of a number of very different mental health problems, including narcissistic personality disorder.

National Alliance on Mental Illness (NAMI)
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National Institute of Mental Health (NIMH)
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