Narcissistic Personality Disorder (NPD)

What Is Narcissism?

“Narcissism” ranges from self-centeredness, in the colloquial usage of the term, to subclinical narcissism, describing someone with narcissistic traits that are insufficient to establish Narcissistic Personality Disorder (“NPD”). Narcissism is also viewed on a continuum from healthy narcissism in mature individuals who can idealize romantic partners, express their talents and skills, and accomplish their goals to immature people who are highly sensitive to wounding, employ destructive, psychotic defenses and have unstable relationships (Solomon, 1989).

The Myth of Narcissus: The word narcissism comes from a Greek myth retold by the Roman poet Ovid in Metamorphoses. Narcissus was a young man who scorned everyone who loved him, including the nymph Echo. As punishment, the goddess Nemesis made him fall in love with his own reflection, a love that could never be returned.

How Common Is NPD?

Studies of U.S. community samples estimate that 0 to 6.2 percent of people have NPD (Dhawan et al., 2010). In a large national U.S. survey, NPD was more common in men (7.7 percent) than in women (4.8 percent) (Stinson et al., 2008).

NPD first appeared as a diagnosis in 1980, in the DSM-III (American Psychiatric Association [APA], 1980), although clinicians had written about pathological narcissism for decades.

Symptoms and Diagnosis of NPD

The symptoms are laid out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR; APA, 2022). NPD begins by early adulthood with a pervasive pattern of grandiosity (sometimes only in fantasy), a constant need for admiration, and lack of empathy, as indicated by the presence of at least five of the following:

• A grandiose sense of self-importance
• Fantasies of unlimited success, power, brilliance, beauty, or ideal love
• A belief that they are special and unique and can only be understood by, or should associate with, other special or high-status people or institutions
• A need for excessive admiration
• A sense of entitlement
• Exploitation or taking advantage of other people
• Lack of empathy
• Envy of others or a belief that others are envious of them
• Arrogant, haughty behavior or attitudes

NPD ranges in severity from people satisfying only five of the criteria with mild behavior to “malignant” narcissists, who demonstrate all nine and are malicious, vindictive, and exhibit more antisocial behavior, similar to sociopathy, or people with an antisocial personality disorder.

Types of Narcissists

Grandiose vs. Vulnerable (Covert) Narcissists

All subtypes of narcissists meet the required criteria for NPD but emphasize different personality traits. Researchers often describe two main types: grandiose and vulnerable. Grandiose, or “exhibitionist,” narcissists are extroverted and fit the common stereotype. Vulnerable narcissists, also called “introverted,” “covert” or “closet” narcissists, may act humble or shy, and have an inadequate self-perception. Yet, they still lack empathy, are self-centered, and entitled. Their grandiosity may be hidden in martyrdom or unfulfilled dreams of greatness.

Other Subtypes (Millon)

Other subtypes classified by psychologist Theodore Millon include:

• Unprincipled: dishonest and acts without morality
• Amorous: seductive and exploitative in romantic relationships
• Compensatory: centered on their own imaginary world and seeks admiration for fabricated or exaggerated accomplishments
• Elitist: competitive opportunist, constantly self-aggrandizing to climb the social or corporate ladder, while trampling over other people

Communal Narcissists

Even more difficult to identify is a third type of narcissism. Researchers named it communal narcissism in 2012 (Gebauer et al., 2012). Communal narcissists value warmth, agreeableness, and relatedness. They see themselves and want to be seen by others as the most trustworthy and supportive person and try to achieve this through friendliness and kindness.

They’re outgoing like the grandiose narcissist. However, whereas the grandiose narcissist wants to be seen as the smartest and most powerful, a communal narcissist wants to be seen as the most giving and helpful. Communal narcissists’ vain selflessness is no less selfish than that of a grandiose narcissist. They both share similar motives for grandiosity, esteem, entitlement, and power, although they each employ different behaviors to achieve them.

Malignant Narcissists

Malignant narcissists are considered to be at the extreme end of the continuum of types of narcissism due to their cruelty and aggressiveness. They’re paranoid, immoral, and sadistic. They find pleasure in creating chaos and taking people down. These narcissists aren’t necessarily grandiose, extroverted, or neurotic, but are closely related to psychopathy and antisocial personality disorder.

What Causes NPD?

How NPD develops is still unknown, but it may be caused by a combination of genetic, psychological, and environmental factors. Several psychodynamic theories focus on the parent-child relationship, particularly with the mother. Otto Kernberg theorized that NPD can develop when a child has a cold, hostile, or envious mother who is hypercritical and devaluing. According to Heinz Kohut, NPD reflects arrested psychological development due to inadequate, empathic mirroring (Russell, 1985). Another theory points to extreme closeness with an overly indulgent mother.

Twin studies suggest genes account for roughly a quarter to two-thirds of the variation in narcissistic traits (Livesley et al., 1993; Torgersen et al., 2008).

How Is NPD Treated?

Although NPD is not curable, it is amenable to treatment. However, people with NPD often don’t see themselves as the cause of their problems and rarely enter treatment, except to manage an external problem, such as a divorce or work-related issue, or following a major blow to their fragile self. Sometimes they come because their spouse insists on conjoint counseling. Occasionally, they seek treatment for loneliness and depression. Medication has not been shown to be effective, except to treat associated depression or anxiety.

Individual Psychotherapy

Although narcissism is difficult to treat, progress can be made over time in talk therapy. Weekly sessions over a shorter term can improve patients’ functioning and adaptation to reality by gaining some control over their defenses and behavior. They can learn to better tolerate criticism, accept realistic goals and limitations, collaborate with others, and manage their anger, rage, and impulsivity. Some therapists believe depth work should be avoided, both because the person sees their difficulties as coming from the outside and because they need to strengthen their defenses against primitive feelings (Russell, 1985).

On the other hand, psychoanalysis and psychoanalytic psychotherapy are generally used for treating the disorder itself and would entail examining early trauma. Ultimately, effectiveness depends on the patient’s motivation and capacity to introspect and take responsibility for their behavior.

Although narcissists may feign empathy in order to get close or win others’ approval, research shows that people with narcissistic traits show more empathy when they’re asked to imagine how another person feels (Hepper et al., 2014).

Newer Therapy Approaches

Research on treating NPD is still limited, but transference-focused psychotherapy, which works with patterns as they show up in the relationship with the therapist, may help more than other approaches (Mitra et al., 2024). Clinicians also adapt schema therapy and mentalization-based treatment, which were first developed for related personality disorders. Whatever the method, progress tends to come when a person can look honestly at their own part in their problems. 

Conjoint Therapy

In relationships with narcissists, underlying vulnerability and shame can provoke escalating cycles of defensive maneuvers involving forms of attack and withdrawal. Destructive defenses further deteriorate perceptions of one another.

In conjoint therapy, couples can be educated that such tactics erode good feelings and damage their relationship. They can build self-awareness and learn how they protect themselves when they’re hurt, what they need and want from each other, and the impact of their current behaviors. This can open a dialogue between them about feelings, wishes, and needs, the way they communicate, and its effect on one another. Partners can attain more realistic and understanding views of one another and learn to tolerate each other’s failure to meet their needs and expectations. Even if a narcissist cannot empathize with feelings, they do have the emotional intelligence that can be tapped to educate them to behave in ways that will better get their needs met (Lancer, 2015a, 2015b).

Finding the Right Therapist

It’s important when seeking treatment to find a psychotherapist or psychoanalyst experienced in treating NPD, who can be empathetic, yet not be intimidated or manipulated by the narcissistic patient. Symptoms, diagnoses, and primary relationships, including parental relationships, should be discussed and goals established. Many narcissists have addictions. Abstinence or sobriety should be the initial focus in therapy.

In a Relationship With a Narcissist?

Loving or working with someone who has NPD can leave you doubting yourself. Over time, many partners and family members start walking on eggshells, apologizing for things they didn’t do, and putting their own needs last. Setting boundaries is hard because people with NPD often react to limits with anger, blame or withdrawal (Lancer, 2015a). Individual therapy can help you see the pattern clearly, rebuild your confidence and decide what you want, even if the other person won’t go to therapy.

Signs it may be affecting you:

• You feel anxious or on guard around them
• You often second-guess your memory or judgment
• Your needs and feelings rarely come first
• You’ve pulled away from friends or family
• Saying no feels risky

Many partners of people with NPD struggle with codependency and low self-esteem, and both respond well to therapy.

If you feel unsafe in your relationship, call the National Domestic Violence Hotline at 800-799-7233. If you’re in crisis or thinking about suicide, call or text 988 (US and Canada), or see our crisis helplines for other countries.

Frequently Asked Questions

Can someone with NPD change?

Yes, people with NPD can change, though it usually takes time. NPD may be less fixed over time than once believed (Stinson et al., 2008), and therapy works best when the person is motivated, often after a loss or crisis, and has built trust with the therapist (Mitra et al., 2024). Progress looks like handling criticism better, taking more responsibility, and treating others with more consideration.

What’s the difference between narcissistic traits and Narcissistic Personality Disorder?

Most of us show narcissistic traits at times, like wanting admiration or feeling special. NPD is diagnosed only when at least five of the nine DSM-5-TR criteria form a lasting pattern that begins by early adulthood and causes problems at work, in relationships and in daily life (APA, 2022). Narcissism sits on a continuum, and NPD is the far end of it.

What is covert narcissism?

Covert, or vulnerable, narcissism describes people who share the core features of NPD, such as entitlement and low empathy, but come across as shy, anxious or self-doubting rather than boastful. They tend to be very sensitive to criticism and defensive in nature, so the condition is easy to overlook (Mitra et al., 2024). Their grandiosity often shows up as quiet resentment or private fantasies of being recognized.

How is NPD diagnosed?

A licensed mental health professional diagnoses NPD through a clinical interview, sometimes with structured questionnaires, comparing a person’s long-term patterns with the DSM-5-TR criteria (APA, 2022). The clinician also rules out conditions that can look similar, such as antisocial personality disorder or bipolar disorder, and generally waits until no other acute mental health crisis is going on (Mitra et al., 2024).

Find a therapist experienced in treating NPD on TherapyTribe.

This article is for information only and is not a substitute for professional diagnosis or treatment. If you have concerns about your mental health, talk with a licensed mental health professional.

References

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.).

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Dhawan, N., Kunik, M. E., Oldham, J., & Coverdale, J. (2010). Prevalence and treatment of narcissistic personality disorder in the community: A systematic review. Comprehensive Psychiatry, 51(4), 333–339. https://doi.org/10.1016/j.comppsych.2009.09.003

Gebauer, J. E., Sedikides, C., Verplanken, B., & Maio, G. R. (2012). Communal narcissism. Journal of Personality and Social Psychology, 103(5), 854–878. https://doi.org/10.1037/a0029629

Hepper, E. G., Hart, C. M., & Sedikides, C. (2014). Moving Narcissus: Can narcissists be empathic? Personality and Social Psychology Bulletin, 40(9), 1079–1091. https://doi.org/10.1177/0146167214535812

Lancer, D. (2015a). Dealing with a narcissist: 8 steps to raise self-esteem and set boundaries with difficult people. Carousel Books.

Lancer, D. (2015b, July). The problem of narcissists. The Therapist, 7–12.

Livesley, W. J., Jang, K. L., Jackson, D. N., & Vernon, P. A. (1993). Genetic and environmental contributions to dimensions of personality disorder. American Journal of Psychiatry, 150(12), 1826–1831. https://doi.org/10.1176/ajp.150.12.1826

Mitra, P., Torrico, T. J., & Fluyau, D. (2024). Narcissistic personality disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556001/

Russell, G. A. (1985). Narcissism and the narcissistic personality disorder: A comparison of the theories of Kernberg and Kohut. British Journal of Medical Psychology, 58(2), 137–148. https://doi.org/10.1111/j.2044-8341.1985.tb02626.x

Solomon, M. F. (1989). Narcissism and intimacy: Love and marriage in an age of confusion. W. W. Norton.

Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., Ruan, W. J., Pulay, A. J., Saha, T. D., Pickering, R. P., & Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(7), 1033–1045. https://doi.org/10.4088/JCP.v69n0701

Torgersen, S., Czajkowski, N., Jacobson, K., Reichborn-Kjennerud, T., Røysamb, E., Neale, M. C., & Kendler, K. S. (2008). Dimensional representations of DSM-IV cluster B personality disorders in a population-based sample of Norwegian twins: A multivariate study. Psychological Medicine, 38(11), 1617–1625. https://doi.org/10.1017/S0033291708002924