Narcissistic Personality Disorder

What is narcissistic personality disorder?

Narcissistic personality disorder is a mental illness affecting how you see yourself and interact with others. Narcissism describes being self-obsessed to the degree that you do not consider the feelings and needs of others. People with narcissistic personalities are often described as being self-obsessed, arrogant, and demanding of attention and praise.

Everyone will occasionally be narcissistic, but narcissistic personality disorder is different because it refers to pathological narcissism. This means narcissism endures throughout an individual’s life and touches every aspect, from relationships to education and employment.

People with this personality disorder act in ways that causes harm to themselves or others. It is common to wrongly assume that the negative behaviors of people with narcissistic personality disorders are a personal choice. As a result, narcissistic personality disorder is a highly stigmatized mental illness.

Types of narcissistic personality disorder

There are two different types of narcissistic personality disorder: overt and covert. The two types share many of the same symptoms, such a sense of superiority, being self-obsessed, and finding it difficult to consider other people’s needs, but manifest in different types of narcissistic behavior. The different types of narcissism are:

Overt narcissism

People with overt narcissism, also known as grandiose narcissism, have the symptoms commonly associated with narcissists, such as being very confident and outgoing or even exhibitionists. Instead, overt narcissists are dominant and assertive and maybe even aggressive.

Covert narcissism

People with covert narcissism, also known as vulnerable narcissism, have symptoms not typically associated with being narcissistic. Instead, they present as withdrawn, depressed, and having low self-esteem. They still believe they are superior to others, presenting them as defensive and sensitive to criticism rather than exhibitionist.

Symptoms of narcissistic personality disorder

A personality disorder is a mental illness that results persistent thoughts, feelings, and behaviors that shape your personality and cause harm to yourself and others. The symptoms of narcissistic personality disorder outlined in the Diagnostic and statistical manual of mental disorders (DSM-5) are ^[4]:

• A grandiose sense of self-importance - People with narcissistic personality disorder believe they are special or superior to others. For example, they may think they’re are more intelligent, powerful, or successful than they are. As a result, people with overt narcissism may boast or exaggerate their achievements, whereas people with covert narcissism appear shy and withdrawn but quietly believe they are superior.
• Preoccupation with fantasies of unlimited success - If you have a narcissistic personality, you may spend time fantasizing about a perfect and successful life you feel that you are owed due to your superiority. These include fantasies of professional success, power, beauty, wealth, ideal love, and admiration.
• Believing that they are "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) - People with narcissistic personality disorder may only want to associate with others or institutions that they consider to be special or superior. This is because they believe others are beneath them or will not understand them.
• Requiring excessive admiration - If you have a narcissistic personality, you will need constant praise or attention and may get angry with others if they don’t give you enough. If other people disagree that you are superior or exceptional, you may not like them and become hostile.
• A sense of entitlement - People with narcissistic personality disorder believe they are superior and deserve special treatment. For example, they believe they might expect other people to agree with them or put them first.
• Exploiting others (taking advantage of people) - Narcissists value their success above other people’s needs and believe they are entitled to get ahead. They might use this belief to justify taking advantage of other people or be cruel or abusive to manipulate someone when they are not getting their way. For example, they may say unkind things or make up lies to put other people down and make themselves look good.
• Lacking empathy (unwilling to recognize or identify with the feelings and needs of others) - If you have a narcissistic personality, you will struggle to understand other people’s feelings and needs and only think of your own. This is why narcissists can be selfish and cruel, as they do not care about helping or harming others.
• Often being envious of others or believing that others are envious of them - People with narcissistic personalities often assume other people are jealous of their superiority, specialness, achievements, skills, and talents. They may try to compete with others, wrongly assume other people are competing with them, and feel resentful if other people have success.
• Showing arrogant, haughty behaviors, or attitudes - If you have a narcissistic personality disorder, you believe you are better than other people and may believe other people’s perspectives are ridiculous or worthless. This manifests in arrogant behavior. People with overt narcissism might be rude or belittling, whereas people with covert narcissism might dismiss you quietly.

These personality traits can prevent someone from having meaningful relationships with family, friends, romantic partners, or colleagues.

People with narcissistic personality disorder may also not recognize that they have a mental illness and instead believe that other people are wrong in assuming they are not superior. This can prevent them from seeking help, and they may even become angry if someone suggests they need help.

Causes of narcissistic personality disorder

Although people with narcissistic personality disorder may appear arrogant, personality disorders usually develop as a response to having low self-esteem and self-worth. The exact causes of narcissistic personality disorder are unknown, but there are several linked possible causes and risk factors that researchers agree on. These are genetics, early life experiences, environment, and culture ^[5].

• Genetics - This thinking suggests narcissistic personality disorder is hereditary, meaning it is common to be passed from parent to child. Still, it is unknown whether this is due to genetics or the psychological consequences of someone with a narcissistic personality. No specific gene has been found for narcissistic personality disorder.
• Early life experiences - Personality disorders have been described as a stress reaction to difficult childhood experiences. Childhood neglect or abuse, criticism in childhood, or living with parents with a mental health condition are known risk factors for narcissistic personality disorder. Excessive praise and pampering in youth, leading to an inflated sense of self, is also a risk factor.
• Environment and culture - Narcissistic personality disorder is more common in individualistic cultures where people focus on individual material gain. This suggests that having a narcissistic personality is linked to our broader culture.

We cannot be certain what causes narcissistic personality disorder because not everyone who lives in an individualistic culture, has a parent with a narcissistic personality, or experiences trauma will go on to develop this condition. However, we know that these factors make you more likely to develop a narcissistic personality.

Diagnosing narcissistic personality disorder

A diagnosis of narcissistic personality disorder, as with any other mental illness, is made by a psychiatrist or mental health professional who will ask questions to explore your life history, thoughts, and feelings. In addition, they will evaluate your personality traits, whether you are capable of empathy, how you behave in the world, and your sense of identity and self-esteem. They will also usually access your medical records.

The diagnosis will be made using the DSM-5 criteria, where someone must have five or more of the following traits ^[4]:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that they are “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectation of especially favorable treatment or automatic compliance with their expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve their ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of them.
9. Shows arrogant, haughty behaviors and attitudes.

People with narcissistic personality disorder are rarely diagnosed; they may assume the difficulties they face in relationships are due to faults in other people. Furthermore, people with narcissistic personalities may not openly talk about their thoughts and feelings.

Narcissistic personality disorder is usually diagnosed in adulthood. It is rarely diagnosed in children and teenagers because their personalities are still developing, while personality disorders are diagnosed if there is evidence of enduring symptoms.

To be diagnosed with a personality disorder, you need more than just a few narcissistic traits. The narcissism is pathological, which means it affects every aspect of a person’s thoughts, feelings, and behaviors and in all aspects of their life.

Prevention of narcissistic personality disorder

No specific cause of narcissistic personality disorder exists, so you cannot prevent it. However, seeking help early on is important to prevent symptoms from worsening.

It is common for people with narcissistic personality disorder to have other mental illnesses, such as depressive disorders, anxiety disorders, or substance misuse disorders. Therefore, it is important to get treatment for these.

Treatment for narcissistic personality disorder

Narcissistic personality disorder is a chronic mental illness that you will always live with. However, some treatments can reduce or even prevent your symptoms from affecting your quality of life. The main forms of treatment are therapy and medication.

Talking therapies

Talking therapies can help you to have better relationships which can improve your work, family, and relationships. You will learn to tolerate criticism, recognize your strengths and weaknesses, and build your self-esteem. The main types of talking therapy used to treat narcissistic personality disorder are:

• Psychotherapy – you will work with a therapist long-term (usually a year or more) to explore how to process early life trauma, improve relationships and develop resilience and healthy coping mechanisms ^[6].
• Cognitive Behavioural Therapy (CBT) – is a shorter one-to-one therapy where you will identify your unhelpful patterns of behavior and learn new ways to behave. As a result, you will replace poor coping mechanisms with healthy ones.
• Dialectical Behavioural Therapy – you will work using a combination of CBT (above) and specific exercises that help you manage and regulate your emotions and tolerate difficult feelings ^[7]. This is often done in groups.

Medications

There are no specific medications that resolve narcissistic personality disorder, but there are some that treat the symptoms. These are:

Antidepressants – these are used the treat low mood, sadness and anxiety that are common in people with narcissistic personality disorder. Common antidepressants include Prozac (fluoxetine), Zoloft (sertraline), Effexor (venlafaxine) and Wellbutrin (bupropion).

Mood stabilizers - these are used to treat volatile moods that can cause extreme emotions and damaging impulsive behaviors. Commonly used mood stabilizers include Lithobid (lithium), Depakote (sodium valproate), Lamictal (lamotrigine) or Tegretol or Carbatrol (carbamazepine)

Antipsychotics – these might be used for narcissistic personality disorder symptoms, including psychosis, mood instability, or inability to control impulsive behaviors. Commonly prescribed antipsychotics might include Abilify (aripiprazole), Geodon (ziprasidone), Risperdal (risperidone) or Seroquel (quetiapine).

Self-care for narcissistic personality disorder

Living with narcissistic personality disorder is hard as you will likely experience continuous problems in your relationships and work life. It is common for people with a narcissistic personality to experience anxiety or depression and misuse alcohol or drugs.

If you have narcissistic personality disorder, you can help by attending regular therapy to help you understand and manage your symptoms. People with a narcissistic personality may find therapy particularly difficult as they find it hard to reflect on or perceive themselves as having problems. However, committing to therapy long-term has been shown to help.

You can also avoid alcohol or drugs, which may worsen your symptoms, and instead choose healthy past times, such as exercise, which instead helps to regulate your emotions.

Helping someone with narcissistic personality disorder

Helping someone with a narcissistic personality disorder can be very challenging due to their selfish personality traits and need for constant attention. Having a relationship with someone with a narcissistic personality, whether it be professional, romantic, or because you are related, can negatively impact your well-being.

There are some things you can do to help someone with a narcissistic personality disorder:

• Become knowledgeable about narcissistic personality disorder.
• Set clear boundaries and hold them. This means you decide what behaviors you will and will not tolerate.
• Stand up for yourself, and do not let them put you down.
• Find a support network to help you when things get tough.
• Maintain your self-esteem and confidence.
• Do not tolerate narcissitic abuse. Educate yourself on what abuse looks like, and walk away if you are being abused.
• Carve out space for yourself.

Although people do not choose a mental illness, you do not have to tolerate the behavior of someone with a narcissistic personality if it is abusive, manipulative, and causes you to become unwell.

FAQs about narcissistic personality disorder

How common is narcissistic personality disorder?

Between 0.5%-5% of adults in the United States are estimated to have narcissistic personality disorder diagnoses, but the prevalence may be much higher as it is rare that someone is diagnosed. Of those diagnosed, 75% are male and 25% female ^[8].

Narcissistic personality disorder vs. borderline personality disorder – What is the difference?

Narcissistic personality disorder and borderline personality disorder are both ‘Cluster B’ personality disorders. In the DSM-5, ten listed personality disorders fall into three distinct clusters (A, B, and C). Cluster B personality disorders are characterized by emotional, dramatic, and unpredictable behaviors.

There is some crossover between Cluster B personality disorders that result in a person thinking selfishly. For example, they think the world revolves around them, are sensitive to criticism, believe other people are the cause of any problems they experience and need a lot of attention in interpersonal relationships. However, they are fundamentally different.

Narcissistic personality disorder symptoms include having an inflated sense of self and taking advantage of other people or situations for personal progression, with little empathy for others. People with borderline personality fear rejection and have an unstable sense of self.