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Narcissistic Personality Disorder (NPD)

By Robert M. A. Hirschfeld, MD, DeWitt Wallace Senior Scholar and Professor, Department of Psychiatry, Weill Cornell Medical College

Narcissistic personality disorder is characterized by a pervasive pattern of feeling superior (grandiosity), needing admiration, and lacking empathy.

  • People with narcissistic personality disorder overestimate their abilities, exaggerate their achievements, and tend to underestimate the abilities of others.

  • Doctors diagnose narcissistic personality disorder based on specific symptoms, such as an exaggerated, unfounded sense of self-importance and talents, a need to be unconditionally admired, and a sense of entitlement.

  • Psychotherapy that focuses on underlying conflicts may help.

Personality disorders are long-lasting, pervasive patterns of thinking, perceiving, reacting, and relating that cause the person significant distress and/or impair the person's ability to function.

People with narcissistic personality disorder have an inflated view of self-worth (called grandiosity). They also have problems with self-esteem. To bolster their sense of superiority and self-esteem, they do the following:

  • Associate with special people

  • Become a part of superior institutions

  • Devalue other people

They also want to be praised.

Narcissistic personality disorder occurs in about 0.5% of the general population. It is more common among men.

Other disorders are also often present. They include one or more of the following:

Causes

Genes and environmental factors may contribute to the development of narcissistic personality disorder. One theory suggests that caregivers may have interacted with the child in a way that did not help the child develop a stable sense of self. For example, caregivers may have been overly critical or praised, admired, or indulged the child too much.

Some people with this disorder have special gifts or talents and become used to associating their self-image and sense of self with the admiration and esteem of others.

Symptoms

People with narcissistic personality disorder overestimate their abilities and exaggerate their achievements. They think they are better than others, unique, or special. When they overestimate their own worth and achievements, they often also underestimate the worth and achievements of others.

People with this disorder are preoccupied with fantasies of great achievements—of being admired for their overwhelming intelligence or beauty, of having prestige and influence, or of experiencing a great love. They feel they should associate only with others as special and talented as themselves, not ordinary people. They use this association with extraordinary people to support and enhance their self-esteem.

Because people with narcissistic disorder need to be excessively admired, their self-esteem depends on being thought well of by others. Thus, their self-esteem is usually very fragile. They are often watching to see what others think of them and evaluating how well they are doing. They are sensitive to and bothered by criticism by others and by failure, which makes them feel humiliated and defeated. They may respond with rage or contempt, or they may viciously counterattack. Or they may withdraw or outwardly accept the situation in an effort to protect their sense of self-importance. They may avoid situations in which they can fail.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Doctors usually diagnose personality disorders based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5—see Classification and Diagnosis of Mental Illness), published by the American Psychiatric Association.

For doctors to diagnose narcissistic personality disorder, people must persistently have an inflated view of self-worth, a need for admiration, and a lack of empathy, as shown by at least five of the following:

  • They have an exaggerated, unfounded sense of their own importance and talents (grandiosity).

  • They are preoccupied with fantasies of unlimited achievements, influence, power, intelligence, beauty, or perfect love.

  • They believe that they are special and unique and should associate only with people of the highest caliber.

  • They need to be unconditionally admired.

  • They feel entitled.

  • They exploit others to achieve their own goals.

  • They lack empathy.

  • They envy others and believe that others envy them.

  • They are arrogant and haughty.

Also, symptoms must have begun by early adulthood.

Treatment

  • Psychotherapy

General treatment of narcissistic personality disorder is the same as that for all personality disorders.

Psychodynamic psychotherapy can be effective. This type of psychotherapy focuses on underlying conflicts.

Some approaches developed for borderline personality disorder may be adapted and used to treat people with narcissistic personality disorder. They include

These approaches focus on disturbances in the ways people emotionally experience themselves and others.

Cognitive-behavioral therapy may appeal to people with narcissistic personality disorder. Their need for praise may enable a therapist to shape their behavior.