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Narcissistic Personality Disorder (NPD)


Andrew Skodol

, MD, University of Arizona College of Medicine

Last full review/revision Dec 2019| Content last modified Dec 2019
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Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for adulation, and lack of empathy. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy.

Because patients with narcissistic personality disorder have difficulty regulating self-esteem, they need praise and affiliations with special people or institutions; they also tend to devalue other people so that they can maintain a sense of superiority.

Estimated lifetime prevalence of narcissistic personality disorder varies widely but may be up to 6.2% of the general US population; it is more common among men than among women.

Comorbidities are common. Patients often also have a depressive disorder (eg, major depressive disorder, persistent depressive disorder), anorexia nervosa, a substance use disorder (especially cocaine), or another personality disorder (histrionic, borderline, paranoid).

Etiology of NPD

Little research about biologic factors that contribute to narcissistic personality disorder has been done, although there appears to be a significant heritable component. Some theories posit that caregivers may not have treated the child appropriately—for example, by being overly critical or by excessively praising, admiring, or indulging the child.

Some patients 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 and Signs of NPD

Patients with narcissistic personality disorder overestimate their abilities and exaggerate their achievements. They think they are superior, unique, or special. Their overestimation of their own worth and achievements often implies an underestimation of the worth and achievements of others.

These patients 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. This association with extraordinary people is used to support and enhance their self-esteem.

Because patients with narcissistic disorder need to be admired, their self-esteem depends on the positive regard of others and is thus usually very fragile. People with this disorder are often watching to see what others think of them and evaluating how well they are doing. They are sensitive to and bothered by the criticism of 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 (grandiosity). They may avoid situations in which they can fail.

Diagnosis of NPD

  • Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])

For a diagnosis of narcissistic personality disorder, patients must have

  • A persistent pattern of grandiosity, need for admiration, and lack of empathy

This pattern is shown by the presence of ≥ 5 of the following:

  • An exaggerated, unfounded sense of their own importance and talents (grandiosity)

  • Preoccupation with fantasies of unlimited achievements, influence, power, intelligence, beauty, or perfect love

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

  • A need to be unconditionally admired

  • A sense of entitlement

  • Exploitation of others to achieve their own goals

  • A lack of empathy

  • Envy of others and a belief that others envy them

  • Arrogance and haughtiness

Also, symptoms must have begun by early adulthood.

Differential diagnosis

Narcissistic personality disorders can be distinguished from the following disorders:

  • Bipolar disorder: Patients with narcissistic personality disorder often present with depression and, because of their grandiosity, may be misdiagnosed as bipolar. Such patients may have depression, but their persistent need to elevate themselves above others distinguishes them from those with bipolar disorder. Also, in narcissistic personality disorder, changes in mood are triggered by insults to self-esteem.

  • Antisocial personality disorder: Exploitation of others to promote themselves is characteristic of both personality disorders. However, the motives are different. Patients with antisocial personality disorder exploit others for material gain; those with narcissistic personality disorder exploit others to maintain their self-esteem.

  • Histrionic personality disorder: Seeking the attention of others is characteristic of both personality disorders. But patients with narcissistic personality disorder, unlike those with histrionic personality disorder, disdain doing anything cute and silly to get attention; they wish to be admired.

Treatment of NPD

  • Psychodynamic psychotherapy

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

Psychodynamic psychotherapy, which focuses on underlying conflicts, can be effective. Some approaches developed for borderline personality disorder may be effectively adapted for use in patients with narcissistic personality disorder. They include

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

Cognitive-behavioral therapy may appeal to patients with narcissistic personality disorder because they may find the opportunity to increase mastery appealing; their need for praise may enable a therapist to shape their behavior. Some patients with narcissistic personality disorder find manualized cognitive-behavioral approaches too simplistic or generic for their special needs.

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