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Narcissistic Personality Disorder (NPD)


Mark Zimmerman

, MD, Rhode Island Hospital

Reviewed/Revised Sep 2023

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.

Patients with narcissistic personality disorder have difficulty regulating self-esteem and thus 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.

Comorbidities are common. Patients often also have a depressive disorder Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more (eg, major depressive disorder, persistent depressive disorder), anorexia nervosa Anorexia Nervosa Anorexia nervosa is characterized by a relentless pursuit of thinness, a morbid fear of obesity, a distorted body image, and restriction of intake relative to requirements, leading to a significantly... read more , a substance use disorder Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more (especially cocaine Cocaine Cocaine is a sympathomimetic drug with central nervous system stimulant and euphoriant properties. High doses can cause panic, schizophrenic-like symptoms, seizures, hyperthermia, hypertension... read more ), or another personality disorder (histrionic Histrionic Personality Disorder (HPD) Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy... read more , borderline Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more , paranoid Paranoid Personality Disorder (PPD) Paranoid personality disorder is characterized by a pervasive pattern of unwarranted distrust and suspicion of others that involves interpreting their motives as malicious. Diagnosis is by clinical... read more ) (2 General references 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... read more ).

General references

  • 1. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment. 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.

  • 2. Stinson FS, Dawson DA, Goldstein RB, et al: Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 69(7):1033-1045, 2008. doi: 10.4088/jcp.v69n0701

Etiology of Narcissistic Personality Disorder

Limited data about biologic factors that contribute to narcissistic personality disorder suggest there is 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 indulgent of 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 Narcissistic Personality Disorder

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 Narcissistic Personality Disorder

  • Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR) criteria

  • 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:

Diagnosis reference

  • 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp 760-764.

Treatment of Narcissistic Personality Disorder

  • Psychodynamic psychotherapy

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.

Treatment references

  • 1. Crisp H, Gabbard GO: Principles of psychodynamic treatment for patients with narcissistic personality disorder. J Pers Disord 34(Suppl):143-158, 2020. doi: 10.1521/pedi.2020.34.supp.143

  • 2. Choi-Kain LW, Simonsen S, Euler S: A mentalizing approach for narcissistic personality disorder: Moving from "me-mode" to "we-mode." Am J Psychother 75(1):38-43, 2022. doi: 10.1176/appi.psychotherapy.20210017

  • 3. Diamond D, Yeomans F, Keefe JR: Transference-focused psychotherapy for pathological narcissism and narcissistic personality disorder (TFP-N). Psychodyn Psychiatry 49(2):244-272, 2021. doi: 10.1521/pdps.2021.49.2.244

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